enabling health care efficiencies via an interoperable health record paul tibbits deputy cio for...
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Enabling Health Care Efficiencies via an Interoperable Health Record
Paul TibbitsDeputy CIO for Enterprise DevelopmentDepartment of Veterans AffairsNovember 12, 2009
Interoperability: Current and Planned
3
Current State
KEYKEYCurrent Sharing (Viewable)
Planned Sharing (funded)
Potential Sharing (unfunded & uncosted)
Current Sharing (Computable)
Potential Sharing (VA funded; DoD identified funding requirements – FY09 supplemental)
On Contract
Potential Sharing (DoD funded)
BEC IS/IT WORK GROUPBEC IS/IT WORK GROUPHEC IM/IT WORK GROUPHEC IM/IT WORK GROUPAccessions & Separations
Combat Military Pay
Activation / Mobilization
MGIB Eligibility Information
Add’l Education Benefit Data
UIC Mailing Address Data
Military Pay Information
Insurance/ Benefit Eligibility
MGIB Program Usage Data
Military Service Imaged Record via DPRIS
Compensation & Pension Data
Member / Veteran Family Member Information for Insurance and Cemetery Benefits
Defense Center of Excellence
(DCOE)
Research Clearing / Data-
mart (LOA2)
TBI Patient Registry (LOA2)
TBI / PTSD Telehealth
Consult (LOA2)
Phase 1 of Common
Services Initiative
Phase 2 of Common
Services Initiative
Non-Clinical Case Mgmt.
(LOA3)
Web-Based FIRP (LOA3)
VA Disability Exam Templates
(LOA1)
Imaging - Theater (LOA4)
Reserve Health Records Access
(LOA4)
Cognitive Assessment Tool
(LOA2)
Clinical Enhancements
Web-Based Training (LOA2)
TBI Extender Codes (LOA2)
Behavioral Health Notes
(LOA2)
Plan Completed Jun 08
Images (Enterprise-Wide)
DoD and VA Shared Health
Data
Post-Deploy Reassessment
Std Ambulatory Data Record
Problem Lists
Additional Inpatient Data
Discharge Summaries
Post-Deploy Assessment
Procedures
Vital Signs
Allergy Data
Radiology Reports
Operative Reports
Other History
Pharmacy Data
Inpatient Consults
Theater Clinical Data
Social History
Pre-Deploy Assessment
Lab Results
Provider Notes
Family History
Questionnaires
Interoperability Plan, V 1.0 Completed Sep 08
Add’l Data Elements (Viewable)
Add’l Data Elements (Computable)Sep 09
Sep 09
Sep 09
Sep 09
Oct 09
Document Scanning (initial)
Inpatient Documentation Expansion
Gateways - Data Migration
Expansion of Questionnaires
Lab Results (computable)
Plan Completed Jun 08
Interoperability Plan, V 1.0 Completed Sep 08
Images (Enterprise-Wide)
Add’l Data Elements (Viewable)
Add’l Data Elements (Computable)
DoD and VA Shared
Personnel / Administrative
Data
eBenefits Portal (LOA4)
Dis Eval Sys Pilot - VTA Tracking
(LOA1)
Wounded Warrior Indicators (LOA4)
Clinical Case Mgmt. (LOA3)
ADT to DFAS (LOA8)
Document Mgmt. System
(LOA1)
4
North Chicago – Captain James A. Lovell Federal Health Care Center
• First FHCC managed jointly by VA and DoD
• Opening Day October 2010
• On Schedule• Provide Information
Management/Information Technology
• Key to establishing VA/DoD electronic health record
Ambulatory Care Center site
Other Government Agencies
Other Government Agencies
Beneficiary / StakeholderBeneficiary / Stakeholder
Managed Care / Fee Private Providers
Managed Care / Fee Private Providers
5
DoD VACommon Services
DoD Unique Data Ex: Enrollment, Operational/Theater Information
VA Unique DataEx: Extended Care Data, Veteran/Dependent Benefits
Proposed Future State
Accession
Training
Readiness
Deployment
Education
Personnel
Data Compensation
Medical Care:
Theater &
Home
Separation
VA Extended
Care
Memorials
Survivor
Benefits
Army
Navy
Marine Corps
Air Force
JOINT
Health | Benefits | Personnel
Virtual Lifetime Electronic Record
VHA
NCA
VBA
Identity Management
Self-Service Logon
Compensation
Benefits & Eligibility
Education
Portable Order Entry
Single Sign-OnPharmacy*
Consults
Lab*
Radiology*
Service History
Other Uniformed Services
Other Uniformed Services
* Orders and results
Nationwide Health Information NetworkHealth Bank or
PHR Support Organization
Community #1
IntegratedDelivery System
Community Health Centers
Community #2
CDC VA
CMS
DoD
SSA
State and Local Gov
Labs
Pharmacies
The Internet
Standards, Specifications and Agreementsfor Secure Connections
Mobilizing Health Information Nationwide
