OpenVista Electronic Health Record System Request for Information Response

Final Project

Independent Masters Capstone Winter Quarter, 2012

Roy Hoppe

OpenVistA1 Electronic Health Record System

Request for Information Response

Independent Masters Capstone Roy Hoppe OpenVistA1 Electronic Health Record System


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INTRODUCTION

RJH Consulting is preparing a report devoted to a review and

comparative analysis of the OpenVistA1 electronic health records (EHR) 5 system

for your facility as per your request. This report will form the foundation for

recommendations to the OpenVistA1 EHR5 for Accountable Care Organizations2

(ACOs) that are interested in investing and implementing EHR5 technology. This

report will be based on information received from your RFI. In addition, the

comparative analysis of OpenVista1 EHR5 system will be supported by insight

from Meaningful Use3 metrics and the findings of interviews conducted with

stakeholders with your ACO2.

PURPOSE

This Request for Information is proprietary to RJH Consulting. It is

drafted and disseminated for the sole purpose of generating information on

OpenVistA1’s EHR5 system in order to promote the quality and connection to

help achieve Meaningful Use3 within your ACO2.

GENERAL

BACKGROUND

Historically, EHR5 systems have been comprehensive end-to-end systems

with significant infrastructure, integration and training requirements. The latest

buzzwords in health IT are meaningful use and usability, where usability, in

particular, having initially been long overlooked is getting a lot of attention.

Most of them are architecturally complex to deploy and maintain, and rely on

proprietary software, systems and data models. However, without adequate

training and education, usability can be an issue.



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Today, health services providers have multiple options to consider in how

they deploy an EHR5 system. The needs of small private practices are vastly

different from those of larger integrated health systems. Providers and policy

makers must consider alternative software and informatics models before

investing in systems. Planning is needed to implement an EHR5 in order to

ensure that it can continue to provide high-quality and high-value healthcare

services in an increasingly electronic and paperless world.

During this time, end users will have a slew of choices when it comes to

vendors. The non-profit Certification Commission for Health Information

Technology (CCHIT) 4, points to over 100 certified products in its portfolio.

American National Standards Institute7-accredited Health Level Seven (HL7)6

International is also developing a set of standards by which to evaluate EHR5

systems. This report will help your stakeholder’s jumpstart their EHR5 selection

process. In it, we'll share the results of the responses to your RFI, taking a look at

what EHR5 system and tools OpenVistA1 offers. We’ll examine features and

functions of OpenVistA1 and match them to the needs of your organization to

help align business processes with your missions and goals.

OpenVistA1

Background

The following requirements are necessary to illustrate OpenVistA1’s

dedication to the success of your EHR5 implementation. We want to share with

you are credentials to demonstrate that we are the right choice for your

organization.

__X_ Vendor’s EHR is CCHIT4 certified

Physicians using CCHIT4 Certified EHRs5 will enhance the quality and

safety of their care and decrease their medical legal risk. Furthermore, CCHIT4

Certified Products tie directly to Health IT Meaningful Use payments, called for



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under the American Recovery and Reinvestment Act (ARRA) 8, whereby

facilities will be eligible to receive payments from the Centers for Medicare and

Medicaid Services (CMS) 9 for EHR5 Meaningful Use3.

__X_ OpenVistA1 EHR caters to small to midsize medical practices

Due to the flexibility of OpenVistA1 EHR5 system, we can accommodate

small-sized ACO2s, single or solo-run medical practice to a group of 15

practitioners; mid-size group can be 15-50 practitioners and larger groups over 50

practitioners.

__X_ OpenVistA1 will provide 2-3 references from past and current clients

We believe that references can provide an excellent way for potential

clients to see the value in our products and services by listening to the testimony

of our previous clients. This way they will find commonalities in problems and

solutions which will emphasis our commitment to quality. References available

upon request.

BUSINESS

OVERVIEW

Midland Memorial Hospital10 is a 371-bed community hospital that

operates three campuses in Midland, Texas. Midland Memorial10 provides a full

range of acute-care services including emergency medicine, cardiovascular

surgery, and advanced radiological and oncology services and serves as a regional

referral center for other communities throughout west Texas and southeast New

Mexico. The Midland Mmeorial10 “OpenVistA1 Implementation Project”

represents a formidable challenge on multiple fronts.

For example, it is the first nongovernmental, acute-care hospital in the

United States to adopt an OpenVistA1-based EHR5; it has a community-based

physician staff representing all major specialty areas; and they want a “best of



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breed” software environment that leverages investments in current solutions that

needed to be interfaced to OpenVistA1. The contract for the project is awarded to

Medsphere Systems15 Corporation.

