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The Importance of Dynamism in the OpenVistA Model

The Importance of Dynamism in the OpenVistA Model. Chris Richardson & David Whitten WorldVistA http://www.worldvista.org June 16, 2005. WorldVistA. Nonprofit, 501(c)(3) public-benefit corporation

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The Importance of Dynamism in the OpenVistA Model

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  1. The Importance of Dynamism in the OpenVistA Model Chris Richardson & David Whitten WorldVistA http://www.worldvista.org June 16, 2005

  2. WorldVistA • Nonprofit, 501(c)(3) public-benefit corporation • Seeks to improve health worldwide by making medical software more accessible, more affordable, and better. • Members include • Developers working, or who used to work, for U.S. DVA • OpenVistA end-users • Other organizations members or representatives • Promote VistA Open-Source • Future development coordination • Including “localization” and “internationalization”… • Change management & licensing • Inter-institutional arrangements and coordination • End-User and Developer Education & Training

  3. What is VistA? Most integrated Health Information Technology (HIT) system in the world Integrated outpatient and inpatient information withlocal flexibility and innovation 100+ Modules Used by over 100,000 users worldwide Including 1,300+ VA facilities; in 20+ care networks 170+ Hospitals 650+ Outpatient Clinics 25+ Million Veterans - 20% some receiving carein more than one facility/location Shows List of Sites with Last Treatment Date Displays CPRS Reports from VHA Facilities Home Care, Long-term Care Facilities, etc…

  4. What is VistA? HIT built on standard, industrial strength technologies Leverages and supports Open Source software community Architecture Client GUI for critical and timely data access at all levels Terminal-interface available for power-users. Security Secure communications between client and servers Database From FOSS (GT.M) to commercial offerings (Caché) Platform managing millions of patient records for decades Blazingly-fast data stores Up to 20 times faster than RDBMS and SQL… Operating Systems and Hardware From “big iron” to commodity 32 and 64-bit hardware platforms From Windows to Unix/Linux servers

  5. What is VistA? Multimedia Patient Records Text Computable data Handwritten and non-electronic data Via “scanning” Other multimedia data accessible… Radiology images EKG waveforms Other medical images pathology slides, endoscopic views, dermatology photos, … Video clips echocardiogram, cardiac cath films, barium swallows, gait analysis, … No double-entry of information 5

  6. What is VistA? Simultaneous user accesses Remote access when needed No loss of patient information Contains “traditional chart components” such as: Progress Notes Orders Procedure Reports Discharge Summaries Problem Lists Lab Results Vital Signs 6

  7. What is VistA? Supports “other chart components” such as: Annotated Diagrams - Stick Figures Advanced Directives Consent Forms Flowsheets Admission and Referral Forms Reports from other medical facilities Augments chart components with: Automated alerts for allergies, directives Periodic Clinical Reminders Inpatient Status and Location Outpatient Appointments 7

  8. What is VistA? Enterprise-wide source for Patient ID with business rules Advanced “Master Patient Index” (MPI) With consolidation capabilities for duplicate records Access of patient medical information stored in other facilities Powerful toolkits For database and client/server Multiple programming languages Java Visual Basic Visual C++ Apache/CGI Delphi …and more to come 8

  9. Why Use VistA? Modular Allows tailoring for the needs of any healthcare organization Improves quality of care Provides ALL patient data in one easy-to-access repository Facilitates communication among caregivers Allows data to be… Entered at the point of service Shared among different sites and/or providers Continuity of inpatient & outpatient records Reduces cost Eliminates duplicate-orders Reduces time spent searching for patient information Eliminates redundant record-keeping Simplifies data-collection for research and reporting 9

  10. Why Use VistA? Reduces errors due to lack of data or poor handwriting Increases patient safety Provides enhanced data privacy and security protections. Automated Clinical Support… Clinical reminders (prevention, treatment,…) Alerts (notifications to clinician about real time issues) Scheduled and un-scheduled batch processing Tracks consults and orders from requests to results 10

  11. Why Use VistA? Adheres to National HIT Standards “Consolidated Healthcare Informatics”(CHI) Initiative DICOM Retrieval and transfer of images and associated diagnostic information HL7 Demographic information Units of measure Immunizations Clinical encounters Clinical Document Architecture for text-based reports LOINC EDI of clinical laboratory test orders EDI of clinical laboratory results Drug label section headers HIPAA ANSI X 12N Billing and Financial Standard Transactions NCPDP Retail Pharmacy Transactions CPT, HCPCS, ICD-9, NDC,… Standard Code-sets • SNOMED CT • Laboratory result contents • Non-laboratory interventions and procedures • Anatomy • Diagnosis and problems, and • Nursing • IEEE 1073 • Connect medical devices to information and computer systems • Allows monitoring of information remotely • FDA • Names and codes for ingredients • Manufactured dosage forms • Drug products • Medication packages • NLM RxNORM • Describe clinical drugs • VA National Drug File Reference Terminology (NDF-RT) • Drug classifications 11

