36C77618R0091-010.docx

Health Information Strategic Plan for

Veterans Health Administration Supporting VA Health Care

Fiscal Years 2018 – 2022

Version 5.3

March 2018

A-1 Detailed Design Document 11/20/01

B-3 Detailed Design Document 11/20/01

TABLE OF CONTENTS

List of Tables

List of Figures

[Name of App] User Guide [Client]

Page 10 [Month] ##, 2002 Version 5.3 18 March 2018 Executive Summary Veterans Benefit From VHA’s Health Information Technology When Tom first got out of the U.S. Army, he wasn’t sure how much of his medical history he would have to write down for the Veterans Health Administration (VHA). When he arrived for his first visit to VHA, Tom discovered that not only did VHA have his complete medical record from his time in the service, but the doctor immediately had a refill for a prescription he had been taking. The doctor also saw a trend suggesting Tom might be on a path toward developing diabetes. Since Tom lives in an area where there isn’t a local Department of Veterans Affairs (VA) outpatient clinic, VHA began to send Tom to a local physician for treatment (community care provider). The physician made notes in the electronic medical record system and Tom has periodic follow-ups with VHA providers. VHA providers have all of those notes thanks to the Nationwide Health Information Network (NwHIN) efforts. This coordinated, integrated medical record from the Department of Defense (DoD) to VHA and community providers allows Tom and his doctors to manage his health and lower his long-term health risks.

When Mary retired after 22 years in the service, she and her family re-located to a rural area located 200 miles from the nearest VA Medical Center (VAMC). Mary was faced with treacherous weather and dangerous driving conditions to see her provider in the Women’s Comprehensive Primary Care Clinic. As a result, she doubted that she would be able to seek care through VHA. After contacting her assigned Women Veterans Program Manager, Mary discovered that her assigned Women Veterans Health Provider would be able to “see” her at a standalone VHA Telehealth Clinic located only 20 minutes from her house.

Mary had some doubts about using telehealth to “see” a provider; however, she thought that she would go for at least one appointment. After arriving at the Telehealth Clinic, Mary was screened by her assigned Telehealth Technician who walked her through what she could expect from the appointment. She then met with her Women Veterans Health Provider via Total Exam equipment for her comprehensive physical. Mary was amazed that she was able to discuss her medical conditions with her provider as if they were in the same room together. The entire experience provided Mary with a great sense of relief knowing that she could establish comprehensive care without having to travel extremely long distances. Mary now meets with her provider every few months through telehealth, and is thrilled with the outstanding care received using modern technologies.

John suffered traumatic brain injury while serving in Operation Enduring Freedom. After receiving initial rehabilitation he was allowed to return home outside of Lewiston, MT with his wife, Sally. Rather than constantly driving to the Fort Harrison (MT) VAMC for long-term rehabilitation, they make use of a tablet computer to communicate with the patient care team. The built-in camera allows for face-to-face discussions with his therapists. The team sends visual and fine motor skill practice to the tablet and can monitor John’s long-term progress. Also, with a VHA outpatient clinic in Lewiston, seeing a physician in person is far more convenient, and the clinic has all the telemedicine facilities necessary to work with the Fort Harrison VAMC specialists. Sally wouldn’t be able to help John in his recovery without these tools. By being home, and Sally feeling empowered and capable, their marriage is more stable and John doesn’t suffer increased stress over the possibility of losing his wife.

The three vignettes you just read are examples of how health information technology (HIT) helps our Nation’s Veterans. This Executive Summary, and the complete VHA Health Information Strategic Plan (HISP), defines VHA’s goals for the enhancement and use of HIT.

HISP Summary Overview The VHA HISP represents the strategic direction for HIT within VHA and is intended to support information technology (IT) budget decisions to best meet VHA needs. Oversight of the VHA HISP is included in the VHA National Leadership Council (NLC) IT Committee (ITC) charter. The IT Strategy Sub-Committee (ITSSC) was established by the ITC to provide strategic oversight.

There are numerous VHA strategic business drivers that evolve over time and impact VHA’s strategy and investments. The VHA HISP describes those drivers (regularly updated as a result of environmental scans) and how VHA strategies align with those drivers. The VHA HISP also provides a characterization of the current VHA IT environment, including IT-related improvement opportunities. The VHA HISP then describes a future vision for VHA HIT, including four HIT goals, and related objectives, derived from the VA goals and objectives, as well as the VHA strategic drivers and strategies.

