Transcript RPMS EHR World VistA 061607

Howard Hays, MD, MSPH
RPMS Program Manager, IHS
World VistA Community
June 16, 2007
Indian Health Service
• Provides comprehensive care to over
1.6 million American Indians / Alaska
Natives
• Nearly 600 health care facilities
Hospitals
Health Centers
Health Stations
Residential treatment centers
Alaska village clinics
Urban programs
Federal
36
61
49
5
Tribal
13
158
76
28
170
34
Indian Health Service
• Over 50% of programs are operated by tribes
through tribally run compacted or contracted
facilities
• 34 urban programs are contracted to provide
care to AI/AN populations in metropolitan
areas
• Remaining care is provided through federally
operated ‘direct’ programs (majority of the
user population still receives care in direct
programs)
• Clinical care
Data Needs
– Provision of care (diagnoses, meds, results, etc.)
– Assessment of quality of care
• Public Health Surveillance
– Fluoridation, Immunization, Suicide, DV/IPV, etc.
• Billing / Collections
– Diagnosis and service codes
• Research
– Collaborations with CDC, AHRQ, academia
• Performance Assessment
– GPRA and other national measures
• Legislative
– Congressional reports, budget justification, etc.
Data Issues in IHS
• Funding and reporting are centralized, but
administration and governance are
decentralized
• Over half of Indian health programs are
administered autonomously by tribes
• Submission of health data from tribes is
voluntary
• Therefore, we (IHS) must provide tools for
quality care and data collection that are
attractive and meet the needs of all
constituents, Tribal and Federal.
RPMS
• Resource and Patient Management
System
• IHS Health Information Solution since
1984
---- A.K.A. ---Really Powerful at Measuring Stuff
What is RPMS?
• RPMS is an integrated Public Health
information system
– Composed of over 60 component applications
– Patient and Population based clinical
applications
– Patient and Population based administrative
applications
– Financially-oriented administrative applications
www.ihs.gov/CIO/RPMS
VistA and RPMS
• Common programming/database architecture
(M/Cache)
• Applications shared by VHA and IHS
• Many developed for use in VHA and adapted for
IHS
• Others developed for use in IHS, some adopted by
VHA
• RPMS focused around Visit data contained in
Patient Care Component (PCC)
• IHS uses HRN instead of SSN
IHS is not VHA
• Cradle to grave care
– Pediatrics
– Prenatal and obstetrical care
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Smaller facilities, more rurally located
Decentralized administration
Tribal autonomy
Community and population-based mission
Very modest IT staffing & budget
RPMS Integrates Multiple
Clinical Systems
The EHR Challenge for IHS
• Produce or acquire an Electronic Health
Record system that:
– Meets clinical and business needs of both
Tribally and Federally operated facilities
– Is scalable to the needs of facilities ranging
from small rural clinics to medium-sized
hospitals
– Is affordable to facilities with no resource
cushion or ability to borrow
– Is sustainable into the future
RPMS – Elements of an EHR for
over 20 Years
Existing elements
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Registration
Scheduling
Pharmacy
Radiology
Laboratory
Immunizations
Reminders (passive)
Problem List
Health Summary
Other PCC functions
Billing
More . . .
Lacking elements
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Provider order entry
Note authoring
Point of care data entry
GUI usability
Active reminders &
notifications
RPMS Electronic Health Record
• Graphical User Interface to RPMS
– User-friendly and intuitive access to RPMS
database for clinicians and other staff
– Componentized to allow incorporation of
CPRS functionality as well as new
capabilities developed within IHS
– Proprietary “framework” for presentation of
various GUI components
The EHR Componentized Framework
The EHR Componentized Framework
The EHR Componentized Framework
• VueCentric
Design Mode
– Build visual
templates from
available
components,
arranging them
on tabs or panes
in an orientation
consistent with
the user’s
workflow
• VueCentric Layout
Manager
– Allows customization
of visual user template
– Orientation via tabs,
tree views, splitter
panes, etc.
– Click and drag to
modify layout
– Addition of color &
style enhancements
– Layout according to
user’s business flow
RPMS EHR Commonalities with CPRS
• Notifications
• Text Integration Utility – note author
• Reminders application
– IHS-specific national reminders
• Consults application
– RPMS has separate referred care application
• Order Entry, Lab, Radiology, Pharmacy
– Numerous IHS customizations esp with
medication management
IHS-Specific EHR Components
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Medication management interface
Immunizations
Patient Education
Problem List
Diagnosis entry and coding
Superbills and CPT coding
Numerous others
Other RPMS Capabilities
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Powerful Database Query Tools
State Immunization Data Exchange
Reference Lab Interface
Support for pediatric care
Support for women’s health & prenatal
Behavioral Health applications
Multiple Case Management applications
iCare Population Management GUI
Clinical Reporting System – performance
measure application (specific to IHS)
Immunization Data Exchange
• IHS and Tribes share many patients with
private sector
– Shot records are often incomplete due to
patient mobility
– Risk for under- and over-immunization
• Data exchange system for pediatric
immunizations developed
– HL-7 data files exported to and imported from
State immunization registries
Reference Lab Interface
• Released for Laboratory v5.2 (IHS patch
1021)
• Uni- or Bi-directional interface with
contracted reference laboratories
– Unidirectional receives lab results into PCC
– Bidirectional sends orders to reference lab
and receives results into lab package (EHR)
• Implementation is fairly labor-intensive
Well Child Care
• CDC Growth Charts – in PCC+ and EHR GUI
• Infant birthweight & feeding choices
• Ages & Stages Questionnaire (ASQ)
– Age-specific screening in 5 dimensions
– Print form, record score in EHR or PCC
– Guidance for abnormal screens
• Well Child Knowledgebase
– Thousands of age-specific reminders, education,
developmental & medical screening, etc.
