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VistA 4 Roadmap February 26, 2015

Version 3.11

List of Changes Date Version Changes 2/26/2015 3.11 VistA Evolution Program Team,

updated with feedback from ExecSec office

2/1/2015 3.10 VistA Evolution Program Team, further updates, formatting

1/29/2015 3.09 VistA Evolution Program Team updates from ASD

1/22/2015 3.08 VistA Evolution Program Team, updates from VAIQ, including both OI&T and VHA

1/8/2015 3.07 VistA Evolution Program Team, formatting fixes

12/16/2014 3.06 VistA Evolution Program Team, proof-read, addition of Gartner information

12/11/2014 3.05 VistA Evolution Program Team, updated with VistA Evolution Interoperability Plan (VEIP) addendum

12/4/2014 3.04 VistA Evolution Program Team, responding to VAIQ (7531281) comments

11/19/2014 3.03 VistA Evolution Program Team, addition to Section 1.1 (Background to the VistA 4 Product Roadmap)

11/17/2014 3.02 VistA Evolution Program Team, added in paragraph on benefit to Veteran in Executive Summary

11/7/2014 3.01 VistA Evolution Program Team, responding to Executive Triad comments

10/17/2014 3.00 VistA Evolution Executive Triad

Table of Contents

1. Principles ....................................................................................................................9 1.1. High-level, Long-term, Health Promoting Goals ...................................................................... 9 1.2. VistA 4 Key Dependencies and Constraints .......................................................................... 10

1.2.1. Dependencies .............................................................................................................. 10 1.2.2. Constraints .................................................................................................................. 10

1.3. Technical Requirements, Aspirations, and Preferences ........................................................ 11

2. Introduction ............................................................................................................. 12 2.1. VistA Evolution ...................................................................................................................... 12 2.2. Changes from the Prior Version of the VistA 4 Product Roadmap ......................................... 12 2.3. Purpose of the VistA 4 Product Roadmap ............................................................................. 14 2.4. Scope of VistA 4 Product Road Map ..................................................................................... 14 2.5. Assumptions for the VistA 4 Product Roadmap ..................................................................... 14 2.6. Sources of Authority for VistA 4 Product Roadmap ............................................................... 15 2.7. Key Performance Indicators (KPIs) ....................................................................................... 15

2.7.1. Phase 1 - Program KPI Identification ........................................................................... 16 2.7.2. Phase 2 - Program-level Metric Development .............................................................. 16 2.7.3. Phase 3 - Technical-level Specification ........................................................................ 17 2.7.4. Phase 4 – Measurement Plan and Operations ............................................................. 17

3. VistA 4 Product Overview ....................................................................................... 18 3.1. VistA Introduction .................................................................................................................. 18 3.2. VistA 4 Vision ........................................................................................................................ 18

4. Generation 3 EHR .................................................................................................... 20 4.1. Technology Direction ............................................................................................................ 23

5. Interoperability ........................................................................................................ 26 5.1. Data and Terminology Standardization ................................................................................. 27 5.2. Interoperability Development/Transition Schedule ................................................................ 29

6. Feature Set 1 ............................................................................................................ 31 6.1. Interoperability through JLV .................................................................................................. 32 6.2. VistA Standardization, Phase 1 ............................................................................................. 33

6.2.1. VistA Standard ............................................................................................................. 33 6.2.2. Methodology ................................................................................................................ 34

6.3. VistA Immunization Enhancements (VIMM), 1.0 ................................................................... 34 6.4. Laboratory ............................................................................................................................. 34 6.5. Graphical User Interface Tools .............................................................................................. 35

6.5.1. Search Functionality .................................................................................................... 35

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6.5.2. InfoButtons .................................................................................................................. 35 6.5.3. Medication Reconciliation ............................................................................................ 35

6.6. VistA 4 API Exposure,1.0: ..................................................................................................... 35 6.7. Enterprise Messaging Infrastructure (eMI) ............................................................................ 36

7. Feature Set 2 ............................................................................................................ 37 7.1. Interoperability Enhancements .............................................................................................. 38

7.1.1. Enterprise Health Management Platform (eHMP) ........................................................ 38 7.1.2. VistA Exchange ........................................................................................................... 38 7.1.3. DoD/VA Gateways ....................................................................................................... 39

