After Visit Summary (AVS) VA Loma Linda Health Care System John M Byrne DO John M. Byrne, D.O. Associate Chief of Staff for Education Chief Health Informatics Officer VA Loma Linda Healthcare System Associate Professor of Medicine Loma Linda University School of Medicine
Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Largest healthcare system in the nation 8,760,000 enrollees 151 hospitals 820 community based outpatient clinics 83.6 million outpatient visits in 2012 340,000 employees 60% of all U.S. physicians trained in VHA rotations VHA Patient t Care Higher patient satisfaction than private sector Consistently outperforms private sector quality indicators 2
Introduction: Who are our patients? Older - average age 64 Sicker Compared to Age-Matched Americans Poorer 3 Additional Non-Mental Health Diagnoses 1 Additional Mental Health Diagnosisi ~ 70% with annual incomes < $26,000 ~ 40% with annual incomes < $16,000 Changing Demographics 10% female overall 3
Veterans Information Systems and Technology Architecture (VistA) VistA - VA Electronic Health Record (EHR) 160 integrated software modules for clinical care, financial functions and administration Business logic, data in VistA Computerized Patient Record System (CPRS) Graphical User Interface for healthcare providers Innovations in Government Award 2006 CPRS ranked highest for ability to provide quality care * VHA seeking Meaningful Use Certification** i * Edsall RL, Alder KG The 2011 EHR user satisfaction survey: responses from 2719 family physicians. Family Practice Management July/August 2011; http://www.aafp.org/fpm/2011/0700/p23.pdf p p p p ** Conn J. Modern Healthcare. October 25, 2012. http://www.modernhealthcare.com/article/20121025/news/310259956, accessed May 2013 4
VA AVS 5
VA Loma Linda Healthcare System (LLVAHCS) VALLHCS AVS Goals Provide patients with a patient-centered clinical summary of outpatient clinic visits Minimize work for providers by automatically populating AVS with data from VistA but include customization Print and upload copy to EHR and patient portal Meet meaningful use criteria 6
Software Development VHA Innovations grant Requirements gathering VALLHCS patients & physicians Prototype Contractor prototype, feedback from clinicians 2009-2010 α, β Testing 2012-2013 Live testing, clinician feedback to local programmer Available to all VALLHCS staff March 2013 Development 2013-2014 Deployed at 6 additional VA sites, clinician feedback Engage VHA Medication Reconciliation & Meaningful Use Approval for national deployment January 2014 Evaluation patient/clinician focus groups, satisfaction 7
Agile or Iterative Software Development Iterative Development Veterans Veterans Contractor VALLCHS Programmer VALLCHS Programmer Clinicians & Informatics AVS Clinicians & Informatics Prototype Development 8
VALLHCS AVS Content Development Prototype - basic data & technical feasibility Expanded data and more esthetic layout Additional data to meet MU plus medication descriptions, patient education and more 9
VALLHCS AVS Architecture Loma Linda AVS Vt Veteran (Stub Note)CPRS Note VistA Imaging (AVS PDF) Electronic Health Record Computerized Patient Record System (CPRS) VistaLink VistA Medication Image Library (MIL) SQL HTTP CPRS C C O W NoSQL (cached data) Provider AVS Web 2.0/Ajax/JSON print AVS JEE Server SQL Server (facility, clinic, user, language, etc settings) 10 VistA = Veterans Integrated Health Information System Technology
AVS Clinician View Opens from CPRS CCOW (Clinical Context Object Workgroup) Open AVS once, changes with CPRS patient selection 11
Auto-refresh every 2 minutes to update data Workflow AVS Clinician View Minimal data entry Orders and encounter form completed 12
LLVAHCS AVS Formatting and Stage 2 Meaningful Use Requirements Patient Information Patient name Demographic information Smoking status Language g preference Today s Visit Provider's name and office contact information Date and location of the visit Reason for the office visit Current problem list Procedures performed Vital signs taken during the visit List of diagnostic tests pending 13
Today s Visit LLVAHCS AVS Formatting and Stage 2 Meaningful Use Requirements Future scheduled tests Immunizations or medications administered during the visit Referrals to other providers. Important Notes Clinical instructions Future appointments Recommended patient decision aids ± Care plan field(s), including goals and instructions + Remote appointments 14
Stage 2 Meaningful Use Requirements My Ongoing Care Current medication allergies Current medication list Laboratory test results. + Primary care team + Medication descriptions + Remote allergies and medications + Clinical charts + Hospital service information 15
VALLHCS AVS Patient Features Upcoming appointments include remote locations 16
VALLHCS AVS Patient Features Primary care provider information includes primary care team (in VA, Patient Aligned Care Team or PACT = Patient Centered Medical Home) 17
VALLHCS AVS Patient Features Medication list includes visual descriptions 18
VALLHCS AVS Patient Features Reconciliation of remote & non-va medications 19
VALLHCS AVS Patient Features Reconciliation of remote & non-va medications 20
VALLHCS AVS Patient Features Customize AVS for patient s needs 21
VALLHCS AVS Patient Features Increase font size for visually impaired 22
VALLHCS AVS Patient Features Charts for trending clinical data 23
VALLHCS AVS Patient Features Add clinical service location, hours & contact information 24
VALLHCS AVS Patient Features Integrated with patient education software Education sheets triggered by ICD-9 codes or search library Print, copy document or copy sections into AVS 25
VALLHCS AVS Patient Features Printed education sheet automatically inputs a message into instructions Copy text from education sheet into AVS 26
VALLHCS AVS Patient Features Translator in setting, translate medical jargon from VistA 27
AVS Note Creation VistA Imaging CPRS 28 28
VALLHCS AVS Summary Primary Care Team Info Patient Education Remote Data Veterans 29
VALLHCS AVS Future Directions Evaluation Randomized d trial, 4 AVS s, content t & length* No difference in satisfaction or content recall Health literacy (S-TOFHLA) no effect on medication recall Patients did not place great importance on formatting VALLHCS AVS Veteran preferences for content and length including additional features of AVS (e.g. medication descriptions) Provider predictors for usage * Pavlik V, et al J Am Board Fam Med March-April 2014; 27:209-218 30
VALLHCS AVS Future Directions Pre-visit summary Reason for visit edited by patient Medications for patient to reconcile Clinical Reminders that are due Patient kiosks VA Veteran Portal System Funding AVS to national deployment Make PVS and AVS available at patient kiosks 31