Technical Overview: Health Information Systems of VHA and DOD
Following is a brief technical description of the IT infrastructures of the Veterans Health Administration (VHA) and the Department of Defense (DOD) TRICARE programs. The VHA and DOD programs utilize modified off-the-shelf technology and specially designed middleware to integrate disparate and legacy systems, as well as a consumer-oriented, Internet-based e-health model to support their patient population’s communication and information needs. The heart of these information systems is the computerized patient medical record that enables electronic documentation of health data, real-time access to important clinical information at the point of care (e.g., radiological images and laboratory test results), and linkages to facilitate administrative and financial processing. Other applications such as those for reporting adverse medical events are spearheading the use of health information systems to improve patient safety.
VETERANS HEALTH ADMINISTRATION
The VHA has one of the largest integrated health information systems (HIS) in the United States. At this time, the system serves 6 million enrollees/5 million annual users in the 22 designated regions. The VHA’s HIS is rooted in the five primary elements of its composition:
Architecture that supports information exchange across multiple clinical disciplines and lines of business.
Computerized patient medical record for clinical documentation and information retrieval.
Performance measurement system that provides tools for analysis and feedback to providers for quality improvement.
Patient safety reporting system to document adverse events and near misses.
e-Health communications system to provide veterans with online access to their medical record and other health information.
In the early 1980s, the VHA began building its electronic architecture using the Massachusetts General Hospital Utility Multi-Programming system (MUMPS) (Veterans Health Administration, 2001a). By 1990, the VHA had upgraded the computer capacity at all its inpatient medical facilities with MUMPS. Throughout the mid 1990s, the VHA redesigned its operational structure to standardize quality, facilitate access to care, decentralize decision-making, improve information management, and optimize patient functional status. In 1996, the VHA introduced the Veterans Health Information Systems and Technology Architecture (VISTA)—its current architecture that provides significant enhancements to the original system in managing day-to-day operations (Veterans Health Administration, 2001a). One year later, the Computerized Patient Record System (CPRS) was introduced to provide clinical documentation capabilities and to function as the center of applications integration.
VISTA brings to the VHA’s HIS a client-server architecture that connects workstations and personal computers with Windows-style applications, to a centralized database. This system is commensurate with the architecture and applications used in most offices or at home today. The VISTA architecture is a compilation of software applications specially developed by the VHA medical facility staff (e.g., vocabulary), commercial off-the-shelf applications (e.g., MS Office), applications acquired through sharing agreements (e.g., National Library of Medicine), and corporate information systems (e.g., Oracle database) (Veterans Health Administration, 2000-2001).
VISTA provides a complete structure for all administrative, financial, clinical, and infrastructure applications in VHA facilities. The administrative and financial applications programs support the operations and management of the medical centers. Specific features include:
Billing—automated exchange of veteran information between benefits administration and the medical facility, automatic coding of DRGs for inpatient care and CPTs for outpatient care, determination of fee-for-service charges.
Patient management—inquiries for eligibility data and income
verification, record tracking to maintain control of records and radiological images, missing patient registry, patient fund accounts for holding/ managing money while in hospital.
Administrative—accounting and receivables management, audit reports, transmission and purge, EEO complaint processing, employee time attendance, tracking of staff education and training; engineering, equipment and facilities management.
Safety—employee accidents with blood-borne pathogens from needles and sharps and body fluid exposure with automatic transfer to national database if necessary, patient incident reports for submission to the National Quality Assurance Database at the VHA’s National Center for Patient Safety.
The information is organized according to patient or department depending on the needs of the clinician or administrator. To facilitate retrieval of veteran information, VISTA includes a master patient index database with the appropriate authentication protocols to verify staff access and restrict unauthorized areas.
Computerized Patient Record System
The CPRS serves as a unifying platform for integrating all patient-oriented applications (administrative, clinical, etc.) across the network. The CPRS is a Windows-type desktop applications program that displays all relevant patient data to support clinical decision-making. The CPRS enables clinicians to enter, review, and continuously update all information related with any patient. Important data, such as a patient’s active problems, allergies, current medications, recent laboratory results, radiological images, vital signs, hospitalization, and outpatient clinic history, are displayed immediately when a patient’s name is selected to provide an accurate, real-time overview of the patient’s current health status before any clinical interventions are requested or performed (Veterans Health Administration, 2001a).
After review of the patient’s information, clinicians can place orders for various items—medications, special procedures and surgeries, nursing orders, diets, and laboratory tests, etc. directly from the CPRS. The CPRS also has a special feature that allows the clinical record to be accessed in the operating room, with automatic generation of the post-operative report (Veterans Health Administration, 2001a). To address concerns related to privacy and access to the patient’s health information, the CPRS is constructed with a method for identifying who is authorized to perform various actions on clinical documents.