7.2. Joint Legacy Viewer (JLV) Enhancements ............................................................................ 39 7.3. iMed Consent Platform Migration .......................................................................................... 40 7.4. Enhancements to Pharmacy ................................................................................................. 41

7.4.1. Medication Order Check Healthcare Application 2.1 .................................................... 41 7.4.2. Pharmacy Enterprise Customization System (PECS) .................................................. 41 7.4.3. Pharmacy Product System (PPS)/National Drug File (NDF) Project (PPS-N and PPS-L) ................................................................................................................................... 41

7.5. VistA Standardization, Phase 2 ............................................................................................. 42 7.6. VistA Standardization, Phase 3 ............................................................................................. 43

8. Feature Set 3 ............................................................................................................ 44 8.1. eHMP Development .............................................................................................................. 45 8.2. Interoperable EHR ................................................................................................................ 45 8.3. Scheduling (VistA Scheduling Enhancements) ...................................................................... 46

8.3.1. Single Queue of Request Lists ..................................................................................... 46 8.3.2. Aggregated View of Clinic Profile Scheduling Grids ..................................................... 46 8.3.3. Resource Management Dashboard ............................................................................. 47

8.4. Enhancements to Pharmacy ................................................................................................. 47 8.4.1. Continued Pharmacy Safety Updates .......................................................................... 48

8.5. VistA Service Assembler ....................................................................................................... 48 8.6. VistA Immunization Enhancements (VIMM), 2.0 ................................................................... 48 8.7. VistA 4 API Exposure, 2.0 ..................................................................................................... 50 8.8. FileMan Modernization .......................................................................................................... 50

9. Feature Set 4 ............................................................................................................ 52 9.1. Scheduling (Medical Appointment Scheduling System) ......................................................... 52 9.2. Full Deployment of eHMP ..................................................................................................... 54 9.3. Veteran Authorization and Preferences (VAP) ...................................................................... 54 9.4. Specialty Clinical Applications ............................................................................................... 55

9.4.1. Women’s Health .......................................................................................................... 55 9.5. Enhancements to Ancillary Systems ..................................................................................... 56

9.5.1. Radiology..................................................................................................................... 56

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9.5.2. Laboratory ................................................................................................................... 58 9.5.3. Pharmacy Medication Order Check 2.2 ....................................................................... 59

10. VistA 4 Product Enablers ..................................................................................... 60 10.1. VA Infrastructure ................................................................................................................. 60

10.1.1. Current VA TIC Cloud Initiatives ................................................................................ 60 10.1.2. Virtualization .............................................................................................................. 60 10.1.3. Virtualization of Database Back End Next Generation ............................................... 61 10.1.4. Caché Mirroring Enhanced Disaster Recovery ........................................................... 61 10.1.5. Storage ...................................................................................................................... 61 10.1.6. VistA Data Center Consolidation ................................................................................ 62 10.1.7. NDCP VistA Migrations .............................................................................................. 63 10.1.8. VistA System Data Center Infrastructure Background ................................................ 65 10.1.9. Wide Area Network (WAN) ........................................................................................ 66 10.1.10. WAN Acceleration .................................................................................................... 67 10.1.11. Target VistA 4 LAN .................................................................................................. 67 10.1.12. Client Virtualization .................................................................................................. 68 10.1.13. Messaging / Middleware .......................................................................................... 68

10.2. Security ............................................................................................................................... 70 10.2.1. Security Requirements and Policies ........................................................................... 70 10.2.2. Technical Controls ..................................................................................................... 72 10.2.3. Web Service Security ................................................................................................. 73

10.3. External Collaborations/Enabling Innovations ..................................................................... 76 10.3.1. Founding of the Open Source Electronic Health Record Alliance ............................... 77 10.3.2. VA Open Source Tiger Team ..................................................................................... 77 10.3.3. VA Policy Creation and Open Source Certification ..................................................... 77 10.3.4. Collaboration with OSEHRA Workgroups .................................................................. 78 10.3.5. VA Established the Open Source and Open Standards Community IT Engagement Program ........................................................................................................... 78 10.3.6. VA Established the Open Source Management Office ............................................... 80

11. Summary ................................................................................................................ 81

12. Appendix A: Data Standards ................................................................................ 82 12.1.1. Core Medical Vocabulary Standards .......................................................................... 82 12.1.2. Information Model Standards ..................................................................................... 82 12.1.3. Secure Data Transport Standards .............................................................................. 84 12.1.4. Privacy and Security Standards ................................................................................. 84 12.1.5. Service Standards ..................................................................................................... 85

