Joint DOD & VA Virtual Patient Record (VPR) iEHR Enterprise Information Architecture (EIA)

I strongly believe VistA modernization must first-and-foremost focus on the requirements-specifications of the DOD-VA iEHR Platform’s Virtual Patient Record (VPR) information model, which supports the user experience GUI, clinical decision support (CDS), evidence-based medicine (EBM) and information exchanges across the DOD and VA; where, the VPR must have appropriate context, privacy and security meta-data tagging, as presented in the 2010 PCAST report; and, the VPR must support semantic web technologies, and the Resource Description Framework (RDF) format in particular.

2013 has a focus on the Data Interoperability Accelerators (DIA) efforts; where, there are seven data domains that are initially targeted for delivery in December 2013 and which directly support 2014 iEHR Informatics Integration and Interoperability Platform (i3P). These were determined to be both the most important data domains clinically, as well as the most important to provide terminology normalization in national standards – for purposes of improved clinical displays and clinical decision support capabilities. These seven domains are:

  1. Medications
  2. Allergies
  3. Lab Results
  4. Documents/Notes (encounter/visit notes, discharge summaries, operative reports, etc.)
  5. Immunizations
  6. Problem Lists
  7. Vital Signs

These seven domains are also included in the required data for transitions of care designated by the Office of the National Coordinator for Health IT (ONC) and the Department of Health and Human Services (DHHS) in their regulations for Meaningful Use Stage 2 (MU2), 2014 Certified Electronic Health Record Technology (CERT). Additionally, MU2 regulations require:

  • Demographics, including
    • identifying and contact information, plus
    • race, gender, ethnicity, preferred language
  • Encounter Diagnoses (inpatient and outpatient)
  • Social History (in particular, Smoking Status)

Further, MU2 regulations require that this health information be exchanged using the HL7 Consolidated Clinical Document Architecture (C-CDA) Implementation Guides for the Continuity of Care Document (CCD); where, C-CDA is being addressed by the VLER project.

2016 Final Operating Capability (FOC) Phase has an emphasis on flushing out the iEHR data domains and/or capabilities; additionally, it must support all the high-value data domains that are MU2 optional parts of the CCD, to include:

  • Procedures
  • Providers (including Provider Type)
  • Payers
  • Plans of Care
  • Family History
  • Advance Directives
  • Functional Status

It should be noted that the DoD and VA have worked directly with the ONC and the various standards development organizations to define these data elements and standards. Consequently, there are very few additional high-priority data domains beyond these Transitions Of Care-oriented national standards, noted above.

Further and reflecting this consistency of requirements, all of these data domains (save Functional Status and Advance Directives) are being shared in one or more of the current data sharing mechanisms (FHIE, BHIE, CHDR, VLER), and are planned to be added into the new DIA data services.

One major addition, however, to the above data domains is medical imaging. While it is perhaps less pressing in routine cases, the actual images taken earlier in the case of a severely wounded warrior/patient, for example, can be critical to proper transition and subsequent care. While network connectivity and bandwidth constraints, for example, have prevented many organizations from sharing medical imaging, the DoD and VA have made important strides in sharing medical images between the departments. Another potential addition is Veterans Benefits adjudication data; where timely adjudications might be facilitated by some additional, yet-to-be-specified data domains and elements.

In conclusion, the subset of the data that is considered “must share” includes:

  1. Identity information and other demographics
  2. Medications
  3. Allergies
  4. Lab Results
  5. Documents/Notes (encounter/visit notes, discharge summaries, operative reports, etc.)
  6. Immunizations
  7. Problem Lists
  8. Vital Signs
  9. Procedures
  10. Social History
  11. Encounter Diagnoses (inpatient and outpatient)
  12. Medical Imaging

Your thoughts?

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Comments

Hi Stephen

dezso csipo's picture

Hi Stephen,

 

Could you please be more specific what you mean under "sharing"?   Giving access and making things viewable is probably the very basic sharing use case.   In between the two agencies there are 7 likely image sharing related use cases.  This is based on 4 activities that may happen on either side of the boundary.  When we were analyzing the San Antonio JIFF for image sharing we assumed the following:  Either agency may:  Order, perform, interpret and finally store an imaging study.  if all functions are performed by one agency then that is by definition not a sharing use case.  that leaves 14 use cases where at least one of the functions is performed by the other agency.  the 14 use cases can be decomposed in to 7 symmetric use cases.   Given that matrix, which one of the ones that are you major interest?   The same kind of logic can applied to any clinical function that has functionality split between the two agencies.   

 

Today we have either agency involved as a passive observer of the work performed by the other agency.   That is not detailed in the use cases that are already established in the active sharing use cases.

 

BTW  VistA Imaging has the highest volume image exchange supported between VA and DoD both to the BHIE framework and HAIMS (whenever it is accessible)

It is my opinion that sharing in the traditional sense does not fully serve the organizations and does not address cost savings achievable at shared facilities.  One needs to look beyond looking at one agencies data from the other, one has to be able to utilize resources and meld the patients into a cohesive interoperable record, where both agencie's providers can interect with it in an equal fashion.

dee

;-D

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VPR and EIA importance in VistA Modernization

Stephen Hufnagel's picture

I concur with your overall comments and I generally like to use the Wounded Warrior and/or continuity of care scenario (es), where any encounter can be with either agency, to work through the details; but, I believe the Virtual Patient Record (VPR) analysis needs to focus on the user experience GUI and Clinical Decision Support (CDS) data domains and scenarios  rather than orders management. My assumption is that a single encounter is done on a single agency EHR and will be locally available during the encounter. For any followon encounters, the orders and results are part of the VPR. For joint hospitals, such as N. Chicago, latency will be the biggest potential issue.

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