CPRS applications include:
Automated order entry for consultations and procedures that lets clinicians know of a possible problem if executed, and tracking and reporting results
Clinical reminder system that allows caregivers to track and improve preventive health care for patients and to ensure the initiation of timely clinical interventions
Remote data view functions allows clinicians to view a patient’s medical history from another VHA facility to ensure the clinician has access to all clinically relevant data from VHA facilities
Health summary reports that display patient relevant data, vital signs and measurements, etc., in a comprehensive report form
Adverse drug reaction tracking with supportive drug reference software and a link to the FDA to report data
Hepatitis C extract for tracking
There are a number of other clinical applications, some of which connect and/or import information to the CPRS. For example:
Scheduling component for treatments, procedures, and follow-up visits
Comprehensive applications for the major diagnostic areas including laboratory systems (with a blood bank registry), and radiology application with digital medical images and recordings of all kinds (e.g., x-rays, cardiogram) that can be accessed at the point of care
Pharmacy application based on bar coding for medication administration, inventory accountability, outpatient pharmacy management, and tracking controlled substances
Documentation module for home-based primary care, mental health notes, and therapeutic care by allied health professionals, and management of nursing care
Immunology case registry to support a local HIV/AIDS database and an oncology registry in order to meet CDC reporting requirements
Dental records for entering treatment data, reports and scheduling
Patient Safety Reporting
The VHA patient safety system considers both adverse events and close calls (events that almost occurred). These incidents are reported, evaluated, and used as educational tools for improving patient safety. When an incident occurs, anyone working in the facility can report it to the facility’s patient safety manager who completes an online form to report it to the VHA National Center for Patient Safety. Incidents are prioritized according to severity and probability to determine if a root-cause
analysis is required. Staff performing a root-cause analysis consider potential issues including: human factors related to communications, training, fatigue and scheduling; environment and equipment; rules, policies and procedures; and barriers that can lead to adverse events or close calls (Eldridge, 2001). When individual incidents in four categories (adverse drug events, falls, missing patients, and parasuicides) do not meet the requirement for a root-cause analysis, they are aggregated for quarterly reviews.
My Healthy Vet
In addition to VISTA, the VHA has established the My Healthy Vet program that provides veterans an online connection to their medical record. The Healthy Vet program is based on the online e-health system designed and implemented by the DOD Military Health System (MHS). Participating veterans are able to obtain electronic copies of key portions of their electronic health records. This record is encrypted and stored in a secure and private environment called an eVAult. The eVAult information is presented in an easy-to-view table format with direct links to more detailed and explanatory information to help veterans: (1) understand what is in their record and what they can do to improve their health condition, (2) add structured medical information in a “self-entered” section, and (3) enable access to the Health Ed Library that includes 18 million pages of information about health conditions, medical procedures, medications, recent health news, and health tools (Veterans Health Administration, 2001b).
Within the architecture, information is exchanged throughout the system using the ANSI accredited HL7 messaging format standards, a standardized reference terminology developed in-house, and a network exchange module that allows physicians to access patient information from any VHA facility (Veterans Health Administration, 2000-2001).
MILITARY HEALTH SYSTEM
The main components of the military HIS consists of:
Architecture grounded in a core clinical database that supports information exchange with multiple other data repositories
Computer-based Patient Record (CPR) for clinical documentation
Theater Medical Information Program (TMIP) for medical readiness of deployed combat forces
TRICARE Online e-Health System provides patients with access to health information
DOD began implementing standard health information systems in the early 1980s with the fielding of tri-service laboratory, radiology, pharmacy, patient appointing and scheduling, and cardiac assistance systems. Each system was tested and implemented at 15 to 20 sites and provided the framework for future health information systems programs. In the mid-1980s, DOD implemented the Automated Quality of Care Evaluation Support System, which provided standard capabilities supporting patient registration, appointing, scheduling, and administration, as well as clinical quality assurance. This system was enhanced over time to provide a broader array of patient administration abilities and was expanded to include biometric/workload information (Military Health System, 2002a)
By the late 1980s, DOD began development of a family of information solutions, called the Composite Health Care System I (CHCS I). CHCS I connects medical departments, hospital wards, outlying clinics, laboratories, and pharmacies by integrating patient registration, appointments and scheduling with laboratory, radiology, and pharmacy order entry and results reporting. CHCS I architecture provides the pharmacy with drug-drug interaction warnings, laboratory applications links with over 100 laboratory instruments, and electronic radiologic images to clinicians. Currently, CHCS I has the capacity to document over 50 million outpatient appointments and perform 70 million prescription transactions annually (Military Health System, 2002a).
Since its implementation, CHCS I has migrated to regionally centralized databases in areas of high patient concentration, enabling the highly mobile military patient population to access their medical records electronically at any site within the region. CHCS I applications are supported by the MHS Data Repository, a clinical data warehouse that aggregates data on health plan utilization, clinical encounters and cost of utilization over the past five years from all military medical facilities worldwide as well as contracted MHS network providers (Military Health System, 2002a).
