Veterans Health Administration: Surveillance of Cardiovascular Disease

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1 Veterans Health Administration: Surveillance of Cardiovascular Disease Paul D. Varosy, MD Director of Cardiac Electrophysiology VA Eastern Colorado Health Care System Assistant Professor of Medicine University of Colorado Denver

2 Overview VHA Data Resources for Disease Surveillance Electronic Health Record (CPRS) Administrative Data (Austin Information Technology Center) Registries VA National Cardiac Device Surveillance Program Outcomes among Veterans with Implantable Defibrillators (OVID) Registry CART: a new paradigm for real-time cardiovascular disease surveillance

3 VHA Data Resources for Disease Surveillance VHA-wide Electronic Health Record (CPRS/VistA) Nationwide national VA Medical Record (since 1970s) Organized/managed at the regional (VISN) level CPRS: rich data for clinical care Text notes and reports Laboratory data Electronic order entry Pharmacy Images (ECGs, radiology, etc.)

4 VA Data Resources for Disease Surveillance Austin Information Technology Center (AITC) Collects data from VHA facilities Clinical Administrative Aggregates and processes data for multiple uses: Administrative (workflow) tracking Quality assessment Health Services Research Controls access for research

5 Data Resources at Austin Information Technology Center VA National Patient Care Databases (NPCD) Medical SAS Datasets (MedSAS) Decision Support System (DSS) Vital Status Files VHA Service Support Center (VSSC) Corporate Data Warehouse (CDW) Resident Assessment Instrument/Minimum Dataset (RAI-MDS) Real SSN

6 Limitations of Administrative Data Clinical records are not entirely field-specific data Text notes and reports Need for processing/abstraction of data Time lag (sometimes years) Risk of loss in translation Lack of clinical granularity Lack of data standardization Example: Left Ventricular Ejection Fraction Dependence on administrative coding Problematic in a system where coding is not tied to reimbursement

7 VHA National Cardiac Device Surveillance Program VHA has been a leader in remote arrhythmia device monitoring: VHA National pacemaker monitoring programs have existed for 28 years Implantable Defibrillator monitoring since 2003 Roles: Remote follow-up of pacemaker and defibrillator function Administrative tracking Support of clinicians and voluntarily enrolled patients

8 Outcomes among Veterans with Implantable Defibrillators (OVID) Registry VHA-wide registry of veterans with implantable defibrillators Setting: veterans enrolled in Device Surveillance Program Funded by VA HSR&D Retrospective data collection Chart review and electronic data abstraction Labor intensive large team of trained chart abstractors Necessary because granularity of necessary data is not adequate with administrative records or text notes in EHR

9 Limitations of Administrative and Registry Data Abstraction of data after the fact of care

10 Limitations of Administrative and Registry Data Abstraction of data after the fact of care is necessary because DATA COLLECTION is not INTEGRATED into the PROCESS of CLINICAL CARE

11 VHA Cardiovascular Assessment, Reporting and Tracking (CART) Program New Paradigm:

12 VHA Cardiovascular Assessment, Reporting and Tracking (CART) Program New Paradigm: Integration of data collection into the process of care

13 Air Traffic Control: Real-time monitoring

14 Current resources for Cardiovascular Surveillance Administrative Data (billing and coding) jet fuel receipts Retrospective chart review/registry enrollment asking the pilots weeks later

15 The CART Concept Clinical tool that improves efficiency of care Integration with CPRS Efficient Report Generation Faster than dictation VHA-wide standardization Report completion in real-time Integration of data collection into the transaction of care allows Transactional quality management Patient safety monitoring Device Surveillance Health Services Research

16 Key to Success: Strategic Collaborations Clinical Champions VHA Office of Patient Care Services VA Quality Enhancement Research Initiative VA Office of Quality and Performance VA Office of Information and Technology

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20 CART:

21 CART vs. Austin: FY 2008 N = 7972 ~27% of coronary angio cases PCI From same sites, same time frame, per Austin data, N = 4079

22 CART Q&M: Major Adverse Event Review Automatic Notification Committee Review Recommended Action 30 days Resolution

23 New Clinical CART Modules CART-Peripheral Peripheral arterial intervention CART-EP Integration with ICD and pacemaker surveillance programs Result: device surveillance with transactional data collection preimplantation implantation clinic remote monitoring CART-CPR Documentation and tracking of in-hospital cardiac arrest CART-CV Clinic

24 CART - Direct Integration with NCDR In Progress: CART-CL NCDR-CathPCI Planned: CART-EP NCDR-ICD Possible Future: CART-CV Clinic PINNACLE

25 Summary: CART Program Post-hoc data transactional data collection Governance that mirrors ACC-NCDR Leveraged use of data collection for Disease surveillance Quality management Workflow tracking Health services research

26 Summary: VHA and Disease Surveillance VHA has wide-ranging programs and data resources for disease surveillance CPRS is a model electronic health record CART Program - transactional disease surveillance

27 Thank You CHF-QUERI Barry Massie, MD Paul Heidenreich, MD IHD-QUERI Stephan Fihn, MD John Rumsfeld, MD PhD Pacemaker and ICD Remote Monitoring Edmund Keung, MD CART Coordinating Center John Rumsfeld, MD PhD (Director) Hans Gethoffer DrIng (Technical Director) Tami Box Meg Plomondon Tom Maddox, MD Tom Tsai, MD (CART-Peripheral) Paul Varosy, MD (CART-EP) P. Michael Ho, MD PhD Greg Noonan Alec Arney Josie Nance VA Office of Patient Care Services VA Principal Deputy Undersecretary for Healthcare Bob Jesse, MD PhD

28 CART Transactional Quality Management Immediate reporting of major complications Chief CV Consultant; CART Leadership; CART QM Committee Chair Monthly Site QA Reports National Reports (VACO, CART-QM Committee) Monthly Reports: Procedure counts (including fiscal year to date) Major adverse event counts (including fiscal year to date) Bi-Annual Reports Detailed site and roll-up data; quality metrics Quarterly VISN-level Reports VISN CMO s