1. Enterprise Health Management Platform
VistA Evolution and
Enterprise Health Management Platform
Region Update by
Marcia Pickard
October 8, 2014

2. Definitions: Program and Products*
Definitions: Program and Products
VistA Evolution is the joint Office of Information and Technology (OIT)-Veteran Health Administration (VHA) program to refresh VistA.
VistA 4 is the featured product
Technical approach is to keep parts of current VistA and gradually add more modern and flexible components to allow more rapid, higher quality, less expensive addition of new functionality.
VLER = Virtual Lifetime Electronic Record System
VistA Evolution
VistA 4 (Clinical Systems)
VLER Interoperability
Population Management & Analytics
Top level coordinates
among product lines
Program
Product Lines
This product line is pre-decisional
Patient-centric, Team-based, Quality-driven

3. 2014 2015 2016 2017 2018 VistA 4 Product Roadmap Colleague EHR
Gen 4: Advanced systems that provide substantial functionality for nurses, physicians and pharmacists; have more decision support and workflow capabilities along with tools that permit providers to more easily bring Evidence Based Medicine to the point of care.
Colleague EHR
(Gartner Gen 4)
Care Coordination
Interoperability and Improved Care Management
Core Care Management and Office of National Coordinator (ONC) Certification
Initial Care Management Capabilities

4. Before VistA Evolution – The Health Informatics Initiative (hi2)
“Transform Healthcare Delivery through Health Informatics” (Health Informatics Initiative or hi2) was created by Secretary Shinseki in May 2010 with these missions:
Provide foundational Information Technology (IT) and Informatics components for Veterans Health Administration (VHA)’s transition from a medical model to a patient-centered model of care.
Build a sustainable collaborative approach, capacity, and tools to deliver informatics solutions to transform health care delivery to Veterans through three major projects or Workstreams.
Build a platform and functionality to support collaboration with VistA Evolution and Computerized Patient Record System (CPRS) – Health Management Platform (HMP)
Transforming Health Care Delivery through Health Informatics (hi2) is a VA Major Initiative launched in September, hi2 will shape the future of VHA health information systems through deliberate application of IT and health informatics to deliver solutions, improves quality and accessibility while optimizing value. The newly formed VHA Office of Informatics and Analytics (OIA) ultimately will incorporate both the clinical and business functions of hi2.
The Initiative supports establishment of cross-cutting health informatics tools designed by health professionals to optimize performance in terms of quality, efficiency and increased job satisfaction. It encourages and facilitates increased patient and family engagement in care and decision-making; and support population and evidence-based care focused on preventive and chronic disease management.  In FY12, the Initiative will continue to develop the infrastructure / framework to support a predominantly web-based Electronic Health Management Platform plus a Software Development Kit - enabling contributions from other software development sources.  Additionally, it will establish a sustainable workforce capacity to support healthcare modernization and improved care delivery. The workforce capacities component will build on agency successes with continued development of informatics career paths and standard position descriptions. It will also deliver additional informatics coursework and improve coordination and communication strategies amongst VA Health Informaticists.

5. Health Management Platform (HMP)
Hi2 committed to providing HMP capabilities to two sites by Sept (IOC carryover from iEHR milestone)
Commitment was met by production implementation of HMP at San Diego, Hampton and San Antonio, including these capabilities:
Google-like Search across patient records
Improved Medication Review
InfoButton links to external medical references
News Feed
Tasks
CPRS classic views
HMP currently complements but does not replace any part of CPRS.

6. Enterprise Health Management Platform (eHMP)
Large contract award to ASMR/Agilex in September – referred to as UX (User Experience)
HMP code has been provided to ASMR/Agilex to serve as the foundation for the enterprise product (eHMP). VPR is being reused, but the UI is a new start.
Hi2 team has transitioned from initiative status, merging with Dr. Nichol’s office – Health Solutions Management – effective October 1, 2014, and will continue to contribute code to eHMP

7. eHMP and eVPR
The combination of the HMP, JLV and User Experience teams’ efforts will become Enterprise Health Management Platform (eHMP)
Will become the eventual CPRS replacement
eHMP will be a Product that consists of multiple components: eHMP GUI, Enterprise Virtual Patient Record (eVPR), and Vista Exchange
VistA will continue to be an authoritative data store where it is so today