– Nationally deployed set with local management
• Additional screening tools (DDST milestones)
Prenatal Care (in development)
• Data collection and entry for:
– First Prenatal Visit
– Interim Prenatal Visits
– Postpartum Visit
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Over 600 data points
Flowchart presentation where appropriate
Data carries over to future pregnancies
Multiple GUI components planned
Flowchart infrastructure extensible to other
types of data
RPMS Behavioral Health System
• First complete electronic record in IHS
(1990s)
• Graphical (GUI) version released 2003
• Widely deployed throughout I/T/U system
– >250 sites
• Designed for A/SA, MH, and SW providers
• Integrated with RPMS medical information
• Supports 3rd party billing for BH services
RPMS Behavioral Health System
• Ability to document:
– 1:1 patient encounters
– Group encounters
– Patient Education, Health Factors and screening
(depression, EtOH, DV)
– Treatment Plans and Treatment Plan reviews
– Case Management Information
– Incidents of Suicide/Suicidal Behavior
BH GUI Screenshot
IBH Screenshot
SRF Screenshot
RPMS Case Management Applications
• Registry-based systems with reminders,
performance indicators, and populationbased reporting
• Immunizations
• Diabetes Management System
• Asthma Management System
• Women’s Health
• HIV Management System
• Population Management (iCare)
iCare Population Management GUI
• Graphical interface for a fully integrated case
management system
• Decision support and patient management for
multiple chronic conditions
• Nationally defined preventive and diseasespecific healthcare reminders
• Customizable patient panels
• Quick performance views using CRS/GPRA
logic for any patient or group of patients
• Plan to incorporate current and future diseasespecific register systems (DM, Asthma,
HIV/STD, CVD, WH, etc.)
iCare provides the ability to create multiple,
predefined and easy-to-define patient panels.
Panels are customizable and unique to the
individual user.
A Panel’s Patient List
Modifying Panels
Modifications made
to individual panels
affect that panel
only
Users choose
which columns they’d
like displayed and in
what order.
Each panel can
have a different
design
“Tags”
iCare utilizes logic
written for other clinical
applications to “tag”
individuals with predefined diagnoses and
conditions
“Flags”
iCare displays patient “flags” related to
•Abnormal labs
•Hospitalizations
•ER visits
•Unanticipated ER returns
Individual “GPRA” View
User’s select which GPRA measures they’d like to view and then
check to see if the measure is met for any individual patient on
the panel.
Aggregated “GPRA” Statistics
iCare uses
“official” GPRA
report logic on
user-defined
populations that
are not currently
available in the
Clinical Reporting
System (CRS)
Patient Record
iCare pulls all available patient
data and displays it in one view
iCare will generate nationally-defined general prevention and
disease/condition specific healthcare reminders that are integrated to
display most stringent criteria applicable to the patient’s chronic
condition(s)
CRS
(Clinical Reporting System)
• Automated reporting system
for tracking over 300 clinical
quality measures, including
22 GPRA measures
• Intended to eliminate the
need for manual chart audits
• Available in both GUI and
roll-and-scroll versions
• Awarded 2005 Nicholas E.
Davies Award of Excellence
in Public Health
CRS
• Identical logic ensures comparable
performance data across all facilities
• Updated annually to reflect changes in the
logic descriptions and to add new
measures
• Local facilities have the option of
transmitting their data for most CRS
reports to their Area Office for Area
Aggregate Reports
CRS 2007 Clinical Measures
• 22 GPRA treatment and prevention measures
• 23 other key clinical performance measure
topics. Examples:
– Diabetes Comprehensive Care
– Osteoporosis Screening
– Comprehensive CVD-Related Assessment
• 22 HEDIS measure topics
• 26 Elder Care measure topics (patients 55+)
• 17 CMS (hospital) measures
Sample Performance Summary
Quality Measurement in IHS
• Sequist, et al. “Information Technology as a Tool
to Improve the Quality of American Indian
Health Care”, AJPH 95:12, Dec 2005
• http://www.ihs.gov/cio/crs/crs_performance_imp
rovement_toolbox.asp
• http://www.ihs.gov/NonMedicalPrograms/Planni
ngEvaluation/pe-gpra.asp
• http://www.ihs.gov/NonMedicalPrograms/Budget
Formulation/bf_cong_justifications.asp (see
2008 pp 202ff)
Advantages of RPMS
• Software is GOTS – public domain - mostly
• Flexible implementation (minimal to full)
• Accommodates paper or electronic
documentation
• Robust database with many standard reports
and powerful queries
• Supports population health mission
• Occupational Health module pending
• Can use local or remote database
Disadvantages of RPMS
• Does not come with any support
• Setup and maintenance of multiple
packages can be challenging
• Not web based or enabled
• EHR GUI requires separate
contract/license
• EHR GUI requires setup of ancillary
packages (pharmacy, lab, radiology) that
may not be used
Discussion