BUSINESS

OBJECTIVES

Since wellness and patient-centered care is at the core of this particular

medical practice, practitioners and staff eagerly wants to adapt an EHR5 that has

standard core features in addition to including extra components to enhance

quality, disease management and population care management. To that end, the

Midland Memorial’s10 staff hopes to continue providing quality service by way of

excellent patient satisfaction scores and improved Healthcare Effectiveness Data

and Information Set (HEDIS)11 results in the coming years. The selected EHR5

technology will assist the practice in achieving this goal.

GUIDING

PRINCIPLES AND

MAJOR PROJECT

OBJECTIVES

• Enhance patient safety, increase clinical efficiency/ improve healthcare quality.

• Standardize the delivery of care across the continuum (acute, ambulatory, and

rehabilitation) and multiple geography locations of care (hospitals and clinics).

• Reduce medical errors and wasteful costs associated with the delivery of health

care.

• Build upon the proven success and experience of the VA in the implementation

of its comprehensive OpenVistA1 EHR5 for Midland Memorial10.

• Leverage the OpenVistA1 EHR5 as a differentiating factor in helping recruit and

retain patients, physicians and staff.

• Leverage the OpenVistA1 to reduce Midland Memorial10 overall systems

lifecycle costs.



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PROJECT

HISTORY

Midland Memorial Hospital10 has determined to replace their “sun

setting” pharmacy and laboratory systems. This review prompted IT steering

committee members to rethink their best-of-breed strategy and take the

opportunity to evaluate a single, integrated solution to meet their clinical,

administrative, and financial needs. During the course of their evaluation of

traditional healthcare IT companies, they were unable to overcome the $20

million price barrier to implement the comprehensive solution they envisioned.

They became aware of OpenVistA1 through their interaction with the Big Springs

VA Medical Center12 and the realization that there were multiple commercial

vendors supporting the OpenVistA1 solution.

Midland Memorial10 next engaged in a rigorous 12-month evaluation of

the technology, product and Health IT service providers. After attending several

national conferences, completing multiple site visits, and a series of intense

product demonstrations to its staff, Midland Memorial10 decides to move forward

with a comprehensive enterprise assessment of the issues related to implementing

the OpenVistA1 solution. After the completion of the assessment, Midland

Memorial’s10 IT steering committee unanimously approves the recommendation

to begin the OpenVistA1 project.

With OpenVistA1 serving as the platform of innovation, a six-month

software development effort ensues to ensure that the product will meet some of

the unique functional specifications of Midland Memorial10. A primary objective

of this effort is to complete the required interfaces to share patient demographic

information, the event points where charges can be captured, and the seamless



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sharing of information among 13 disparate information systems Midland

Memorial10 wants to retain. This process is successfully completed by a talented

team of OpenVistA1 engineers who had a thorough knowledge of the system and

leveraged standard VA design concepts, improved existing software tools, and

developed new integration utilities to accomplish the work. These efforts prove

highly successful and set the stage for the next step, the clinical configuration of

the system.

Clinical configuration of the system begins with the training of six newly

hired registered nurses who form the core of Midland Memorial’s10 clinical

information technology (IT) team. These individuals, under the direction of a

Midland nurse informaticist, are training to become “super users” of the graphical

user interface to OpenVistA1, known as the Computerized Patient Record System

(CPRS) 13. This training gives them the knowledge needed to create templates,

order sets and clinical reminders; set clinical rules; and configure other

OpenVistA1 clinical modules. Staff from Medsphere15 augments their staff

during the design, configuration, training and deployment of the OpenVistA1

system. The goal of the training program is designed to allow Midland

Memorial10 to become a self-sufficient organization that would not be dependent

on a vendor for many of the ongoing operational and maintenance tasks.

Multiple committees convene, under the direction of the IT steering

committee, to ensure a smooth transition to the OpenVistA1 EHR5. These multi-

disciplinary subcommittees include Computerized Provider Order Entry, Bar

Code Medication Administration, Forms, Pharmacy, Medical Records and

Ancillary Department committees. The various subcommittees report up to the

IT steering committee, which meets monthly for the duration of the project.



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Midland Memorial10 and Medsphere15 also establish a joint project governance

structure with regular project communication and issue resolution meetings.

