1. LEVERAGING INFORMATION SYSTEMS TO TRANSFORM PATIENT CARE AT Central Arkansas Veterans Healthcare System MICHAEL WINN, MEDICAL CENTER DIRECTOR MARGIE SCOTT MD, CHIEF OF STAFF

2. A flagship Department of Veterans Affairs (VA) healthcare provider, CAVHS is one of the largest and busiest VA medical centers in the country with 551 operating beds. In FY 2010, CAVHS treated 77,136 unique patients which included: 738,245 Outpatient Visits 27,942 emergency department visits 12,430 Patient Discharges

3. CAVHS Mountain Home Hot Springs El Dorado CAVHS Little Rock/ North Little Rock Mena Medical Center Outpatient Clinic CAVHS provides services to our veterans through 8 Community- Based Outpatient Clinics (CBOC’s) El DoradoConway Hot SpringsRussellville Mena Mountain Home Pine Bluff Searcy CAVHS provides a comprehensive spectrum of inpatient and outpatient healthcare services within the Little Rock and North Little Rock facilities. CBOCs offer our rural veterans the following services close to home: primary care, mental health, wellness care, social work, teleretinal imaging, laboratory, radiology, pharmacy. Pine Bluff Searcy Russellville Conway

4. CAVHS CAVHS serves as a teaching facility for more than 1600 students and residents enrolled in approximately 90 educational programs. Affiliations: University of Arkansas for Medical Sciences (includes the College of Medicine, Nursing, Pharmacy, Public Health and Health Related Professions); plus other additional educational affiliations

5. VISN 16 As part of VISN 16, CAVHS serves about 170,000 veterans residing throughout 46 counties in Arkansas.

6. Programs –Ambulatory Care –Audiology & Speech Pathology –Complex Laboratory Services –Emergency Medical Services –Home Health Care Services –Medical Services Cardiology Dermatology Endocrinology Gastroenterology Hematology/Oncology Nephrology Pulmonary Renal Respiratory Care Telemedicine –Neurology –Nuclear Medicine –Nutrition and Food Services –Physical Therapy –Primary Care Services –Radiology –Surgical Services Ambulatory Surgery General Surgery Thoracic Surgery Vascular Otolaryngology Neurosurgery Ophthalmology Orthopedics Urology GYN Plastic Podiatry Operating Beds: 195 Type of Facility: Tertiary Care Little Rock Campus John L. McClellan Memorial Veterans Hospital

7. North Little Rock Campus Eugene J. Towbin Healthcare Center Special Programs Comprehensive Homeless Program Dental Services Geriatric Services Adult Day Health Care Community Living Center Respite Community Residential Care Senior Companions Independent Living Alzheimer's Chronic Mentally Ill Geriatric Research, Education and Clinical Center Home Health Care Services –Mental Health Services PTSD Special Treatment Section Residential Rehabilitation Treatment Program Veterans Industries/Transitional Residence Program Inpatient Psychiatry MHICM Psychiatric Telehealth –Physical Medicine & Rehabilitation –Primary Care Services –Prosthetic & Sensory Aids Services –Research Operating Beds: 356 Type of Facility: Primary Care, Extended Care, Rehabilitative Care, Mental Health Care

8. CAVHS DATA DRIVEN---- FOR BETTER DECISIONS

9. WORLD CLASS INFORMATION SYSTEM DATA WAREHOUSE VSSC VistA CPRS WEB SERVICES BWATP?

10. VistA CPRS CPRS Computerized Patient Record System BWATP?

11. CPRS TOOLS FOR MEDICATION RECONCILIATION JOINT COMMISSION STANDARD MUST OCCUR AT CHANGES IN MEDS, LEVELS OF CARE e.g. admission, transfers and discharges Opportunity to prevent medication errors, improve patient education Supplements Bar Coded Medication Administration (BCMA) safety features

12. STORM Involves physician, pharmacist and nurse Documentation occurs smoothly using pre-discharge order set that includes: – Meds to start, stop and changed dosing instructions. – Automatically generated pharmacist alert – Alphabetized list of all active meds (Outpt, Inpt, NonVA) – List automatically loads into Discharge Instructions – Discussed with patient by nurse.