13. Appendix B: Acronyms ......................................................................................... 86

14. Appendix C: Reference/Bibliography .................................................................. 91

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15. Appendix D: Care Coordination Description ...................................................... 92

16. Appendix E: VistA Standardization List of Applications ................................... 93

17. Appendix F: Data Domain and National Standards ........................................... 95

18. Appendix G: Key Performance Indicators .......................................................... 96

List of Tables Table 1. Technical Requirements, Aspirations, and Preferences for VistA 4 .............................11 Table 2. Data Domains and Terminology Standards .................................................................27 Table 3. JLV Patch Schedule ....................................................................................................40 Table 4. Pharmacy e-Prescribing Milestones ............................................................................47 Table 5. VistA Service Assembler, Increments ..........................................................................48 Table 6. VIMM 2.0 Increment Schedule ....................................................................................49 Table 7. Legacy VistA Clinical Packages ..................................................................................50 Table 8. FileMan Increment Schedule .......................................................................................50 Table 9. FY 12 Migrations .........................................................................................................64 Table 10. FY 13 Migrations .......................................................................................................64 Table 11. FY 14 Migrations .......................................................................................................64 Table 12. FY15 Migrations ........................................................................................................64 Table 13. Remaining VistA Migrations ......................................................................................65 Table 14. VistA Data Center Consolidation Timeline Through 2013 ..........................................65 Table 15. Security Control Classes, Families, and Identifiers ....................................................72 Table 16. CITE Activities ...........................................................................................................79

List of Figures Figure 1. Example of VA-DoD Data Sharing Progress ..............................................................21 Figure 2. VistA 4 Conceptual Architecture .................................................................................24 Figure 3. Example Terminology Mappings ................................................................................28 Figure 4. Feature Set 1 Gantt Chart ..........................................................................................32 Figure 5. Regional Diagram for Data Center Consolidation .......................................................63 Figure 6. Next Generation WAN topology .................................................................................67 Figure 7. Industry-standard Web Services Stack .......................................................................75 Figure 8. Information exchange between VHA, OI&T, and the community ................................79 Figure 9. Relationship of Care Planning, Care Management, and Care Coordination ...............92

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Executive Summary

In 2009, the Departments of Veterans Affairs (VA) and Defense (DoD) were charged to establish a method by which active and retired Servicemembers and Veterans could easily access their health records. Specifically, the Departments were called upon to “work together to define and build a seamless system of integration so that when a member of the Armed Forces separates from the military, he or she will no longer have to walk paperwork from a DoD duty station to a local VA health center. Their electronic records will transition along with them and remain with them forever.”1 To achieve this, the Departments are on complementary paths for modernizing their respective electronic health record (EHR) systems. Both Departments remain fully committed to the use of open standards and open architecture to ensure seamless interoperability and information sharing across the two systems. Through enhancements to its legacy systems, VA will fulfill the President’s vision and provide clinicians the best healthcare information technology available, including state-of-the-art clinical decision support and analytics. This will, in turn, ensure that our Nation’s Servicemembers, Veterans, and their dependents receive timely and high quality care. To oversee enhancements to VA’s EHR, known as Veterans Information Systems and Technology Architecture (VistA), the VistA Evolution Program was established. In accordance with the 2014 National Defense Authorization Act (NDAA), Section 713, by December 31, 2016, the VistA Evolution Program will deliver a modernized VistA – VistA 4. VistA 4 will not only have the technical capability to bring evidence-based medicine to the point of care and to provide functionality for multiple care venues, but it will also be interoperable with DoD’s EHR system, consistent with the key performance indicator to improve clinical decision making. VistA 4 will provide the full complement of clinical capabilities of a true Generation 3 EHR2 upon its enterprise-wide deployment in Fiscal Year (FY) 2018. This will enable VA to maintain its track record of excellence, providing world-class value and quality in health care delivery to Veterans, Servicemembers, and their dependents. By emphasizing patient-centered care plans, VistA 4 will significantly improve Veteran health outcomes and care coordination. Moreover, with an interoperable EHR, each Veteran will have a single, approved longitudinal care plan that is coordinated and comprehensive. The plan will begin with a Veteran’s inception into the service and move along with them through each stage of active duty, eventual separation or retirement from service, and Veteran status. Interoperable EHR systems will improve the speed and accuracy of clinical decision making and will ensure that authorized beneficiary and medical data are accessible, usable, shared, and secure to meet the needs of Veterans and their care team. Patient safety will be improved, as the chance that critical clinical findings will go unresolved will be greatly lessened. Additionally, standardization of terminology across DoD/VA will not only promote more accurate monitoring and management of an individual