  12. Why Use VistA? Open Source / Public Domain Free (unless implemented on top of a commercial database) Significantly reduces Total Cost of Ownership (TCO) Fully-functional Fully-integrated HIS, RIS, LIS, PACS, … Enterprise-wide National-scale Multiple sources of support NOT proprietary… NOT tied limited support sources for an extended period of time… 12

  13. Some VistA Components Clinical Functionality Adverse Reaction Tracking Clinical Reminders Consults/Request Tracking CPRS Dentistry Dietetics Health Summary Hepatitis C Extract Home Based Primary Care Imaging & Multimedia Immunology Case Registry Inpatient Medications Including Intravenous, Unit Dose, etc. Intake and Output Laboratory Including EDI, Anatomic Pathology, Blood Bank Lexicon Utility Medicine Clinical Services Mental Health Nursing Oncology Outpatient Pharmacy Patient Care Encounter Patient Information Admission, Discharge, Transfer, Registration 13

  14. Some VistA Components Clinical Functionality (cont.) Pharmacy Automatic Replenishment / Ward Stock Bar Code Medication Benefits Management (PBM) Controlled Substances Data Management (PDM) Drug Accountability / Inventory Electronic Claims Mail Out Pharmacy National Drug File Outpatient Pharmacy Prescription Practices (PPP) Primary Care Management Problem List Prosthetics Radiology/Nuclear Medicine Remote Order Entry Social Work Spinal Cord Dysfunction Surgery Including Risk Assessment Visual Impairment Vitals/Measurements Women's Health … 14

  15. Some VistA Components Administrative Authorization/Subscription Utility Automated Information Collection System Automated Medical Information Exchange Automated Safety Incident Surveillance Tracking System Decision Support System Extracts Duplicate Record Merge: Patient Merge Engineering Equipment/Turn-In Request Event Capture Incident Reporting Library Master Patient Index Including Demographics Network Health Exchange Occurrence Screen Police and Security Record Tracking Resident Assessment Instrument Scheduling Survey Generator Voluntary Timekeeping … 15

  16. Some VistA Components System FileMan Kernel Kernel Installation and Distribution System (KIDS) Kernel ToolKit MailMan SQL Interface (SQLI) Health Level Seven (HL7) Patient Data Exchange (PDX) National On-Line Information Sharing Patch Module Remote Procedure Call Broker List Manager Remote Data Views Victory Programming Environment (VPE) … 16

  17. CPRS 17

  18. CPRS • Computerized Patient Record System • Patient centered view of record • Dynamically updated client-server architecture • Remote Procedure based • Centralized updates of functionality • Central data storage and validation • Efficient code maintenance • Graphic User Interface • Transparent visualization of patient record • Consistent user interface model • Separation of View-Model-Controller

  19. Clinical Reminders 19

  20. Clinical Reminders • Recommendations, not Practice Standards • Disease Screening • Immunization • Patient Education recommendations • Guidelines to assist in clinical practice • Appropriate utilization based on • clinical judgment • patient's current status.

  21. Consult/Request Tracking 21

  22. Health Status 22

  23. Federal VistA Adopters Veterans Administration (VistA) Department of Defense (CHCS) Indian Health Service (RPMS) U.S. Public Health Service NASA 23

  24. US VistA Adopters Washington D.C. West Virginia South Carolina Oklahoma Minnesota Washington City of Berkeley, CA City and County of San Francisco …and more to come 24

  25. International VistA Adopters City of Bogotá, Colombia Germany Egypt Kenya American Samoa …and more to come 25

  26. Recent VistA Embracers Panamá México Japan China Malaysia Jordan India …and still more to come 26

  27. HardHats Virtual community of worldwide VistA users… Historical information about VistA Mailing-list Access to a worldwide community of VistA users Technical Information / Documentation FileMan M Utilities and Information VA Utilities Etc. VistA-distributions VistA under: InterSystems Caché Fidelity GT.M 27

  28. Relationships Between US Government and External Communities Freedom of Information Act Releases Vista Users Distributions U.S. Government Veterans Affairs Health & Human Services WorldVistA Community Collaborative Development Vista Programmers Enhancements, Bug Fixes, Etc.

  29. M Technology MUMPS “Massachusetts General Hospital Utility Multi-Programming System” Also known as “M” Programming language, database management system and related bindings and protocols Predominant world-wide in large integrated hospital information systems. Also successful for systems in financial, travel, shipping, and other industries.