SYSTEM

ARCHITECTURE

The enterprise architecture chosen by Midland Memorial10 includes a

centralized server cluster with a single OpenVistA1 database residing at Midland

Memorial’s10 main campus facility. Midland Memorial10 selects InterSystems

Cache product for its “M” language and database environment due to its robust

capabilities, proven scalability and rich management tool set, which had been

deployed in large-scale clinical settings. The multi-campus enterprise is the first

acute-care hospital to deploy the OpenVistA1 EHR5 solution on a Red Hat

Linux16 infrastructure. A high-availability cluster, using multi-processor x86

servers and clustering software, is installed and configured by Hewlett-Packard

(HP) 14. This technology configuration provided Midland Memorial10 with an

affordable, high-performance, and completely redundant solution using a mix of

open source tools, proven application servers, and commodity x86-based

hardware.



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SOFTWARE

SOLUTION

Midland Memorial’s10 best-of-breed software environment presents some

challenges for a fully integrated solution like OpenVistA1. Medsphere15 is

required to develop several enhancements and interfaces to present a unified

solution within the VistA framework. Midland Memorial10 currently uses

McKesson’s Precision 2000 Health Information System. Precision serves as the

authoritative source of patient demographics, registration, scheduling, master

patient index, and other master files. It is also the primary source of order entry

by the ward clerks for laboratory, cardiopulmonary, dietetics and related consults.

Once patients register, the information is sent to OpenVistA1 by standardized

HL76 messages where it is then “filed” away in the appropriate places within

OpenVistA1.

From here, at key steps of the clinical-care process, various “events”

trigger the charge capture engine to fire off a charge-related message to the

Precision system. After the clinical course of care has ended, the Precision

system generates a bill and manages the revenue cycle from that point forward.

Medsphere15 developed a unique technology solution to assist with both the filing

and the charge capture component of this interface. The primary OpenVistA1

modules initially to be deployed at Midland Memorial10 included the following:

• FileMan • Radiology and Nuclear Medicine • Kernel • Computerized Patient Record Sys • MailMan • Adverse Reaction Tracking • Patient Information Management • Authorization/Subscription Utility • Master Patient Index (MPI) • Clinical Reminders • Inpatient Pharmacy • Consult/Request Tracking • National Drug File • Health Summary • Outpatient Pharmacy • Problem List • Laboratory



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Medsphere15 OpenVistA1 Enhancements Developed for Midland Memorial

The above packages provided the foundation of the OpenVistA1 solution.

From here, Medsphere15 was required to make the following modifications. This

list is not comprehensive, but is representative of the types of changes required to

adapt OpenVistA1 technology in a non-VA setting.

GENERAL: • Fee Tables in OpenVista1 linked to a foreign system’s Charge Master File • Common Physician Identifier • Protocol Event Points for charge capture with HL76 interfaces • Options to populate User (NEW PERSON) file from a foreign registry PATIENT REGISTRATION: • Creation of a common Medical Record Number • Creation of Account Number file and corresponding field in Visit file • HL76 interface from authoritative medical manager to OpenVistA1

PHARMACY: • Charge capture for real-time or batch transmission to foreign billing system • High Dose Alerts • Pharmacokinetic Dosing • Link Lab Results to Inpatient Med Order LABORATORY: • Charge capture for real-time or batch transmission to foreign billing system • HL76 interface for intake of lab orders • HL76 interface for reporting out of lab orders • Tracking Specimen Transfers between Facilities • Faxing of Laboratory Results • Creating multiple interfaces for Blood Bank RADIOLOGY:

• HL76 interface for intake of radiology orders • HL76 interface for reporting out of radiology orders • HL76 interface for intake of radiology result reports • Charge Master file automatically populates/ updates Radiology procedure file IMAGING:

• Developed document scanning enhancement



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PROJECT

CHALLENGES

• Clinical business transformation and Health IT systems implementation.

• Hardware and Infrastructure Enhancements:

• Upgrade network infrastructure to accommodate user’s needs.

• Upgrade existing hardware for improved reliability and performance.

• Upgrading clinician work spaces to increase access and ergonomics.

• Interface challenges integrating over 15 disparate information systems.

• Mission-critical application training 1,500 users for 24/7organization.

• Project management challenges of moderating expectations, managing

personnel, and developing a repeatable deployment methodology with no

commercial precedent.

• Developing an internal support function aligning to organization and the end

users needs; integrating customer and vendor application support.

The following describes OpenVistA1’s ability to match Meaningful Use3 Stage 1

• Computerized physician order entry (CPOE);

Orders for lab orders, procedures, diagnostic studies, immunizations and

referrals can be entered electronically and tracked throughout their lifecycle

to a completed or resulted status. Medication prescriptions can be entered

electronically, and OpenVistA1 EHR5 supports e-prescribing to pharmacies.