1 Obama, Barack. “Remarks by The President on Improving Veterans Health Care.” The White House, Office of the Press Secretary. Eisenhower Executive Office Building. 9 April 2009. http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-on-Improving-Veterans-Health-Care-4/9/2009/. 2 See Handler, Thomas J. and Barry R. Hieb. Gartner’s 2007 Criteria for the Enterprise CPR. Gartner, 2007.

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http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-on-Improving-Veterans-Health-Care-4/9/2009/

Veteran’s care, but will also enable cross-Agency data analysis and research to address service related diseases.

VistA 4 enhancements will be built upon an efficient and agile Service-Oriented Architecture (SOA) framework for ease of development and deployment, consistent with the key performance indicator to shorten the time to delivery of needed functionality. The VistA Evolution Program will deliver the product on an interoperable, secure, and reliable technical infrastructure. VistA Evolution will adopt enhancements outlined by the VA Enterprise Infrastructure design, including cutting-edge regional Data Centers and a fault-tolerant NextGen Wide Area Network (WAN). The VistA 4 Product Roadmap outlines how VA will build upon the institutional knowledge investment in VistA to achieve this goal. The VistA Evolution Program will deliver VistA 4’s capabilities in four Feature Sets. The first Feature Set was successfully delivered at the close of FY 2014.


1. Principles

1.1. High-level, Long-term, Health Promoting Goals The VistA 4 initiative must be shaped by a number of core principles, each of which is a critical success factor:

• The implementation of information technology at VA must be planned and executed to provide measurable improvement in specific high-priority areas of VA’s mission.

• For VistA4, the improvement is in meeting the health needs of Veterans.

• The implementation of information technology within VA will be designed to facilitate reengineering of those processes necessary to improve mission execution in measurable ways.

• The VistA Evolution Program will be designed to be a foundational component of a broader initiative to strengthen the role of VA as a thought leader in US healthcare by:

o Estimating, in advance, the quantitative improvements in healthcare access, quality, safety, and cost needed to optimize Veteran health and socioeconomic well-being; and,

o Implementing a system architecture that is constrained to be both necessary and sufficient to optimize the end-user experience for Veterans, VA staff, and other key stakeholders.

• Implementing a system architecture that is constrained to be both necessary and sufficient for future evolution in a rapidly changing healthcare and technological environment.

• The implementation of information technology within VA health systems must be Veteran-centric, resulting in seamless integration of health data with other healthcare systems, regardless of the physical location of the information, its perceived ownership, or the organizations involved.

• VA’s strategic technology decisions must integrate customer needs (clinicians and Veterans, Servicemembers, and their dependents) and the organization’s internal processes to drive mission execution improvements in measurable ways.

• VA’s IT management processes must be totally integrated from the idea stage through final implementation to ensure the delivery of higher added value outcomes for customers.

• VA must maintain a creative attitude in all its informatics efforts – thinking in long-term ways, being flexible, confronting obstacles boldly, thinking broadly, and setting bold targets, with an emphasis must be on long-term solutions.

• VA must move from individual technology acquisitions to the concept of technology assimilation. Design must emphasize a total systems point of view focused on objective mission improvement, and not just collections of capabilities.

• VA program management must value agility, responsiveness, and rapid innovation – from the end user experience at the point of care to the ability to rapidly modify its Information Management /IT resources in response to changes in clinical practice and integrate new technology as it becomes available.


• VA must identify those system elements for which adherence to standards and

standardization is essential and required (such as data definitions, data models, and data exchange) and be flexible in those elements where it is not.

• VA’s information system design must provide the infrastructure and services to promote rapid development of modular functionality and allow end user optimization of personalized configuration to meet their needs and workflow.

• VA’s systems must increasingly be oriented to provide access for Veterans, Servicemembers, and their dependents, and meet their needs through their modality of choice.

• VA should evaluate open source options when planning new technology to address unfulfilled needs, to accelerate development and reduce cost and complexity.