8. Enterprise Health Management Platform (eHMP)
eHMP User Experience
Vista Exchange
Clinical Decision Support
Context Persistence
Orders Selection Service
Orders Management Service
Data Annotation Service
Clinical Workflow
Concept Relationship Service
Documentation and Text Search Service
Business Rules Management System
eHMP Services
Middle tier Components
JLV View
CPRS Features
HMP IOC Features
ONC Certification Features

9. eHMP – User Experience
eHMP will provide end user clinical encounter and care coordination transaction capabilities, data visualization, and decision support integration between Provider, Patient, and System facing components and devices. Different capability configurations will be available based on user roles. eHMP will:
become the eventual CPRS replacement
maintain the joint VA/DoD JLV functionality
provide new clinical functionality
be used for ONC 2014 edition certification

10. VistA Exchange and eVPR
VistA Exchange is the VistA 4 clinical application data services engine, providing an enterprise Virtual Patient Record service (eVPR) optimized for the enterprise Health Management Platform (eHMP) and other point of care applications and workflows
eVPR includes information model binding, terminology normalization, knowledge enrichment, and search indexing for all available longitudinal patient record data aggregated from VA, DoD, and exchange partner sources.

11. Abstracted Architectural Roadmap
2014
2015
2016
2017
2018
Cut IT funding
Pop Health
Scalable architecture
Advanced decision support
Better user experience
Add data abstraction layer
External applications
Native standardized data
eHMP
Replace some VistA applications
Enhance VistA database and some VistA applications
Critical fixes
VistA Base
Enhance interoperability (get data from external providers)
Standardize clinical terms
VLER
Patient-centric, Team-based, Quality-driven

12. eHMP FY 14-16 PSI Functional Roadmap (Proposed)
PSI-6 Nov 18 – Feb 23 ‘15
Tasks
CPOE
Drug-Drug/Drug-Allergy Interaction
Drug-formulary Checks
eSignatures
Documentation
Immunizations
Smoking Status
Info Presentation
Persist user references
User-defined views/filers
CPRS Graphing
Patient Inquiry/Insurance/MHV
T.O.C.
Receive, Display, and Incorporate TOC
Create/Transmit TOC
CDS
Open CDS
PSI-7 Feb 24 – May 18 ‘15
Tasks
ePrescribing
Documentation
Clinical reconciliation - Med reconciliation
Info Presentation
VistA Web Health Summaries/Report
VistA Imaging
CPRS Graphing
Reports CPRS
T.O.C.
Clinical Summary (AVS)
CDS
ONC CDS
PSI-8 May 19 – Aug 24 ‘15
Tasks
Orders/Tasks
Documentation
Amendments
Note objects
Free text notes & old note objects
Info Presentation
Image Viewer
Printing
CPRS Graphing
Reports CPRS
T.O.C.
Data Portability
Clinical Summary (AVS)
CDS
Patient Specific Education
Open CDS other
Authoring
Concept Relationship
Other CDS
Workflow Management
Care Plan Basic

13. eHMP FY 14-16 PSI Functional Roadmap (Proposed)
PSI-9 Aug 25 – Nov 17 ‘15
Tasks
Order sets
Quick orders
Order Menu
Formulary Restricted
ePrescribing
Documentation
Progress Notes Modernization
Documentation Kit [Legacy/New]
Family History
Smoking status
Functional Status
Annotation*
Encounters
Templates, fields, objects
Info Presentation
VBA User
Printing
Reports CPRS
Concept-driven displays
PSI-9 Continued
CDS
Clinical Reminders Replacement – KBS help?
Other CDS
Concept relationship authoring
Workflow (CDS support)
Care Plan
PSI-10 Nov 17 – Feb 22 ‘16
Tasks
Order authoring
Order sets
In patient meds for Outpatient
Documentation
Progress Notes Modernization
Dialogs [Legacy/New
Info Presentation
Printing
CDS
Clinical Reminder Translation - Contract?
Other CDS
Workflow (CDS support)
Care Plan