  30. M Technology Main features include: Comprehensive procedural language Support for object-style event-driven processing Integrated hierarchical data management facility Bullet-proof database security and transaction processing Multi-user, multi-tasking operating environment Integrated inter-process communication Support for distributed data and distributed processing High-performance client-server networking capabilities

  31. M Technology (cont) Available with “M” are: Relational data manipulation tools Industry-standard SQL SQL-based connectivity ODBC Interfaces to windowing managers ANSI X3.64 standard support for character devices ANSI GKS standard support for graphics devices

  32. What are Ontologies? Controlled Vocabularies and Taxonomies descriptions built from simpler components broad coverage of data values Formalized Rules and Facts hierarchically arranged categories first order logic formal semantics specialization and generalization classification system dynamic inference rules augmenting system integrated search using rules and facts

  33. How does VistA use Ontologies? Two Answers – both true VistA doesn’t use Explicit Formal Ontologies Long history of development (from 1980’s to present) Implements progressive ontological concepts as available VistA uses Ontologies throughout Many ontological components used Declarative (table driven) strategy is common Hierarchical data structures with inheritance Rule driven methodologies used Expert system used for order checking Controlled vocabularies for workload, diagnosis Permission Security System is rule based

  34. How does VistA use Ontologies? • Implicit Ontology based on database definitions and business rules • VA FileMan Database has strong modeling capabilities • Hierarchical, based on Codd and Date’s original theories • Primary focus on clinical and medical information storage • Consistency and Integrity maintenance • Database elements and user interface consistency • Procedural verification and action semantics • Declarative (table driven) implementation • Cross table and field constraint system

  35. How does VistA use Ontologies Enterprise-wide consistent vocabularies Lexicon based on UMLS National Drug Formulary Ongoing Standardization Process Drug Classes Drug Ingredients Allergy names Packaging, Medical Routes ICD9 DRGs (545 entries) CPT codes /AMA procedures (~17,000 entries) Progress Note Titles and Hierarchy

  36. How does VistA use Ontologies Lexicon based on Unified Medical Lexicon System (UMLS) Table driven Vocabulary system MAJOR CONCEPT MAP (~120,000 entries) CONCEPT USAGE (~120,000 entries) EXPRESSIONS (~153,000 entries) EXPRESSION TYPE (7 entries) EXPRESSION FORM (14 entries) CODES (63,000 entries) CODING SYSTEMS (33 entries) SEMANTIC MAP (~174,000 entries) SEMANTIC CLASS (15 entries) SEMANTIC TYPE (133 entries) SOURCE CATEGORY (487 entries) etc.

  37. How does VistA use Ontologies Hierarchically Driven System • User Menu based on Organization’s Functional Areas • Role based security • Menu Items based on day-to-day actions • Graphical Interface (CPRS) Parameters • Default values hierarchy • individual, department, software subsystem, local hospital • Values used for data entry and data presentation • Rule driven capabilities • Access to resources (orders, consults, progress notes) • Students require co-signers • Deleting, Modification, Viewing

  38. How does VistA use Ontologies Order Checks Expert System • ORDER CHECKS (27 entries) • ORDER CHECK COMPILER FUNCTIONS (56 entries) • ORDER CHECK DATA CONTEXT (7 entries) • ORDER CHECK DATA FIELD (158 entries) • ORDER CHECK DATA SOURCE (15 entries) • ORDER CHECK ELEMENT (139 entries) • ORDER CHECK NATIONAL TERM (14 entries) • ORDER CHECK PATIENT RULE EVENT (# entries dependent on site ~300,000) • ORDER CHECK RULE (71 entries)

  39. How does VistA use Ontologies Order Checks Expert System • ORDER CHECKS (27 entries) • ORDER CHECK COMPILER FUNCTIONS (56 entries) • ORDER CHECK DATA CONTEXT (7 entries) • ORDER CHECK DATA FIELD (158 entries) • ORDER CHECK DATA SOURCE (15 entries) • ORDER CHECK ELEMENT (139 entries) • ORDER CHECK NATIONAL TERM (14 entries) • ORDER CHECK PATIENT RULE EVENT (# entries dependent on site ~300,000) • ORDER CHECK RULE (71 entries)

  40. GLUCOPHAGE-CONTRAST MEDIA GLUCOPHAGE-LAB RESULTS LAB ORDER FREQ RESTRICTIONS MISSING LAB TESTS FOR ANGIOGRAM PROCEDURE NO ALLERGY ASSESSMENT ORDER CHECKING NOT AVAILABLE POLYPHARMACY RECENT BARIUM STUDY RECENT ORAL CHOLECYSTOGRAM RENAL FUNCTIONS OVER AGE 65 SIGNIFICANT DRUG INTERACTION Some Order Checks Currently Used ALLERGY-CONTRAST MEDIA INTERACTION ALLERGY-DRUG INTERACTION AMINOGLYCOSIDE ORDERED BIOCHEM ABNORMALITY FOR CONTRAST MEDIA CLOZAPINE APPROPRIATENESS CRITICAL DRUG INTERACTION CT & MRI PHYSICAL LIMITATIONS DANGEROUS MEDS FOR PT > 64 DISPENSE DRUG NOT SELECTED DUPLICATE DRUG CLASS ORDER DUPLICATE DRUG ORDER DUPLICATE OPIOID MEDICATIONS DUPLICATE ORDER ESTIMATED CREATININE CLEARANCE 40

  41. Summary VistA and Ontologies • large Hospital Information System • multiple sources of content suitable for inclusion and formalization • History of Innovative inclusion of technologies • Consistent data model and management system • Non-unified ontological approach • Would benefit from Standard Upper Ontology

  42. Thank You Questions? Chris Richardson & David Whitten http://www.worldvista.org June 16, 2005

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