Lawrence Deyton, MSPH, MD VA Overview Lawrence Deyton, MSPH, MD Chief, Public Health With thanks: Dr. Gary Roselle, Syed Tirmizi, Gail Graham, John Quinn, Linda Danko, et al

History Veterans programs date back to Colonial times VA created in 1930 as an independent agency Cabinet-level department created in 1989 Major eligibility changes in 1996 Now the 2nd largest Cabinet-level department (second to DoD) Budget over $75,000,000,000 VHA $29 B, VBA $35 B 210,000 employees

VA Mission Motto: Abraham Lincoln Serve America’s 25 million veterans and their families with dignity and compassion by providing health care services and benefits earned in service to this Nation Motto: “To care for him [and her] who shall have borne the battle and for his widow and his orphan.” Abraham Lincoln

Missions of the Veterans Health Administration Medical care Graduate medical education Research Emergency preparedness

VA Medical Care The largest integrated healthcare system in US: 158 hospitals (18,828 beds, 5.4M BDOC) 132 nursing homes (33,408 ADC) 73 home care programs 43 domiciliary programs 206 veterans counseling centers 854 clinics (50 M outpatient visits) 186,600 employees (VHA)

Fiscal Year 2004 – VHA statistics 7.1 million total enrollees of 25 million US veterans 5.1 million patients treated $29 billion total budget 200 million 30-day equivalent Rx’s dispensed 190 million lab tests performed

Who Are VA Patients? Older - 49% over age 65 Sicker - Compared to Age-Matched Americans 3 Additional Non-Mental Health Diagnoses 1 Additional Mental Health Diagnosis Poorer 70% with annual incomes < $26,000 40% with annual incomes < $16,000 31% have no health insurance Changing Demographics – 4.5% female overall Females: 22.5% of outpatients less than 50 years of age

VA Medical Care Enrolled veterans eligible for full spectrum of general and specialty medical/preventive services including drug benefit Special focus on conditions related to military service: Prosthetics, rehab and blind rehab Environmental exposures (agent orange, Gulf War syndrome, depleted uranium & radiation, cold injury, etc. PTSD and mental health issues Special focus related to VA populations served: Geriatrics/extended care Women Veterans programs and services Chronic diseases; diabetes, cardiac, kidney, cancer, infectious diseases, mental health/substance abuse, homelessness

Veterans Health Administration Education Mission Affiliated with 107 of 125 U.S. Medical Schools and 1,200 education institutions VA has more than 5,000 affiliation agreements for Associated Health Programs 84,510 Total trainees (Academic Year 2001)

Veterans Health Administration Research FY04: 1.5 billion dollars of research Mission: improve veterans health care Medical Research Rehabilitation Research Cooperative Studies (large multi-center clinical trials) Health Services Research Accomplishments: Invention of cardiac pacemaker, CT technology First successful liver transplant, insulin pump Multi-center clinical trials; Tb, MI & CHF tx, HTN, DM 2 Nobel Prize winners, 6 Lasker Awards

Emergency Responses VA/DoD Contingency (PL 97-174) – VA back up for DoD in event of war or national emergency involving armed conflict NDMS – VA, HHS, DoD, FEMA (DHS) – assists state/local govts with medical & PH disasters and hospital capacity DEMPS – VA part of Federal Response Plan when Presidential Disaster Declaration in made Ad hoc – local responses to emergencies

2004: Who is “VA”? Veterans Health Administration Budget, Staff, & Patients: ~193,000 Employees (~15,000 Doctors, 56,000 Nurses, 33,000 AHP) 6% decrease since 1995 13,000 fewer employees than 1995 ~ $27.4 Billion budget 42% increase since 1995: flat at ~ $19B from 1995 - 1999 5.1 million patients, ~ 7.5 million enrollees 104% increase in patients treated since 1995: from 2.5 million patients / enrollees in 1995

Success in Supporting Health Delivery for Millions of Veterans VistA (veterans health information system and technology architecture) Features Include: 100+ separate business packages that support day-to-day activities of healthcare operations, including Registration / Enrollment / Eligibility Systems Provider Systems for delivery of healthcare Management and Financial Systems And CPRS……

VistA / CPRS (Computerized Patient Record System) VistA/CPRS supports the largest integrated health system in the United States serving over 5 million veterans Delivers an integrated record covering all aspects of patient care and treatment Includes electronic order entry and management, narrative notes entry, laboratory results, consultation requests and reports, alerts of abnormal results, imaging, clinical reminders, and much more VistA Web allows clinicians to see health data from any other VA facility where the veteran has received care

And CPRS Is Actively Used... National VistA Statistics (Total / Daily) Documents (Progress Notes, Discharge Summaries, Reports) 658,000,000…….. +550,000 each workday Orders 1.35 Billion……....+910,000 each workday Images 300,000,000………+475,000 each workday Medications Administered with the Bar Code Medication Administration (BCMA) system 630,000,000………+605,000 each workday as of March 2005

Success In Supporting Health Care Delivery For Millions Of Veterans VistA is a success Publicly owned by VA; plan to remain so for the next generation system Strong interest by public/private in using VistA (IHS, DC Dept of Health, etc) National software w/ local flexibility/innovation: Innovation developed locally & enterprise wide Standard packages distributed system-wide Initial system (1983-1996) built on “dumb terminals” “Decentralized Hospital Computer Program (DHCP)” Steady deployment of packages and enhancements Applications separated out by Hospital/Clinic “Service” Simple “roll-and-scroll” screens

In 1996, VA launched the “Computerized Patient Record System” -- CPRS-- a comprehensive, integrated Electronic Health Record (EHR)

How it all Began…… CPRS evolved from DHCP’s text-based Order Entry/Results Reporting Initial design and subsequent enhancements guided by clinicians “Visually” organizes and presents all relevant data on a patient in a way that supports clinical decision making Phased implementation of CPRS Placed in “production” at first VA site in July 1996 Began use at 3 more sites between August and December 1997 Installed in “lead” site in each of VA’s 22 regions by June 1998 Implementation completed at all VA Medical Centers (>170) in December 1999

VA Today Every VA Medical Center uses Electronic Health Records

Electronic Health Records and Computerized Provider Order Entry (CPOE) 100 % VA Medical Centers have Electronic Health Record CPOE is one of the Leapfrog Group’s “Top 3 Safety Strategies” Outside of VA, CPOE < 8% nationally < 30% among Academic Medical Centers Nationally, 93% of all VA Rx’s by CPOE Ultimate Goal: 100% VA is the Benchmark for CPOE All Medical Centers also have Desktop Imaging

Combining Text and Images

Clinical Reminders Links Reminder With the Action With Documentation Contemporary Expression of Practice Guidelines Time & Context Sensitive Reduce Negative Variation Create Standard Data With the Action With Documentation

Online Demo of CPRS Try a working copy of VA’s Computerized Patient Record System (CPRS) at www.va.gov/cprsdemo