A number of applications within the architecture support administrative and clinical operations. The Pharmacy Data Transaction Service creates a centralized data repository that records information about prescriptions filled for DOD beneficiaries at 340 MTF pharmacies worldwide, the over 40,000 pharmacies in the retail network, and the National Mail Order Pharmacy Program (Military Health System, 2002a). The pharmacy service provides real-time checking of a patient’s current medication list and allergies to identify and avert errors. The Defense Blood Standard System is a computerized processing and tracking system for blood products and services. The Defense Medical Logistics Standard Support System pro-
vides effective management of the military’s global health system and the needs of active duty operational missions. The Centralized Credentials Quality Assurance System supports the management of the professional credentials for medical personnel, disciplinary actions taken against personnel, and risk management case tracking throughout the MHS.
The MHS continues to build upon the enterprise architecture and is now beginning implementation of the next generation of technology. The Composite Health Care System II (CHCS II) is the military’s clinical information system that will generate, maintain, and provide secure online access to a CPR and associated applications programs. CHCS II provides the structure for a lifetime medical record from the beginning to the end of military service. The testing phase of CHCS II was completed in July 2002 for which pilot studies utilizing the CPR were set up at four sites in selected medical departments—Naval Medical Center Portsmouth, VA (Family Practice and Pediatric Clinics); Langley Air Force Base, VA (Family Practice Clinic); Seymour Johnson Air Force Base, NC (Family Practice Clinic); and Fort Eustis, VA (Primary Care, General Surgery, Internal Medicine, and Troop Medical Clinics). Full deployment of CHCS II will be facility-wide and scheduled for phase in on a region-by-region basis over a three-year period beginning in fall 2002 (Military Health System, 2002c).
CHCS II has three fundamental elements: 1) a seamlessly integrated Windows-type user interface (screen) for documentation at the point of care as well as the display of data derived from multiple external sources (e.g., laboratory); 2) an enterprise-wide, industry standards-based Clinical Data Repository that will serve as a “clinical warehouse” for the information contained in the CPRs and applications connected to the CPR; and 3) a migration architecture that ensures the ability to easily integrate innovative technology programs to the system as they become available in the future. By the end of calendar year 2003, CHCS II is expected to cover 37 percent of MHS beneficiaries, by the end of 2004, 71 percent, and by the end of 2005, 100 percent (Military Health System, 2002a).
Patient Safety Application
Within the MHS, if an adverse event or medical error occurs, the event is reported immediately to the supervisors and administrators where an investigation is undertaken. The MHS Patient Safety Center handles the investigations and all other matters related to adverse events. Its Website averages 1000 user sessions per month, and a quarterly newsletter on patient safety is distributed to 1500 personnel (Military Health System, 2001).
The MHS patient safety system is modeled after the VHA, whereby root-cause-analysis is carried out and used for quality improvement in patient care. In addition to the reporting system, queries can be performed on information in the Clinical Data Repository in order to identify deviations from standard practices or anomalous events in the data.
Theater Medical Information Program
The TMIP supports the medical readiness of deployed combat forces around the world. TMIP plays a vital role in force health protection by providing critical data for the clinical care of battlefield casualties and management of military medical assets. The TMIP system functions on an independent temporary database system that is linked to the Clinical Data Repository. During a deployment, the relevant medical information from the CPRS (held in the repository) is accessed through the TMIP. All clinical documentation related to local treatment during deployment is held in the temporary database. Upon return of the force personnel, the new medical information is downloaded into CHCS II and the Clinical Data Repository (Military Health System, 2002d).
TRICARE Online is the military’s e-health communications system. It is an online system that provides information on health conditions and interactive health tools, disease management and treatment compliance recommendations, a directory of TRICARE medical facilities and providers, and a communications system for appointment scheduling. In the near future, the online system will have technology capabilities for telemedicine and other e-health initiatives. The system is currently in prototype testing at five medical centers with a roll out to all facilities scheduled for late 2002 (Military Health System, 2002b).
If desired, patients can create their own Personal Healthcare Homepage to store medical information and resources in a secure environment. The application allows patients to create a personal health journal, store favorite links to health or wellness sites, and access disease tracking and management tools.
The Website also contains structured provider/patient messaging allowing patients to receive appointment reminders, request routine health tests, and by fall 2002 to refill and renew prescriptions. The VHA is currently utilizing TRICARE Online as a model for the development of their e-health system.
Eldridge, N. 2001. Presentation to the National Committee on Vital and Health Statistics. Washington DC: Department of Veterans Affairs National Center for Patient Safety.
Military Health System. 2001. Patient Safety Program. Instruction Document. Department of Defense.
———. 2002a. Reference Paper from Office of Interagency Program Integration and External Liaison. Department of Defense.
———. 2002b. “Tricare Online.” Online. Available at https://www.tricareonline.com/ [accessed Sept. 23, 2002b].
———. 2002c. Presentation: The Military Computer-based Patient Record (CHCSII). Department of Defense.
———. 2002d. Presentation: Theater Medical Information Program. Department of Defense.
Veterans Health Administration. 2000-2001. IT Architecture.
———. 2001a. Office of Information System Design and Development. VISTA Monograph.
———. 2001b. VISTA and Health eVet Vista. Veterans Health Administration.