Although VHA IT is advanced and matured in many areas, there are numerous improvement opportunities and gaps that will require a significant investment in both dollars and commitment to meet the future vision goals. IT transformation and change initiatives / investments are on the critical path, along with VHA’s adoption and effective use, to capitalizing on these opportunities. The VHA HISP describes the current IT programs and planning elements that will help VHA align scarce resources with VHA needs in the most effective manner. Finally, identified IT improvement opportunities and gaps are mapped to current IT programs in order to demonstrate which IT programs support VHA’s movement toward achieving the HIT goals. For example:

· The Medical Appointment Scheduling System (MASS), when implemented, will help resolve VHA’s scheduling and access issues. In the meantime, Veterans Health Information Systems and Technology Architecture (VistA) Scheduling Enhancements (VSE) will make incremental improvements to the current system until MASS is ready for implementation.

· The VHA Electronic Health Record (EHR) Modernization effort supports VHA’s adoption of a commercial off-the-shelf (COTS) EHR solution to attain the goal of providing seamless care for Veterans, including access to a comprehensive EHR and shared, transparent care pathways.

· User interface for both providers and Veterans is being expanded, which will help VHA meet the goal of improving IT capabilities and service to the Veteran.

The content of this mapping is described in the body of the VHA HISP document.

Introduction Purpose and Scope The VHA HISP represents the strategic direction for HIT within VHA. This document describes the IT strategic direction being followed by VHA’s Office of Health Informatics (OHI) Strategic Investment Management (SIM) as it aligns and prioritizes VHA IT investments with VHA business strategies and leads development of IT requirements for IT solutions. This enables VHA’s clinical and business leaders to meet strategic and tactical objectives[footnoteRef:1]. VHA OHI is working with leaders, subject matter experts (SMEs), and the IT development community to define the interconnectivity and characteristics of the various IT programs that are required to achieve strategic objectives. VHA OHI also identifies and documents interdependent requirements to help ensure interoperability and streamlined process support for workflows that transcend individual work units. [1: The VHA HISP (i.e. this document) is designed to focus specifically on the strategic direction of HIT within VHA as a whole, as opposed to the strategic direction of a particular organization within the administration.]

Although written as a separate document, the VHA HISP is best understood when taken in context with the VHA and VA overall strategic and operating plans. Within VHA, there is an administration-level strategic planning effort, as well as numerous complementary documents being developed by the Veterans Integrated Service Networks (VISNs) and program offices, some of which may include IT components. The VHA HISP is formulated to support the Managing for Results process (formerly known as the Planning, Programming, Budgeting, and Execution (PPBE) process) and the VHA IT Governance process. Additional information on the VHA IT Governance Process can be found in Appendix A. The VHA HISP also informs the VA Enterprise Roadmap and Information Resources Management (IRM) Strategic Plan, which are developed by the Office of Information and Technology (OIT), as well as the VA Strategic Plan and Operational Plans for VHA, VHA Program Offices, and VISNs. The intended timespan coverage of the VHA HISP is Fiscal Year (FY) 2018 through 2022.

Figure 1 presents a graphical representation of the relationship between the HISP, strategic planning documents, and other strategic elements.

Figure 1 – VHA HISP Impact on Strategic Planning VHA HISP Governance Oversight of the VHA HISP is included in the VHA NLC ITC charter. The ITC established the ITSSC to oversee this function. ITSSC membership represents a cross section of VHA field operations and program offices, as well as representatives from OIT. The main objectives of the ITSSC are to develop the VHA HISP and define the prioritization criteria for each multi-year planning cycle. The ITSSC researches, develops, and defines the VHA HIT strategy and mission to include strategic direction, goals, and priorities. Within this scope, the ITSSC is responsible for:

· Deciding the VHA strategic IT priorities, goals, and direction (to be used in evaluating and prioritizing the VHA-related budget line items in the VA IT Multi-Year Program [IT MYP]).

· Deciding the prioritization criteria and policies for IT requirements and ensuring these align with VHA policies, VA/VHA strategic and operational plans, and NLC/Under Secretary for Health (USH) objectives.

· Coordinating with other NLC Committees to ensure the VHA HIT strategy and mission are aligned and consistent with planned VHA funding.

· Recommending VHA IT products that are no longer meeting a strategic need, and therefore possibly eligible for retirement/sunsetting.

The ITSSC meets monthly to review and validate content, and assess VHA’s evolving strategic drivers. Additionally, ITSSC members provide input to the VHA HISP between monthly meetings.

Intended Audience Figure 2 shows the entities which comprise the intended audience of the VHA HISP.