1.2. VistA 4 Key Dependencies and Constraints

1.2.1. Dependencies VistA 4 key dependencies are:

• Stakeholders are able to contribute at predefined involvement points as identified in project plans and schedules.

• Suitable integrated test environments are available (copy of a production account that includes VistA and interoperability components) for functional and performance testing of each project. Because development of an identity management system is outside program scope, the identity management service provided by VA’s Master Veteran Index (MVI) will be utilized. It will serve as the identity interface to the DoD’s Identity Management Service.

• An enterprise messaging solution must be deployed in support of VistA 4 messaging requirements.

• Supporting technology resources (toolsets, network resources, development/test hardware and platform software and environments) will be available on schedule in the development, test and production environments.

• Supporting infrastructure resources (security, performance testing, architecture, software distribution mechanisms, etc.) will be available on schedule in the development, test and production environments.

• Supporting network infrastructure will allow VistA 4 to meet performance metrics.

1.2.2. Constraints • Applications must support and comply with the OneVA EA.

• Applications must comply with Section 508 Compliance criteria.

• VistA 4 must comply with DoD/VA Interagency Program Office (IPO) interoperability requirements.

• VistA 4 must meet statutory and regulatory requirements, such as Meaningful Use.


• Development will follow Project Management Accountability System (PMAS), tailored

appropriately.

In general, the VistA Evolution Program will support the attainment of the overarching VistA 4 product requirements, aspirations and preferences outlined in Table 1.

1.3. Technical Requirements, Aspirations, and Preferences Table 1. Technical Requirements, Aspirations, and Preferences for VistA 4

Domain Requirements, Aspirations, and Preferences

Management Agile: Require gated Agile methodology based on user stories or feature development, as appropriate to the task.

Transition: Aspire to an orderly transition that supports incremental improvements to legacy platforms until the new platform demonstrates viability. Resource business process re-engineering and change management.

Sourcing: Prefer open-source solutions that have robust development and user communities, especially those with commercial support. Secondarily, prefer propriety technologies with robust user communities that contribute to improved technology and content, next open source, and then proprietary solutions, without broad use.

Technical SOA: Aspire to a limited set of components and services in a service-oriented architecture (SOA) that can be reused and configured to address a wide spectrum of functionality.

Standards: Require new components to have consistently implemented, well maintained standards, and adequately specified APIs and service interfaces. Prefer nationally recognized open standards with broad community support. In critical areas, standards compliance remediation will be undertaken to ensure interoperability, quality, and safety.

Design: Require compatibility with VA SOA Design Principles where applicable. Obtain Office of the National Coordinator for Health Information Technology (ONC) EHR certification.

Informatics Design

User Experience (UX): Require a UX that facilitates accurate understanding of the patient’s health and health care, appropriate decisions for interventions, and efficient execution of health care activities; require adherence to ONC EHR certification criteria relating to user-centered design. Minimize the number of user-interfaces in simultaneous use, e.g., CPRS plus new GUI.

Clinical Decision Support (CDS): Require knowledge-based systems to create and use well coded, well maintained structured data and relationships and potentially other knowledge artifacts that can be maintained independently from specific solutions

Data: Require transactional acquisition of well-coded data from the point of care or during health related activities that can be used for measurement and improvement of healthcare processes


2. Introduction

2.1. VistA Evolution VistA Evolution is a joint program of VA Office of Information and Technology (OI&T) and Veterans Health Administration (VHA) that will oversee the evolution of VistA into a Generation 3 EHR that is interoperable with DoD’s EHR. This will promote improved outcomes in quality, safety, efficiency, and satisfaction in health care, including care purchased in the community, for Veterans, Servicemembers, and their dependents.

The VistA Evolution Program will leverage open standards endorsed by the ONC3 and adhere to key open architecture tenets, such as open transport formats (e.g., HL7 messaging), open interface specifications, and design patterns, to enable open and scalable solutions.

2.2. Changes from the Prior Version of the VistA 4 Product Roadmap A previous version of the VistA 4 Product Roadmap was delivered on March 24, 2014 in response to the FY 2014 NDAA. This iteration of the VistA 4 Product Roadmap provides an update on the capabilities that have been delivered since then, and provides more detail on the future deliveries in Feature Sets 2, 3, and 4.

In addition to a chronological breakdown of development (grouped into four Feature Sets), the capabilities that will be delivered are described in depth, with a focus on their ability to enhance patient care.

