The Importance of Dynamism in the OpenVistA Model Chris Richardson & David Whitten WorldVistA June 16, 2005

The Importance of Dynamism in the OpenVistA Model

Chris Richardson & David WhittenWorldVistA

http://www.worldvista.orgJune 16, 2005

2

WorldVistAWorldVistA

• 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?What is VistA?

• Most integrated Health Information Technology (HIT) system in the world– Integrated outpatient and inpatient information with

local 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 care

in 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


• 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


• 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


• 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


• 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


• 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?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


• 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


• 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


• 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 ComponentsSome 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


• 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


• 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


• 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

CPRSCPRS

17

18

CPRSCPRS

• 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 RemindersClinical Reminders

19

20

Clinical RemindersClinical 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 TrackingConsult/Request Tracking

21

22

Health StatusHealth Status 10/14/2004 15:50 ****************** CONFIDENTIAL Clinical Data (1y) SU MMARY ****************** HSPATIENT,ONE 000 -31-9898 1A(1&2) DOB: 07/13/1950 -------------------------- BDEM - Brief Demographics -------------------------- Address: 394 N 700 E Phone: 801 444 1264 Kaysville, UTAH 84037 Eligibility: SC LESS THAN 50% Age: 54 Sex: MALE Ethnicity: DECLINED TO ANSWER Race: WHITE PCMM Team: PRIMARY Phone: 801 -588-2121 PCMM Provider: HSProvider,One Phone: 801 -588-5030 Analog Pager: 801 -588-5555-3938 Inpat. Prov/Attn: HSProvider,Two Phone: Treating Facility Type Station Last Seen ---------------------------- ----------- ------- ---------- ELY CBOC 660GC 06/28/2000 ------------------------- BADR - Brief Adv React/All ------------------------- Allergy/Reaction: DUST, STRAWBERRIES, CHOCOLATE, MILK, SHRIMP ------------------ ----------- PLL - All Problems ----------------------------- 2 Problems ST PROBLEM LAST MOD PROVIDER A Migraine (ICD 346.90), Onset 01/25/2000 03/28/2 004 HSProvider,One A Diabetes (ICD 250.00) 02/08/2004 HSProvider,One ------------------- RXOP - Outpatient Pharmacy (max 1 year) ------------------- ---------------------- ORC - Current Orders (max 1 year) ---------------------- Item Ordered Status Start Date Stop Date REVIEW GERIATRICS Cons Bedside pend 05/14/2004 09:31 ------------- PN - Progress Notes (max 50 occurrences or 1 year) ------------- 09/16/2004 21:07 Title: CARDIOLOGY AUTHOR: HSPROVIDER,ONE IHD Lipid Profile: Outside lipid profile in past year at another VA or non -VA facility. Outside LDL >129 mg/dL Date: March, 2004 Location: Outside Physician's Office < THE ABOVE NOTE IS UNSIGNED > - DRAFT COPY * DRAFT COPY * DRAFT COPY * DRAFT COPY * DRAFT COPY * DRAFT COPY - * END * Press <RET> to continue, ^ to exit, or select component:

10/14/2004 15:50 ****************** CONFIDENTIAL Clinical Data (1y) SU MMARY ****************** HSPATIENT,ONE 000 -31-9898 1A(1&2) DOB: 07/13/1950 -------------------------- BDEM - Brief Demographics -------------------------- Address: 394 N 700 E Phone: 801 444 1264 Kaysville, UTAH 84037 Eligibility: SC LESS THAN 50% Age: 54 Sex: MALE Ethnicity: DECLINED TO ANSWER Race: WHITE PCMM Team: PRIMARY Phone: 801 -588-2121 PCMM Provider: HSProvider,One Phone: 801 -588-5030 Analog Pager: 801 -588-5555-3938 Inpat. Prov/Attn: HSProvider,Two Phone: Treating Facility Type Station Last Seen ---------------------------- ----------- ------- ---------- ELY CBOC 660GC 06/28/2000 ------------------------- BADR - Brief Adv React/All ------------------------- Allergy/Reaction: DUST, STRAWBERRIES, CHOCOLATE, MILK, SHRIMP ------------------ ----------- PLL - All Problems ----------------------------- 2 Problems ST PROBLEM LAST MOD PROVIDER A Migraine (ICD 346.90), Onset 01/25/2000 03/28/2 004 HSProvider,One A Diabetes (ICD 250.00) 02/08/2004 HSProvider,One ------------------- RXOP - Outpatient Pharmacy (max 1 year) ------------------- ---------------------- ORC - Current Orders (max 1 year) ---------------------- Item Ordered Status Start Date Stop Date REVIEW GERIATRICS Cons Bedside pend 05/14/2004 09:31 ------------- PN - Progress Notes (max 50 occurrences or 1 year) ------------- 09/16/2004 21:07 Title: CARDIOLOGY AUTHOR: HSPROVIDER,ONE IHD Lipid Profile: Outside lipid profile in past year at another VA or non -VA facility. Outside LDL >129 mg/dL Date: March, 2004 Location: Outside Physician's Office < THE ABOVE NOTE IS UNSIGNED > - DRAFT COPY * DRAFT COPY * DRAFT COPY * DRAFT COPY * DRAFT COPY * DRAFT COPY - * END * Press <RET> to continue, ^ to exit, or select component:

22

23

Federal VistA AdoptersFederal VistA Adopters

• Veterans Administration (VistA)

• Department of Defense (CHCS)

• Indian Health Service (RPMS)

• U.S. Public Health Service

• NASA

23

24

US VistA AdoptersUS 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 AdoptersInternational VistA Adopters

• City of Bogotá, Colombia

• Germany

• Egypt

• Kenya

• American Samoa

• …and more to come

25

26

Recent VistA EmbracersRecent VistA Embracers

• Panamá

• México

• Japan

• China

• Malaysia

• Jordan

• India

• …and still more to come

26

27

HardHatsHardHats

• 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 Relationships Between US Government and External Communitiesand External Communities

U.S. Government Veterans Affairs

Health & Human ServicesWorldVistA Community

Vista Users

Vista Programmers

Freedom of Information Act Releases

Enhancements, Bug Fixes, Etc.

Distributions

Collaborative Development

29

M TechnologyM 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 TechnologyM 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)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?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?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?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 OntologiesHow 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


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


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


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


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

Some Order Checks Currently UsedSome 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

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

40

41

SummarySummary

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 YouThank You

Questions?

Chris Richardson & David Whittenhttp://www.worldvista.org

June 16, 2005

Documents

The Importance of Dynamism in the OpenVistA Model Chris Richardson & David Whitten WorldVistA June 16, 2005