Figure 2 – VHA HISP Audience Drivers and Strategies for the Future of VHA Healthcare VHA Strategic Drivers VHA conducts regular environmental scans of the health information environment in order to identify specific strategic drivers that impact VHA strategy and help prioritize VHA IT programs and investments. The environmental scans look for changes relative to the following categories:

· Veteran Demographics and Needs – Demographic trends play an important role in the evolution of HIT in VHA. Predictive analyses of demographics, social factors, and specific healthcare requirements help to anticipate the volume of care needed in certain specialties.

· Healthcare Industry Business Impacts – The healthcare industry as a whole faces several significant changes over the next few years and VHA must be able to function effectively as a key player in the healthcare industry.

· VA / Government Legislation and Guidance – Key changes expected to impact the VA Healthcare System because it is a government department.

· HIT Impacts – Expected IT changes with a potential to impact business practices and processes, and contribute to healthcare transformation. These drivers include rapid incorporation and use of emerging health best-practices, sharing of clinical knowledge and workflows, accommodation of clinical decision support (CDS) at the point of care, and selected security-related drivers developed by VHA’s Security Architecture team.

· VHA Performance Gaps / Improvement Opportunities – Areas where it is critical for VHA to improve its clinical or business performance, as identified through the assessment of performance measures, product effectiveness, external and internal inspection, and Lean-based continuous improvement projects.

The current VHA strategic drivers are listed in Table 1. The table lists each driver, the implications of the driver, and the relative category. Drivers may be related to multiple categories, but only the main category is included in the table.

Table 1 – VHA Strategic Drivers

Healthcare Industry Business Impacts

Healthcare Industry Business Impacts

HIT Impacts

HIT Impacts

HIT Impacts

HIT Impacts

HIT Impacts

Current State of VHA HIT Overview of the Current VHA HIT Environment VHA continues to maintain its status as the largest integrated healthcare system in the United States. The VHA healthcare system has grown from 54 hospitals in 1930 to 170 VAMCs and more than 1,061 outpatient sites today.[footnoteRef:10] VHA currently serves more than 9.05 million Veteran enrollees and Veteran family members who receive care through VHA healthcare programs (as of FY2016).[footnoteRef:11] VHA facilities provide a broad spectrum of medical, surgical, and rehabilitative care. VHA’s commitment to delivering timely, high-quality healthcare to America’s Veterans, while controlling costs, remains a top priority. [10: VHA Vitals, VHA Office of the Under Secretary for Health, Issue 21, January 31, 2018.] [11: National Center for Veterans Analysis and Statistics, Department of Veterans Affairs Statistics at a Glance, June 2017.]

With the understanding that VHA’s needs far exceed available resources, it’s major areas of focus over the past few years have included enhancements to VistA through the VistA Evolution (VE) Program (now called EHR Modernization (EHRM)), expanding access to care in response to VACAA through the Community Care Program (CCP) (formerly the Veterans Choice Program (VCP)), and providing alternate forms of access through telehealth and mobile care programs.

VistA and EHR Modernization (Formerly VistA Evolution) VistA is a nationwide information system and EHR developed by the VA. It consists of more than 180 applications for clinical, financial, administrative, and infrastructure needs in VA integrated into a single, common database, permitting all VA applications to share one single, authoritative data source for all Veteran-related care and services. Designed by clinicians for clinicians, VistA is patient-centric as well as facility-centric, and embodies the clinical workflow processes that support VHA’s models of care. It enables measurable improvements in health outcomes and is central to VHA’s ability to deliver high-quality care to a large and varied Veteran population.

During its early years, VistA provided advanced capabilities compared to what was generally available at that time. Almost 50% of the clinicians (physicians, nurses, etc.) in the United States have worked for the VHA while working towards their degree and have been trained on the VistA system; thus, VistA is one of the most familiar and widely used EHRs in the United States.[footnoteRef:12] Outside of VHA, VistA has been implemented by dozens of healthcare providers[footnoteRef:13] and is supported by multiple companies and organizations. Within government, the Indian Health Service supports a version of VistA called Resource and Patient Management System (RPMS) throughout its entire Indian Health System. [12: Peter Groen, “Emerging GIS Map of Healthcare Sites Using VistA EHR Systems”, http://www.openhealthnews.com/hotnews/emerging-gis-map-healthcare-sites-using-vista-ehr-systems, April 30, 2013.] [13: http://www.hardhats.org/adopters/vista_adopters.html]

At this time, however, the COTS EHR market has overtaken VistA in terms of overall functionality and VistA would no longer be considered a leading edge product compared to today’s readily available leading COTS EHR products.[footnoteRef:14] Compared to COTS EHR systems, VistA faces many challenges including the following: [14: Gartner Consulting, VistA Comparison to the Commercial Electronic Health Record Marketplace, February 4, 2011, pg. 25.]