Architecture and Technical Challenges
Top 10… SOA General Misconceptions
10. Orchestration = dynamic discovery = dynamic consumption9. Configurable = loosely coupled8. Identity is Identity, and there is only 17. SOA is a “Big Bang Theory”6. Granularity of services is easy to define5. Standards and Specifications compliance is strictly defined4. WSDL exchange = interoperability3. Security and auditing can be retrofitted2. Service-Oriented Architectures are primarily a technical or
management approach
And the #1 General misconception is…1. SOA is the answer to interoperability (and you can buy one)
Approaching Service Orientation• Strategic Governance needs to
enforce the “design by standards” approach versus “design by product” across the Enterprise
• Critical elements required to scale Tactical Governance Model
– Enterprise review boards– Programmatic Governance
Boards: Enterprise Management Processes
– Functional Governance Boards: portfolio and capability establishment
– Technical Governance Boards• Roadmap for core services
utilized by all development efforts
• Reference Architecture to enable experimentation and development including Standards, Specifications, Patterns and Practices (SSPPs)
VA Internal Use Only 9
FEA
Infrastructure Components
Information & Data
Applications
Services
Business Components (Functions, Sub-functions, and Capabilities
Strategic Goals & Objectives Eight for
Excellence
Eight for Excellence
VHAVHA
Domains of Value
Domains of Value
MedicalResearc
h
MedicalResearc
h
MedicalCare
MedicalCare
MedicalEducatio
n
MedicalEducatio
n
Care MgmtCare Mgmt
EmployeeHealth Record
EmployeeHealth Record
Sub-Function
1
Sub-Function
1
Sub-Function
2
Sub-Function
2
Sub-Function
3
Sub-Function
3
Sub-Function
4
Sub-Function
4
Information Element 1
Information Element 1
Service 1Services
2Service n…
Service 1
Service 3
VBA Service 4
NCAService 6
Composite Apps
Messaging
Discovery Security
Core Services
BRM
DRM
SRM
TRM
PRM
ESM
Information Element 3
Information Element 3
Information Element 4
Information Element 4
Information Element 2
Information Element 2
Information Element 5
Information Element 5
Information Element 6
Information Element 6
VBAVBA NCANCA
VBAStrateg
y
VBAStrateg
y
NCAStrateg
y
NCAStrateg
y
VBALines of Business
VBALines of Business
NCALines of Business
NCALines of Business
VBABusiness
Area
VBABusiness
Area
NCABusiness
Area
NCABusiness
Area
VBASub-Functions
VBASub-Functions
NCASub-Functions
NCASub-Functions
VBAInformation
Element
VBAInformation
Element
NCAInformation
Element
NCAInformation
Element
VBAService
6
NCAService
6
VHAService
VBAService
VBAService
NCAService
VBAService
NCAService
E-SOA Governance
VA Pillars Governance
RequirementFramework
RequirementFramework
OrganizationalGovernance
OrganizationalGovernance
OpenCommunity
Process
OpenCommunity
Process
BusinessProcess Modeling
BusinessProcess Modeling
Data Strategy
Data Strategy
MetricsMetrics
Test &Assessment
Test &Assessment
Certification &Accreditation
Certification &Accreditation
DeploymentStrategy
DeploymentStrategy
Education &Training
Education &Training
Technical Standards
Example: Chapter 33 Tactical Governance• Implementing Governance for Chapter 33
– Established OED / Chapter 33 Architecture and Engineering Governance Board– Established ESOA / Chapter 33 Architecture Integrated Product Team (IPTs) to
manage issues in key areas• Security, Architecture, Infrastructure
VA Internal Use Only 10
ESOA / Ch 33 Arch IPT Charter
OED / Ch 33 Arch-Eng Governance Board Charter
SPAWAR (Chair)Ch 33 Technical Team
VBA-SEEIE
OED-SE
OED-SE (Chair)VBA Architect
PM RepEIE Rep
BOIBI RepField OpsSecurity
• Identifying and managing critical gaps in Governance for Chapter 33
– Process and artifacts that:• Identify connection to systems outside CH33• Determine responsibility for changes to these
systems• Determine service agreement type• Enable CH33 service deployment and
certification
• Developing service-oriented Standards, Specifications, Patterns and Practices (SSPP) and an associated reference implementation of core services
Chapter 33 Tactical Governance
Chapter 33 Governance Model is scalable to the Enterprise level
Innovation
