Modifying An Open-Source Information Extraction Tool To Identify RadLex .

VA OrganizationDepartment ofVeterans Affairs(VA)Veteran’s BenefitsAdministration(VBA)Veteran’s HealthAdministration(VHA)National CemeteryAdministration(NCA)Courtesy of Kevin Meldrum

Veterans Affairs - VHA

VHA Facilities 163 Hospitals800 Clinics135 Nursing Homes43 Domiciliaries180,000 Healthcare Professionals Serving 6 Million Veterans per YearCourtesy of Kevin Meldrum

VHA Volume Hospital sizes vary from 100 to 1000 beds. Outpatient visits vary at each facility from30,000 to 450,000 visits per year 46.5 million outpatient visits per year 564,000 inpatient admissions per year 167 million prescription-months filledCourtesy of Kevin Meldrum

VistA:In Every VA Medical Center For 15 years!6

2006 – Innovation Award for VistAVA’s Electronic Health Record (EHR)7

Achievements The VA’s EMR been estimated to improveefficiency by 6% per year Pharmacy prescription accuracy hasimproved to 99.997% VA hospitals only 1/13 systems that haveachieved HIMSS stage 7, the highest level ofrecord integration Public domain software available through thefreedom of information act directly from theVA’s website or network of distributors8

History of VistA 1977 – 1981 “The Underground”1980s – Service Focused Software1990s – Physician Focused Software1997 – Release of Computerized PatientRecord System (CPRS) www.hardhats.orgCourtesy of Kevin Meldrum

Database Developed using M or MUMPSlanguage/database– Runs on InterSystems Cache version of MUMPS– Open source engine called GT.M for Linux and Unixcomputers is available10

VistA:A Chart Metaphor Combining Text and Images000-505000Single longitudinal health record isimmediately available in Outpatient Inpatient & Long-term care settings000-50500011

VistA Imaging Integrates images with the electronic medical record Can be used independently or integrated into VistA Includes– Radiology– EKG’s– Pathology– GI lab– Dermatology– Wound Care– Scanned Documents12

From A Few Sites To The Largest Health CareSystem In The U.S. Under One ManagementIn The BeginningNIST (Then NBS) was asked to turn the existingsystems-technology strategy into a systemsarchitecture designDr. John Chase, the VA’s Medical Director agreed to deploy the system atthe VA HospitalsDr. Robert Kolodner (later the National Health Information TechnologyCoordinator) and George Timson were involved since 1977– 1978 - Minicomputers sent to about 20 VA MedicalCenters– 1979 - “Underground Railroad” formed referred toas conspirators against the enemy13

DHCP - Hospital Information System – 1981Congressman Sunny Montgomery arranged for DHCP to bewritten into law as a program at the VA– 1982 - Official deployment of core applications– 1993 - Order Entry / Results ReportingThe four major adopters of VistA (VA, DoD, HIS, and theFinnish Consortium) each took VistA in a slightly differentdirectionThe Finns actually were the first major adopter14

VistAElectronic Health Record (EHR) – Thename was adopted in 1994 under KenKizer– 1996-99 - CPRS (“Clinical Desktop”)– 2000 - Bar Code Medication Administration– 2004 – My HealtheVet(Personal Health Record – PHR)– 2010 – Blue Button (Data Download)

Bar Code Medication Administration (BCMA) Virtually Eliminates Errors at the Point of AdministrationBCMA Assures the:Right MedicationRight DoseRight PatientRight ProviderRight Time16

Home TelehealthLargest telehealth programin the world60,000 veterans receivedtelehealth services in 201117

VA Provides My HealtheVet:A Personal Health Record For Veterans18

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VA Conceived of and Provides:“Blue Button”20

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Blue Button Apps Competition

VISTA Layered ApproachCPRS Graphical User InterfaceVistA Health RemindersVistA Core PackagesA/D/TBillingLaboratory Pharmacy RadiologyNursingAppt MgtEnrollmentDieteticsEtc.VistA KernelMenuTreeAccess &PrivilegesDataJobMessagingDictionary SchedulerMUMPSMUMPS ProcessesMUMPS DataCourtesy of Kevin Meldrum

CLINICAL PATIENT RECORDVISTA SOFTWARE PACKAGESVistaIMAGINGMEDICALRECORDSADMISSION TRACKINGVOLUNTARYSERVICEINTEGRATED DATABASEPERSONSBLOOD RSURGERYBAR SCRIPTIONSMEDICINEAUTHORIZATIONSUBSCRIPTIONUTILITY RMACYIMAGESMEDICAL CARECOST THSCHEDULINGPROBLEMLISTSOCIAL WORKDENTALTEXTINTEGRATIONUTILITIES ACYFUNDS CONTROLACCOUNTING &CONSULTS y of Kevin Meldrum

http://www.ehealth.va.gov/EHEALTH/CPRS Demo.asp

Lessons LearnedUser Involvement is ESSENTIAL Discover major innovations by front line users/developers Learn from the “Positive Deviants” Start with the Early Adopters Include users at all stages32

Major Innovations from Local UsersBar Code Medication Administration (BCMA) 1992 - the idea of Sue Kinnick, RN –a Nurse at the VA Medical Center in Topeka, Kansas VA wide by 2000 Now going nationwide in U.S. How many lives saved andadverse outcomes avoided?33

