1. User-Driven Innovation of VistA: Central Regional Hospital Stephen Oxley, M.D, CMO Central Regional Hospital Butner, NC Open Innovation in Electronic Health Records HIMSS14 Orlando, FL February 23, 2014

2. Central Regional Hospital is one of three psychiatric hospitals operated by the North Carolina Department of Health and Human Services (NCDHHS)

3. Central Regional Hospital 398-beds Located 10 miles northeast of Durham, North Carolina in the Research Triangle region of the state. Was completed and occupied in July 2008.

4. EMR Implementation Central Regional Hospital chose to implement an open-source EMR Chose the Veterans Healthcare Information Systems and Technology Architecture (VistA)

5. EMR Implementation VistA is available for download from several sources in several flavors CRH chose a version available from an open-source VistA community non-profit organization

6. EMR Implementation This version was selected because: It was true enough to the VA version to be able to accept all updates from the VA patch stream Its main modification had been to allow VistA to work with a totally open-source stack: Linux GT.M VistA

7. VistA Innovations Self-implementation

8. Self-Implementation Hired as full-time employees: A technical expert with 18 years experience with VistA in the VA A physician with extensive experience configuring VistA for end-users Leveraged this expertise by knowledge transfer to 15 other existing employees

9. Self-Implementation It took 30 months from project initiation to last go-live Trained 1526 end users System used for care on all 398 beds

10. VistA Innovations Self-implementation Patient pictures

11. Added Patient Pictures

13. VistA Innovations Self-implementation Patient pictures Primary contact

14. Added Primary Contact

16. VistA Innovations Self-implementation Patient pictures Primary contact MOCHA replacement

17. MOCHA Replacement Medication order checking is one of the most valuable patient safety features of an EMR The VA has compiled, maintained and done open-source distribution of a drug database they call the National Drug File (NDF)

18. MOCHA Replacement Until recently VistA has used the National Drug File (NDF) for medication order checking However, the NDF only supports a limited set of order checks Commercially available drug databases new offer a wider range of order check information

19. MOCHA Replacement The VA has modified VistA to take advantage of the commercially available drug information and do expanded order checks To accomplish this upgrade, the VA created the Medication Order Check Healthcare Application (MOCHA)

20. MOCHA Replacement While MOCHA dynamically accesses the most recent commercially available drug data: it uses expensive proprietary technology it requires a very expensive subscription to the proprietary drug database it resides on VA servers and is not accessible to VistA users outside the VA

21. MOCHA Replacement

23. VistA Innovations Self-implementation Patient pictures Primary contact MOCHA replacement Interface to ADC management system Automatic Replenish/Ward Stock (AR/WS)

24. Interface to the ADC System CRH uses Automated Dispensing Cabinets for medication storage and distribution at the hospital ward level

25. Interface to the ADC System The ADC Server holds each patients medication profile and also tracks what medications are stocked in which cabinet and which drawer within the cabinet

26. Interface to the ADC System The Pharmacist processing med orders in VistA Pharmacy needed to know if a medication was stocked in the ADC on the patients ward. The ADC Server needed to update a patients medication profile when an order was entered or discontinued.

27. Interface to the ADC System We leveraged the ARWS module in VistA to map the cabinets information for VistA Pharmacy. We employed the open- source HL-7 interface engine, MIRTH, to facilitate the communication between VistA Pharmacy and the ADC Server

28. VistA Innovations Self-implementation Patient pictures Primary contact MOCHA replacement Interface to ADC management system Automatic Replenish/Ward Stock (AR/WS)

29. Open-Source Innovation The State of North Carolina could not afford to implement a proprietary EMR Open-source software allowed us to implement a very powerful system for about $2700 per bed An open-source system made customization to meet our unique needs readily available and affordable