13. EFFECTIVENESS Clearer instructions from physician Listing allows pharmacist to readily detect duplicate meds Facilitated patient instruction by nurse

14. EFFECTIVENESS cont’d

15. Med Rec Interventions By Pharmacists June 2009-March 2010 DRUG INTERACTIONS

16. VistA Veterans Health Information Systems and Technology Architecture BWATP?

17. VistA Data Extracts VistA is “real time” All other sources are retrospective (e.g. External Peer Review Program data is two months old) Allows for “concurrent” monitoring FY 2009 CAVHS struggling with a few performance measures that were clinical reminder driven. Reminders were enhanced and education provided Did not always help sufficiently Daily “automated “ reviews of Clinical Reminder completion began first quarter FY 2010

18. DAILY AUTOMATED CLINICAL REMINDER REVIEWS VistA Clinical Reminder due report template developed for 22 reminders. Half nursing driven Half provider driven Schedule to run each morning Patient-specific listing of missed reminders by clinic/provider generated and sent to provider or nurse caring for that patient. Corrections expected Missed reminders plummeted by 90% in two weeks

19. DAILY AUTOMATED CLINICAL REMINDER REVIEWS continued Weekly aggregate report also automated Weekly aggregate report also automated Put into dashboard containing: Put into dashboard containing: – 22 Reminders – By location and service, including CBOC – Targets Listed – Color coded (Blue=100%, Green=above target, Red=below target) – Present at 2 nd Morning report each Wed – Relevant service chiefs involved in action plans – Available to all staff, including CBOCs, via Web site

20. EXAMPLE OF WEEKLY DASHBOARD

21. RESULTS Four Examples

22. RESULTS One More Example

23. VSSC (VHA Support Services Center) BWATP?

24. USING VSSC DATA Excellent source of workload, performance measure, cost and other types of data Updated every two weeks Primary source is VistA Data available for each VA Medical Center, clinic, CLC, etc. Useful for management, performance improvement and strategic planning

25. TRACKING IMPACT OF CBOCS VSSC MARKET SHARE DATA

26. DATA WAREHOUSE BWATP?

27. DATA WAREHOUSING VISN 16 developed first data warehouse in VHA Used CAVHS IT staff Housed at CAVHS Advanced SQL Relational Database (relatively easy to learn by Non IT staff) Biweekly extract of VistA (e.g. outpatient visits, discharges, procedures, prescriptions, ancillary tests, diag codes, costs) Provider Dashboards developed in 2005

28. PROVIDER DASHBOARDS Individual dashboards for 70 physicians and APNs in Primary Care, Geriatrics, and Endocrinology Generated, distributed monthly Used to guide performance improvement and also performance awards

29. PROVIDER DASHBOARD EXAMPLE

30. PROVIDER DASHBOARDS continued Dashboards generated that aggregate performance results up to: – Each CBOC – Each division (Little Rock and North Little Rock) – Healthcare System (entire organization)

31. PROVIDER DASHBOARDS continued Example of a CBOC Level Tracking

32. PROVIDER DASHBOARDS Impact of Dashboards

33. DATA WAREHOUSING continued Example of special study Analysis of colonoscopy and biopsy results for patients: – With Positive FOBT leading to diagnostic colonoscopy – Screening colonoscopy by age and risk factors

34. COLONOSCOPY STUDY continued Data Warehouse environment facilitated complex analysis of multiple fields across several VistA packages – Clinical Laboratory (FOBT results) – Procedures (colonoscopy performed) – Tumor Registry (cancer staging) – Anatomical Pathology (tissue analysis, dysplasia or cancer present) Skills can be developed by non-IT staff VistA programming for similar analysis requires strong “M” programmer, limited to a few IT staff.

36. FY10 DUSHOM SYSTEMS REDESIGN Fee Services Initiative BETTER

38. FY10 CAVHS Systems Redesign OR 1 st Case Start Time Initiative BETTER

39. CODE FLASH STARTED

40. BETTER

43. RAPID RESPONSE TEAM Early adopter of this patient safety initiative Best practice according to VISN 16

44. Web Services BWATP?

45. LEVERAGING INFORMATION SYSTEM TECHNOLOGY FOR BUSINESS PLANNING CAVHS WEB ENTRY OF BUSINESS PLANS “BEST PRACTICE” - 2010 CAREY SITE VISIT TEAM CREATES INDIVIDUAL SERVICE BUSINESS PLANS FOR BUSINESS PLAN HEARINGS CREATES DATABASES FOR SWOC ANALYSIS, FTEE REQUESTS, FUND CONTROL POINT REQUESTS, EQUIPMENT NEEDS, PLANNING ACTIONS, ETC. BUSINESS PLAN HOMEPAGE

46. BUSINESS PLAN TRAINING SERVICES GIVEN GUIDANCE FOR COMPREHENSIVE JUSTIFICATION FOR RESOURCES

47. LISTENING TO OUR EMPLOYEES IMPLEMENTATION OF UNIT SHARED GOVERNANCE LEVERAGING SATISFACTION DATA

49. ALL HAZARDS EMERGENCY PREPAREDNESS TRAINING 2000-2010

50. DISCUSSION