1. VETERANS HEALTH ADMINISTRATION Quality Improvement using the VA Electronic Health Record Matthew Bidwell Goetz, MD Chief, Infectious Diseases VA Greater Los Angeles HCS

2. VETERANS HEALTH ADMINISTRATION VHA and quality of care VA is now recognized nationally for quality Transformation into a quality institution occurred in conjunction with other changes – Reorganization to a primary care-focused system – Quality measurement and accountability – Independent data gathering programs – Public availability of performance data – Institution of an integrated, comprehensive EHR

3. VETERANS HEALTH ADMINISTRATION How did the EHR help improve quality? 100% access to records Availability of remote data (other VAs) and DoD data Ability to identify patients by disease or other characteristics (coding, use of data elements) Ability to use data to create reports, provide feedback Decision support tools at point of care including reminders to providers

4. VETERANS HEALTH ADMINISTRATION Examples of Summary Reports

5. VETERANS HEALTH ADMINISTRATION Secure, web-based national registries for use by all VA primary care providers

6. VETERANS HEALTH ADMINISTRATION Group comparisons

7. VETERANS HEALTH ADMINISTRATION Care Managers can produce customized, team-level reports

8. VETERANS HEALTH ADMINISTRATION Provider access to information on patients not meeting indicators

9. VETERANS HEALTH ADMINISTRATION Quality Measures in the VA

10. VETERANS HEALTH ADMINISTRATION Use of the Computerized Patient Record System (CPRS) for Management of Individual Patients

11. VETERANS HEALTH ADMINISTRATION Selected views of CPRS Cover Page Imaging and Procedure ReportsLaboratory Reports Clinician Notes

12. VETERANS HEALTH ADMINISTRATION CRPS: customized patient-specific reports

13. VETERANS HEALTH ADMINISTRATION GLA HIV Viral Loads, Includes patients not on treatment Viral Load

14. VETERANS HEALTH ADMINISTRATION System-Wide Quality Improvement in HIV - Testing Facilitation by the VA Electronic Health Record (EHR) and the Functionality of CPRS

15. VETERANS HEALTH ADMINISTRATION How did the VA EHR and CPRS help HIV testing initiatives? Able to identify patients not previously tested and avoid repeatedly offering tests the previously tested Able to use data to create reports, provide feedback Decision support tools at point of care

16. VETERANS HEALTH ADMINISTRATION Using CPRS – based decision support (Clinical Reminders) Used for a wide variety of purposes in the VA – Screening for depression, traumatic brain injury – Screening for Tobacco & alcohol use – Hypertension identification and management – Diabetes monitoring – Vaccination rates – Etc. Contributes to attainment of performance standards

17. VETERANS HEALTH ADMINISTRATION Examples of Clinical Reminders Sample reminders for an HIV- infected patient OI prophylaxis Hepatitis screening Primary care indicators Reminders can be determined by the status of the patient Reminders can be customized at each facility

18. VETERANS HEALTH ADMINISTRATION Provider – specific reminder completion rates

21. VETERANS HEALTH ADMINISTRATION Relative Increase in Testing 50%390%556% Pre- vs Post-Intervention Routine HIV Testing Multi- VISN QI Project – Adjusted Rates Control SitesLocal Central No ImplementationImplementation Implementation

22. VETERANS HEALTH ADMINISTRATION VA-Wide Changes in HIV Testing vs Use of HIV Testing Clinical Reminder Sites without Clinical ReminderSites with Clinical Reminder 20092010

23. VETERANS HEALTH ADMINISTRATION Acknowledgements VA HSR&D: QUERI core funds, SDP 06-001, SDP 08-002 VA Clinical Public Health: moral, financial and logistical support QUERI-HIV/HEP colleagues: Steve Asch, Allen Gifford, Jane Burgess, Tuyen Hoang, Hersch Knapp, Henry Anaya and many, many others Slides on the development of clinical dashboards – Caroline Goldzweig