• Recording patient demographics;

Patient demographics can be recorded using OpenVistA1 EHR’s5

• Maintaining a problem list of diagnoses;

OpenVistA1 EHR5 supports comprehensive problem lists using ICD917 codes

with problems separated into Active and Inactive Problems. Status and

severity can be tracked along with onset, diagnosed and resolved dates.

• Prescribing electronically (e-prescribing);

OpenVistA1 EHR’s5 allows providers to easily perform e-prescribing to

community pharmacies and mail order pharmacies.

• Maintaining an active medication list for patients;

The OpenVistA1 EHR5 maintains complete patient medication lists using

NDC codes and includes active, inactive and temporary prescriptions.



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• Implementing drug/allergy checks at the point-of-care;

OpenVistA1 EHR5 supports automatic drug-to-drug and drug-to-allergy

interactions as well as contraindication alerts and duplicates medication

checking.

• Preventive medicine and health education;

OpenVistA1 EHR’s5 health maintenance templates display the status of

preventative care for patients, and feature standard-based alerts based on

guidelines from the AAFP18 and USPSTF19. At a glance, providers can be

prompted to order overdue exams, tests and procedures.

• Sending patient alerts and reminders;

OpenVistA1 EHR5 supports custom reminder letters that can be generated on

an individual basis. OpenVistA1 EHR5 Report Writer can run custom reports

to identify patients that are due for care and the data can be exported to Excel

for mail merge.

• Sharing patient records among providers;

Multiple-location practices can instantly access and document inpatient

records from any location. This provides patients with the flexibility to make

appointments or receive test or lab results at any location without causing a

paper chase for the practice.

• Providing patients with electronic copies of their medical records;

The OpenVistA1® Patient Portal is an optional online gateway to the system

that allows patients to review documents online that include medical records,

lab results, etc. OpenVistA1 EHR5 Medical Summary Utility provides

several different methods of extending the patient chart including the export

and import of CCR20 and CCD21.

• Support for and/or integration with systems for verifying insurance

eligibility and submitting claims electronically; and,

Integrated into OpenVistA1 EPM workflow, OpenVistA1 RTS allows

practices to electronically perform eligibility checking via HIPAA22-

compliant ANSI7 x12 270/271 Eligibility Inquiry and Response files.

OpenVistA1 EPM can submit claims to any clearinghouse using the ANSI7

x12 data standard or submit directly to multiple payers that accept the ANSI7

x12 data standard.

• Data sharing with immunization registries and public health

agencies.

HL76 immunization export interface can be supported.



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Meaningful Use Stage 1 Health Outcomes

Policy Priority Care Goals Objectives Measures

Improving quality,

safety, efficiency,

and reducing

health disparities

Provide access to Comprehensive patient health data for patient's health care team

Use CPOE CPOE is used for at least 80% of all orders 23

Use evidence-based order sets and CPOE

Implement drug-drug, drug-allergy, drug- formulary checks

The EPl has enabled this functionality23

Apply clinical decision support at the point of care

Maintain an up-to-date problem list of current and active diagnoses based on ICD-917-CM or SNOMED CT ®

At least 80% of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data23

Generate lists of patients who need care and use them to reach out to patients

Generate and transmit Permissible prescriptions electronically (eRx)

At least 75% of all Permissible prescriptions written by the EP are Transmitted electronically using certified EHR5 technology23

Report information for

quality improvement and public reporting

Maintain active medication list

At least 80% of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data23

Maintain active medication allergy list

At least 80% of all unique patients seen, by the EP, have at least one entry or (indication of “none” if the patient has no medication allergies) recorded as structured data23



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Record demographics o preferred language o insurance type o gender o race o ethnicity o date of birth

At least 80% of all unique patients seen by the EP

have demographics recorded as structured data23

Health Outcomes

Policy Priority Care Goals Objectives Measures

Record and chart changes in vital signs: o height o weight o blood pressure o Calculate and display: BMI o Plot and display growth charts for children 2-20 years, including BMI.