Innovation Components
Greenfield Incubation—field innovators propose new opportunities
Strategic Incubation*—leadership identifies opportunities Innovation Diffusion—evaluation of the quality of products
and how products work in the healthcare delivery process Collaborative Tools—technologies used to advance
innovation and encourage the building of communities of interest
Workforce Development—activities undertaken to build a culture of innovation and a knowledgeable workforce
VA OI&T Innovation Advancement Program (IAP)
*cross-Administration strategic initiatives to be undertaken; points of contacts have been identified
12
Innovation Evaluation• Innovation criteria
– Improves patient care (e.g., safety, quality or access)– Improves efficiency (e.g., clinical workflow or cost/benefit)– Impacts numerous Veterans, staff or other stake holders– Addresses an unmet need rather than incrementally improves existing methods– Helps meet an organizational requirement (e.g., Joint Commission or Congressional
mandate)
• Three review teams, five reviewers per team with multi-discipline and leadership level mix
• Preliminary Review Process:– Addressed Conflicts of Interest – Randomly assigned LOI to teams– Used blinded independent review with established Innovation Evaluation Criteria on 1-5
scale– Group discussed and determined final scoring
• Final Review Process and Criteria: – Same review teams, evaluated full proposals– Benefit factors: Quality, Efficiency, Scope, Novelty, Requirement– Feasibility factors: Team, Approach, Environment
Greenfield Award Overview
Category
Reviewed LOIImpactingCategory
AwardsImpactingCategory
AwardPercent
Administrative 114 29 25%
Clinical 159 43 26%
Education 56 21 38%
Other 34 9 26%
Veteran Direct Impact 124 36 29%
44 TOTAL CONCEPTS SELECTED FOR FUNDING
Program Management and Acquisitions
16
Analysis of Ongoing VA Programs
• 280+ programs reviewed• 8 program attributes analyzed• Many programs exhibited signs of trouble
– Greater than 13 months behind schedule– Greater than 50% over initial cost estimate– Decrease in software quality between releases– Inadequate skills to complete program
• Substantial change required
17
Incremental Development
• All new VA IT projects/programs must use an incremental development approach– Frequent customer delivery milestones at maximum of six months– Customer must test and accept functionality
• To be approved for investment, a program or project must have:– An identified customer sponsor and integrated project team (IPT)– Program plan that documents frequent delivery milestones– Documented, agreed to requirements for initial milestones– Clear plan for necessary program disciplines– Clear access to necessary program resources– Customer, program, and vendor acceptance of PMAS– Jointly established success criteria
18
Program Management Accountability System (PMAS)
• All incremental development programs will be managed rigorously to schedule– A program/project will be halted on its third missed customer delivery milestone
• Once halted, substantial changes must be made before the program can restart– Need for program/project will be re-assessed– Program approach will be re-assessed– Make/buy and program design decisions will be re-assessed– Program management assignment will be revisited– Government staff assignments will be revisited– All service contracts will be re-visited– New program plan must be approved
• Flexibility can be earned
Collaboration is key to IT success.
Acquisitions•Established a dedicated acquisition office to
support OIT program planning and execution•Provide life cycle acquisition support from
program inception through completion by a multi-functional IPT
•Implementing joint Program Management Reviews to improve contract performance and program execution
•Collaboration with industry through early involvement of requirements and transparency
Acquisitions plays a dedicated and integral role in project IPTs.
Conclusions
• Investment vs. Value
• Consensus of IT “Sellers” and “Buyers” on Business Need
• Need for Incentives
• Information Interoperability
• Collaboration at all Levels Essential
• Rigorous Program Management and Acquisitions Process