Since the March 24, 2014 delivery of the Roadmap, VA has successfully delivered the capabilities described in Feature Set 1 (noted in the updated Roadmap). VA will continue to deliver major program milestones with multiple deliverables of capability each year. Readers with a technical (IT-centric) or clinical (health-centric) background can gain a deeper understanding of VA’s plans for the evolutionary enhancement of the VistA product in the next years throughout this document.

A key difference between the March 24, 2014 edition of the Roadmap and this iteration is the focus on technical architecture. The previous edition of the Roadmap contained a preliminary product architecture. However, the product architecture has been moved from this document into a new architecture document, allowing for the Roadmap to focus deeply on a chronological narrative of the product. Additionally, since the March 24, 2014 document, Product Set 2, Product 3, and part of Product Set 4 (now called Feature Sets) have been updated with descriptions of the capabilities to be delivered.

The Executive Summary has been re-written to better reflect the intent of the Roadmap, and provide the reader with a more detailed explanation of its content, intent, and purpose. Additionally, the Introductory section now contains more background on the VistA 4 Product Roadmap, which will be updated as each new edition of the Roadmap is delivered.

3ONC is organizationally located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.


Key Performance Indicators (described in greater detail in Section 2.7) were also added to the Roadmap; a mapping between the ten KPIs and Roadmap capabilities is found in Appendix G: Key Performance Indicators.

Section 1 outlines the core principles that will undergird the delivery of VistA 4. Section 2 provides an introduction to the Product Roadmap, with a focus on the legislative background and document history, while Section 3 provides an overall vision of the VistA 4 Product.

Section 4 provides an overview of VistA 4 as a Generation 3 EHR, to be fully delivered in 2018. A Generation 3 EHR is defined as a system that has the technical capability to bring evidence-based medicine to the point of care and provide functionality for multiple care venues.

Interoperability was broken out as a major section within its own right and updated, as part of Section 5; additionally interoperability concepts are now included throughout the document, where relevant.

Sections 6 through 9 concern the Feature Sets, with a description of each capability contained therein. In the prior iteration of the Roadmap, only Feature Set 1 (now found in Section 6) was fully detailed.

Section 10 covers the triad of enabling capabilities for the VistA 4 product, including infrastructure, security, and external collaborations. In line with VA directives, the planned infrastructure adheres to a Trusted Internet Connect (TIC) compliant policy. Additionally, legacy VistA and other applications are in the process of migrating to a smaller number of data centers, in accordance to policy of data center consolidation. The networks supporting these data centers and the interconnections between them are described in Section 10.1, adherence to security standards is described in Section 10.2, and lastly, Section 10.3 focuses on collaboration with the open source community.

Finally, Section 11 provides a final summary of the document.

Since the March 24, 2014 version of the Roadmap, additional Appendices have been added. These include:

• Appendix A: Data Standards, which contains a summary of key standards, as defined in the DoD/VA Health Standards Profile (HSP), including medical vocabulary, information model standards, privacy and security, secure data transport and service standards.

• An addition to Appendix F: Data Domain and National Standards, which lists data domains and the relevant national standard.

• Appendix G: Key Performance Indicators. The VistA 4 Product Roadmap is written as a supporting document for the VistA Evolution Program Plan (see Appendix C: Reference/Bibliography). The VistA Evolution Program Plan focuses on the overall effort required to evolve VistA to meet VA’s overarching vision for an enhanced electronic health record, including clinical enhancements and seamless integration with DoD. As such, these two documents should be considered linked; adjustments to one document will require modifications to the other to ensure they remain synchronized.


2.3. Purpose of the VistA 4 Product Roadmap

The VistA 4 Product Roadmap illustrates the timeline for development, purchase, and integration of VistA 4 components. As this roadmap focuses on the product, this timeline does not account for deployment of code nationwide, training users, or changing business practices.

This timeline is broken down into a series of Feature Sets, described below, that will be delivered in the following four major milestones reflecting support for healthcare and interoperability:

1. Feature Set 1 by September 30, 2014: Successfully delivered (Basic clinical viewer and laying foundation for new capabilities)

2. Feature Set 2 by September 30, 2015 (Rich clinical viewer and interoperability advancements, development and field deployment of enterprise Health Management Platform, Interoperability and Pharmacy enhancements)

3. Feature Set 3 by December 31, 2016 (Veteran-centric capabilities and Interoperable EHR, per FY 2014 NDAA, Section 713)

4. Feature Set 4 by September 30, 2018 (Longer-term care- coordination and interoperability objectives)

2.4. Scope of VistA 4 Product Road Map This document includes the background and vision for VistA 4, along with the functional capabilities that have been (Feature Set 1) and will be (Feature Sets 2, 3, and 4) delivered. Also outlined are desired outcomes, as denoted in the KPIs, along with anticipated benefits to VHA, clinicians, and Veterans.