For at least 80% of all unique patients age 2 and

over seen by the EP record blood pressure and BMI; additionally plot growth chart for children age 2-2023

Record smoking status for patients 13 years old or older

At least 80% of all unique patients 13 years old or older seen by the EP have smoking status recorded23

Incorporate clinical lab test results into EHR as structured data

At least 50% of all clinical lab tests ordered whose results are in a positive/ negative or numerical format are incorporated in certified EHR5 technology as structured data23

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach

Generate at least one report listing patients of the EP with a specific condition23

Report ambulatory quality measures to CMS9 or the States

For 2011, provide aggregate numerator and denominator through attestation as discussed in section II(A)(3) of this



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proposed rule; For 2012, electronically submit the measures as discussed in section II(A)(3) of this proposed rule23

Health Outcomes Policy Priority Care Goals Objectives Measures

Send reminders to patients per patient preference for preventive/ follow up care

Reminder sent to at least 50% of all unique patients seen by the EP that are age 50 or over23

Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules

Implement 5 clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II (A) (3). 23

Check insurance eligibility electronically from public and private payers

Insurance eligibility checked electronically for at least 80% of all unique patients seen by the EP23

Submit claims electronically to public and private payers.

At least 80% of all claims filed electronically by the EP23

Engage patients

and families in

their health care

Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies), upon request

At least 80% of all patients who request an electronic copy of their health information are provided it within 48 hours23

Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP

At least 10% of all unique patients seen by the EP are provided timely electronic access to their health information23



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Provide clinical patient summaries for each office visit

Clinical summaries are provided for at least 80% of all office visits23

Health Outcomes Policy Priority Care Goals Objectives Measures

Improve care

coordination

Exchange meaningful clinical information among professional health care team

Capability to exchange key clinical information (for example, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically

Performed at least one test of certified EHR5 technology's capacity to Electronically exchange key clinical information23

Perform medication

reconciliation at relevant encounters and each transition of care

Perform medication reconciliation for at least 80% of relevant encounters and transitions of care23

Provide summary care

record for each transition of care and referral

Provide summary of care record for at least 80% of transitions of care and referrals23

Improve population

and public health

Communicate with public health agencies

Capability to submit electronic data to immunization registries where submissions were required and accepted

Performed at least one test of certified EHR5 technology's capacity to submit electronic data to Immunization registries23

Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice

Performed at least one test of certified EHR5 technology's capacity to provide electronic syndromic surveillance data to public health agencies (unless the public health agencies to which an EP submits do not have capacity to receive info electronically) 23



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Ensure adequate

privacy and

security protections

for personal health

information

Ensure privacy and security protections for confidential information through operating policies, procedures, technologies and law compliance. Provide transparency of data sharing to patient.

Protect electronic health information created or maintained by certified EHR5 technology through appropriate technical implementation.

Conduct or review a security risk analysis per 45 CFR 164.308 (a)(1) and implement security updates as necessary23

References 1. OpenVistA http://sourceforge.net/projects/openvista/

2. Accountable Care Organizations https://www.cms.gov/ACO/

3. Meaningful Use http://healthit.hhs.gov/portal/server.pt?open=512&objID=1325&mode=2

4. Certification Commission for Health Information Technology http://www.cchit.org/

5. Electronic Health Records http://www.himss.org/ASP/topics_ehr.asp

6. Health Level Seven http://www.hl7.org/

7. American National Standards Institute http://www.ansi.org/

8. American Recovery and Reinvestment Act http://www.recovery.gov/About/Pages/The_Act.aspx

9. Centers for Medicare and Medicaid Services http://www.cms.gov

10. Midland Memorial Hospital http://www.midland-memorial.com/

11. Healthcare Effectiveness Data and Information Set (HEDIS)

http://www.ncqa.org/tabid/187/default.aspx

12. Big Springs VA Medical Center www.bigspring.va.gov/

13. Computerized Patient Record System cprs

www.va.gov/vdl/documents/clinical/...patient...(cprs)/cprssetup.pdf

14. Hewlett Packard http:// www.hp.com

15. Medsphere Systems http://www.medsphere.com

16. Red Hat Linux http://www.redhat.com

17. The International Classification of Diseases http://icd9cm.chrisendres.com/

18. American Academy of Family Physicians (AAFP) http://www.aafp.org/online/en/home.html

19. U.S. Preventive Services Task Force (USPSTF) http://www.ahrq.gov/clinic/uspstfix.htm

20. Continuity of Care Record (CCR) www.nchica.org/Past/06/presentations/Kibbe.pdf

21. Continuity of Care Document www.hitsp.org/ConstructSet_Details.aspx?&PrefixAlpha=4...32

22. The Health Insurance Portability and Accountability Act 0f 1996 http://www.hhs.gov/ocr/privacy/

23. Meaningful Use Standards https://www.cms.gov/.../Downloads/MU_Stage1_ReqSummary.pdf

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