· VistA was custom built based on the needs of VHA, however this makes it more difficult to share information or be interoperable with DoD and external partner systems.

· VistA’s existing language (Multi-User-Multi-Programming-System (MUMPS)), design, and architecture is costly to maintain and update. Manual restructuring of MUMPS into a modern language and architecture has proven to be very labor-intensive and extremely high risk.

· VistA is lacking or lagging in functionality in many areas, including but not limited to user interface, clinical display, and multi-step clinical workflows. The functionality gap is expected to increase as the COTS market continues to innovate.

· VistA provides limited support for CDS and has limited ability to access and interpret data using different views and analytics. This is exacerbated by a lack of enterprise data standardization.

VHA has made some strides in an effort to mitigate these challenges. For example, VHA established the Open Source Electronic Health Record Alliance (OSEHRA), a mechanism to open the aperture to broadly-based public and private sector contributions[footnoteRef:15]. OSEHRA’s mission is to "build and support an open source community of users, developers, service providers, and researchers engaged in advancing EHR software and related HIT." [15: http://osehra.org/content/frequently-asked-questions-0#1.1]

Additionally, the VE Program was established to oversee the implementation of substantial enhancements and modifications in order to achieve health information sharing with DoD and external partners, enhance capabilities to providers and patients, and improve efficiency and maintenance. Moving forward, this effort will be known as EHRM and will involve replacing the EHR portion of VistA with a COTS EHR system. On June 5, 2017, VA Secretary Dr. David Shulkin announced the decision for VHA’s next generation EHR:

“Having a Veteran's complete and accurate health record in a single common EHR system is critical to that care, and to improving patient safety… our current VistA system is in need of major modernization to keep pace with the improvements in health information technology and cybersecurity, and software development is not a core competency of VA. I said recently to Congress that I was committed to getting VA out of the software business, that I didn’t see remaining in that business as benefitting Veterans. And, because of that, we’re making a decision to move towards a commercial off-the-shelf product.”

Secretary Shulkin’s full statement can be found at the following link: https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2914. Additional information on the way forward for EHRM is available in Section 6 Transition Efforts.

VACAA, Veterans Choice Program, and Community Care The VHA’s goal is to enhance our healthcare system and improve service delivery to better serve Veterans and set the course for long-term excellence and reform. President Obama signed VACAA into law (Public Law 113-146) on August 7, 2014 and amendments were made in the Department of Veterans Affairs Expiring Authorities Act of 2014 (Public Law 113-175) on September 26, 2014. The legislation focuses on increasing access and program expansions, as well as additional collaborations and business process improvements. It included requirements to implement 21 program modifications or expansions, one entirely new benefit program, complete three required independent assessments, and to produce 12 reports.[footnoteRef:16] The independent assessments, which were conducted by the Centers for Medicare & Medicaid Services (CMS) Alliance to Modernize Healthcare (CAMH) and the MITRE Corporation, provide VA a way to transparently review vital programs, organizations, and business practices to make VA more accountable to Veterans. The Integrated Report and the 12 major assessment reports are available at the following link: http://www.va.gov/opa/choiceact/factsheets_and_details.asp. [16: Veterans Day Progress Report: Veterans Access, Choice, and Accountability Act 2014, VA Fact Sheet, November 3, 2014.]

VACAA also called for the creation of a separate Commission on Care. The Commission evaluated the Independent Assessment Reports, held public meetings, listened to a broad range of stakeholders, including Veterans and leaders of Veterans Service Organizations, made site visits to VHA facilities; and exchanged ideas with individual Veterans, VA and VHA leaders, VHA employees and healthcare providers, members of Congress, economists, and healthcare experts. Based on this research, the Commission developed a Final Report that outlines a list of recommendations aimed to enhance VHA’s ongoing reform efforts by providing both a systems-oriented framework and vitally needed changes in organizational structure. The full Commission on Care report can be accessed at: https://commissiononcare.sites.usa.gov.

At its root, VACAA is a law that expands the number of options Veterans have for receiving care to ensure Veterans have timely access to high-quality care. VCP was developed to allow eligible Veterans to access primary care, inpatient and outpatient specialty care, and mental health care from community providers when the local VA healthcare facility cannot provide the services due to: lack of available specialists, long wait times, or extraordinary distance from the Veteran’s home. Additional information on VCP can be found at: https://www.va.gov/opa/choiceact/.