VISTA Web34

VistAWeb Overview Intranet web application used to view remote patientinformation found in VistA, Department of Defense (DoD)and the Health Data Repository (HDR) databases. Alternative to CPRS Remote Data View (RDV) Queries the Health Data Repository (HDR)– access to patient clinical data residing in theHDR-Interim Messaging Solution (IMS) and HDR-Historical– Allergies, Vitals, Outpatient Pharmacy VistaWeb servers and software are maintained inSilver Spring, MD.35

History Initially developed as “class III” (homegrown) software in Ann Arbor (VISN 11) Converted to nationally supported “class I”software and released in Spring of 200536

Ways to Access VistAWeb Remote Data Buttonin CPRS CPRS Tools Menu Standalone webpage (URL)–example next slide37

VistaWeb Access via websiteIn Internet Explorer enterhttps://vistaweb.med.va.gov/Select yourVISNand then yourVAMC “site”Then .Enter yourACCESS/VERIFYCodes

1996 – Test Site for CPRS at the VA Medical Center in Seattle, WA39

Importance of User Input and Integration into WorkflowClinical Reminders Dialogue BoxVA’s Clinicians:"Have Clinical Decision Supportalerts/reminders fit OUR workflow."40

Transition in the 90’s Major challenges included– Required physician entry of data but majorityof physicians did not know how to type– Brought focus away from the patient and to theterminal/workstation and room design andergonomics were such that this meant lookingaway from the patient41

Major Challenges– Performance was slow and became increasinglyslow until much additional hardware wasthrown at the system– Training was a major challenge because of thelimited hours available for physicians to betrained on the system– Difficulty with the transition from paper to theelectronic record; for a period of time needed tohave information from both systems

– Additional versions came out quickly and it wasdifficult to keep up– Lack of ability to provide feedback for specificissues except at a national level andprioritization was done nationally43

– IT (IRM) became a vendor for PACS using VistAimaging and ended up competing withcommercial systems and this made them slowto interface to commercial systems System plays relatively poorly with third partysystems Would very much like to have an API to be able tohave software find information within the system– Database very unfriendly to perform searchesfor information

– Sign on process very slow and requires sign-inat workstation as a windows user and then signin to CPRS which required separate processesand then another sign in to use the VistAimaging system Users would not sign-out and this created securityissues Could take 5 minutes to sign in and sign out andmajor issue when going from room to room

– Despite national system no standards for howprogress notes, radiology codes, and otherthings are coded and so difficult to share data– Despite many efforts, difficult to transferinformation from one VA hospital to anotherespecially across VISN’s and ability to shareinformation between VA and DoD surprisinglyconstrained with no real ability to share images– VA imaging was one of the last systems toutilize DICOM standard and was based onpathology TIFF solution46

What Was Really Good About VA’s VISTA CPRS Windows interface made access andsearching for information easy and patientinformation was ubiquitously availablethroughout the enterprise Ability to plot laboratory data made it mucheasier to do trend analysis Chart metaphor made it easier forphysicians, nurses, etc. to make transitionfrom paper chart to EMR47

Images from all modalities including pathology,dermatology, ophthalmology, GI lab, OR, medicaldocuments in addition to just radiology andnuclear medicine All healthcare providers were mandated to useVISTA and to do physician/provider order entry– Transcription was supported for a brief period of timefor attending physicians only but this was eventuallyphased out– This was easier because the majority of progress notesin the VA were written by residents and fellows ratherthan VA attending physicians.

Intelligent System System does not incorporate intelligence Iwould like to see in 2013 system– Spell and grammar checker– System doesn’t learn from my habits and acts asthough it is meeting me for the first time eachtime– System doesn’t allow me to search and list asubset of my patients

– System organized like paper chart withextremely limited search capability within asingle patient and none across multiplepatients Can not search within a patient’s record forinformation easily; later versions had primitive textsearch but was very difficult to find instances, say ofrash in a patient50

– Clinical alerts/reminders information overloadwith minimal intelligence with regard topresentation and ordering of these– No good messaging system but instead requiresusers to sign onto VistA but physicians rotate inand out from University of Maryland

Issues 52Radiology package old terminal emulator and little done to enhanceAlert fatigue, alerts not presented in intelligent mannerSystem does not recognize or learn from meNot well integrated with third party software and difficult to add additional 3rdparty software

Look into core measures monitoring butseems limited and little in the way ofdecision support for diagnosis or treatment Sign in and sign out difficult Can’t really search within or amongdifferent patient records to find similarpatient

Things such as pain not in the system Different ways progress notes, radiologystudies, etc named across the system Designed like chart not optimized to besmart and searchable and intelligent andspecific to needs of the user

Clinical Decision Support VISTA does a great job monitoringperformance retrospectively:– Patients whose BP is within parameters– Counseling given for smoking cessation– Diabetics given tests for diabetic retinopathy However next generation systems shouldassist in diagnostic and treatment optionsin a real time fashion55

text integration utilities (tiu) outpatient pharmacy clinical patient record authorization subscription utility (asu) bar code medication administration women's health blood bank problem list vista consults / result tracking clinical reminders medical care cost recovery courtesy of kevin meldrum