14. eHMP FY 14-16 PSI Functional Roadmap (Proposed)
PSI-6 Nov 18 – Feb 23 ‘15
VPR Sync
Sync Overhaul
Cache update on write-back
Support CDS to update RPCs
User Identity & Access Services
ABAC
User Repository
User Provisioning
ONC Audit
Performance
VistA Routine Dep
Split Resource Server (clusters)
Monitoring
System Monitoring
External Integration
jMeadows
NwHIN
DoD Adapter
VPR APIs VX Patient record
VSA Spike
PSI-7 Feb 24 – May 18 ‘15
User Identity & Access Services
SSO/PIV Authentication
Performance
SOLR
PEP
Authentication Validation in parallel
Monitoring
Production Level Monitoring (similar to JLV)
External Integration
jMeadows
VSA
DR/Failover
2 sites
PSI-8 May 19 – Aug 24 ‘15
Performance
Concept Searches
Reverse Proxy Change
External Integration
VSA
PSI-9 Aug 25 – Nov 17 ‘15
DR/Failover
Multi site

15. Modularity and SDK in eHMP
Development modularity and services will exist at multiple levels – user interface, middle tier, data levels
Software Development Kit (SDK) will be made available to the community.
The SDK is comprised of:
Application Development Kit (ADK) to drive development of the client-side web application. Build using JavaScript, backbone.js, marionette, bootstrap. Resulting application is SPA, static HTML served from web server (no J2EE server)
Resource Development Kit (RDK) to drive the development of service side resources (web services) to support the web application. Build using JavaScript, express.js. Deploy to node.js; relies on npm for package management.

16. eHMP Application Development Kit (ADK)
ADK provides mechanisms for applet developers to
Discover the current patient
Fetch patient data from vista exchange, can use canonical model (based on VPR) or provide custom "view" model
Bind data to backbone views, provide templating
Choose preselected display paradigms (tableview, etc) and UI controls. UI style set by application
Create three different "size" views to support responsive / adaptive design
ADK provides mechanisms for screen designers to
Create a screen, choose from predefined layouts and assign applets to regions
ADK provides for application designers
Runtime UI shell for application. Displays current patient, current user. Provides navigation
Mechanism to choose the screens that are part of the application
ADK also provides
CI pipeline/devops for pulling applets/screen configurations from artifact repository, compiling, packing, testing, and publishing to artifact repository. This produces a CM-ed version of the web application (which includes specific version of applets)

17. eHMP Resource Development Kit (RDK)
Resource = a single web service (e.g., save allergies)
Resource Family = collection of resources
Resource Server = deployable unit, including a family and configuration
RDK for resource developers
Configuration of the resource family
For each resource, specifies relative mount path and method using standard express signature function(request, response, next)
Specifies resource characteristics (sensitive, audit information)
Request provides resource information about the request: url, path parameters, query parameters, header, current user, access to RDK utility methods, access to current resource server, configuration information, logger
Response provides resource ability to send response: status code, json or text body, media information
Resources with handles to common external systems, including JDS, VistA(s), solr search engine

18. eHMP Resource Development Kit (RDK)
RDK for deployment engineers when creating a resource server
Group resources into a logical deployment unit called a resource server.
Specify how many processes using cluster/fork
Deployment engineer chooses which resource family should be registered using: (show code)
Resource Server deployed behind a reverse proxy (apache httpd) for load balancing
Ability to enable: authentication, authorization/PEP, audit
Specify logging rules, configuration, resource caching rules
Routes calls to resources based on URL and media type (content-negotiation)
Provides health check (binary and discrete information) based on each resource registered. Deployment engineer can specify additional health check rules.
RDK also provides
Centralized dependency management
Automatic creation of resource directory
CI pipeline/devops for pulling applets/screen configurations from artifact repository, compiling, packing, testing, and publishing to artifact repository. This produces a CM-ed version of the web application (which includes specific version of applets)

19. Logical View of Patient Encounter – VistA 4 (Simplified)
‘Local’ VistA
RPC
CALLS
(WRITE)
eHMP
integrates
HMP/Mobile/JLV
Team – Patient - System
RPC Broker
READS – (VDEF, RPC and FMQL)
VistA Shadow
Remote
VistA
Terminology Service
CDS Support
Services
VistA Exchange
SFC(Ret) Smith’s Care Team
READS
Future Services
(ie., Orders)
Future Services
(Knowledge Base)
Remote
VistA
READS
Access
Management
Identity Management
MHV
CDW
VINCI
VLER DAS
Consent
Management
FHIR VA
DoD
Partners
VA Partner
DMIX / DHMSM HIE
VA Partner
MDR
BHIE SHARE
AHLTA
DHMSM
VA Partner
CHCS
DoD VLER ADAPTER
HSDW
DoD Partner
Essentris
DoD Partner
CDR
PDTS
DoD Partner
ESB connections
(with VSA services)
DRAFT