Since VCP is not a permanent program, VA has partnered with Congress to work though the remaining legislative needs to build a single program for community care. VA has a number of statutory authorities, programs, and other methods for purchasing community care. CCP, a re-engineered approach to the former VCP, plans to consolidate existing methods for community care into a single, efficient program integrated into the broader context of VA's healthcare system. A Veteran-centric design is expected to provide straight forward eligibility criteria and a single set of clinical and administrative systems and processes, deliver effectively coordinated care, and allow Veterans to choose their providers. Additional information on CCP can be found in Section 5 Future Vision for VHA HIT and Section 6 Transition Efforts of this document.

Telehealth VHA has implemented new innovative IT practices to improve Veterans’ access to healthcare, such as telemedicine and mobile clinics, to provide care to the more than 6.26 million total unique patients (FY2016) within VHA.[footnoteRef:17] Telehealth increases access to high quality health care services by utilizing information and telecommunication technologies to provide health care services when the patient and practitioner are separated by geographical distance. In FY2017, VHA provided care to more than 727,000 unique patients via the three telehealth modalities; home telehealth, clinical video telehealth, and store-and-forward telehealth. This amounted to over 2.18 million telehealth episodes of care. Additionally, 45% of these Veterans lived in rural areas, and may otherwise have had limited access to VA health care.[footnoteRef:18] [17: U.S. Department of Veterans Affairs, VA Benefits & Health Care Utilization, 2017.] [18: VHA Vitals, VHA Office of the Under Secretary for Health, Issue 21, January 31, 2018.]

The use of telehealth technologies, including video conferencing, store-and-forward imaging, and home telehealth devices, enables patients with chronic diseases such as diabetes, heart failure, and chronic obstructive pulmonary disease (COPD) to be monitored at home. These advances help reduce hospital admissions, clinic visits, and emergency room visits. Elderly or disabled patients are able to stay in their homes longer and it is possible to provide cutting-edge specialty care even in sparsely populated areas. These types of programs are especially beneficial for the most expensive 5% of the overall patient population who, in part because they frequently visit hospitals and outpatient clinics, account for approximately 50% of healthcare costs.[footnoteRef:19] [19: Concentration of Health Expenditures in the U.S. Noninstitutionalized Population – 2014, Agency for Healthcare Research and Quality, Rockville, MD, Statistical Brief #497, November 2016.]

Telehealth aims to improve the health of Veterans by providing technologies that expand clinical care beyond the traditional office visit and improve health care coordination between Veterans and their care teams. VHA is dedicated to providing the most up-to-date technologies to enhance patient experiences and will continue to embrace opportunities to optimize access to care via IT advancements in both telehealth and mobile services. Additional information on the desired future state of VHA HIT related to telehealth can be found in Section 5 of this document and information on planned efforts to attain that vision can be found in Section 6.

Strengths in the Current VHA HIT Environment VHA was an early adopter of EHR systems, patient-centered IT, and other HIT capabilities. VHA has made enormous strides over many years in the development and enhancement of HIT and VistA. For example, VHA has implemented many successful IT projects to improve the Veteran experience including:

· Bar Code Medication Administration (BCMA) – Prevents medication errors and improves the quality and safety of medication administration.

· VistA Imaging – Helps VA hospitals achieve an enterprise-wide paperless and filmless EHR by capturing 39 million new images each month, displaying 9-11 million images for review each month, and storing a total of more than 2 billion images nationwide as of July 2011.[footnoteRef:20] [20: https://www.va.gov/health/imaging/]

· Big Data analytics via the Corporate Data Warehouse (CDW) – VHA’s CDW has 6.6 billion lab tests, 3.8 billion clinical orders, nearly 2 billion outpatient encounters and 10.5 million inpatient admissions. This data is used to assess Veteran health and can be leveraged by scientists to develop innovative solutions and improve healthcare delivery.[footnoteRef:21] [21: Conn, Joseph, VA puts the 'big' in big data predictive analytics, Modern Healthcare, August 2014.]

· VHA Consolidated Mail Outpatient Pharmacy Program (CMOP) – Allows for economies of scale to save money on prescriptions for Veterans. This program has been ranked #1 for customer service by JD Power and Associates for multiple years.

Table 2 lists the major strengths of VHA HIT.

Table 2 – Strengths in the Current VHA HIT Environment