2.5. Assumptions for the VistA 4 Product Roadmap The following assumptions guide the VistA 4 Product Roadmap.

• Sufficient funding is available and properly phased in the out-years;

• The DoD/VA IPO, by law and charter, is the authoritative source for all guidance related to DoD/VA interoperability; the Interagency Clinical Informatics Board (ICIB) will provide additional input.

• Actions are being taken to resolve the following items from the DoD/VA Gap Analysis Summary Report (see Appendix C: Reference/Bibliography):

o Ensure that the gaps identified by the DoD/VA Gap Analysis are addressed;

o Comply with data and terminology standards for relevant date;

o Work toward “horizontal consistency” – use of the same small set of standards across all exchanges; and

o Work collaboratively with DoD to create standards-compliant adapters to data sources.

• The data standards for interoperability are defined in the Interagency Program Office – Healthcare Information Interoperability Technical Package, Version 3.0, November 18, 2014; for more information, see Appendix A: Data Standards.


• Products must support and comply with both the OneVA Enterprise Architecture (EA) and

established VA Architecture, Strategy, and Design (ASD) design patterns;

• DoD and VA will continue efforts to share information about the Veteran, find common representations of Veteran information that can be understood, and make this information available on demand (under appropriate security controls);

• Each Department will store information about the Veteran, making it readily available to the other Department;

• VistA 4 will be based upon approved VA SOA Design principles4; and

• The following terms are defined as: o Interoperability: The concept of VistA Interoperability is derived from the NDAA

definition, joined with the Institute for Electrical and Electronic Engineering (IEEE) Standard Computer Dictionary definition for Interoperability, and is as follows:

The ability of VistA to work with other systems or products without special effort on the part of VistA users.

o Generation 3: The term Generation 3 is shorthand for designation of Generation 3 capabilities, according to Gartner's 2007 criteria for the Enterprise Computerized Patient Record (CPR)5 (Handler and Hieb). There are many specific criteria; as a whole, Generation 3 means, with respect to an electronic health system, a system that has the technical capability to bring evidence-based medicine to the point of care and provide functionality for multiple care venues.

o Interoperable: The VistA Evolution program, as well as the NDAA directive, defines the term interoperable as: The ability of different electronic health records systems or software to

meaningfully exchange information in real time and provide useful results to one or more systems.

2.6. Sources of Authority for VistA 4 Product Roadmap Any information pertaining to the structure, authority, or governance of the VistA Evolution Program exists in the VistA Evolution Program Plan.

2.7. Key Performance Indicators (KPIs) In the VistA 4 Product Roadmap, the established KPIs were connected to the rationale and goals of the roadmap, further demonstrating that the design of the roadmap is related to overall VistA

4 VA OI&T’s Technology Strategies SOA design patterns: http://www.techstrategies.oit.va.gov/docs_design_patterns_soa.asp 5 Note that Gartner considers CPR a more precision definition of the electronic records used in acute care settings. However, Gartner does use EHR to refer to federal health IT initiatives. Therefore, in this context, CPR can be taken as standing for EHR.


Evolution strategic program goals. More information, including the KPI methodology, performance architecture process, and the list of the high-level Program KPIs, may be found in Appendix G: Key Performance Indicators.

The KPI methodology has four phases:

1. program-level KPI identification

2. program/clinical metrics development

3. technical KPIs/data specifications

4. monitoring/measurement protocols

KPIs will provide the VistA Evolution Program with a vision of its impact and health value.

Both VHA and OI&T inputs are needed for the KPI methodology. In order to make the KPIs meaningful and measurable, VHA metrics (phase 1 and 2, clinical or program impact) must be connected to OI&T metrics (phase 3 technical and system performance, and phase 4 system behavior monitoring or output queries).

2.7.1. Phase 1 - Program KPI Identification Develop Global KPIs from Strategic Goals: This phase of the KPI development focused on defining the KPIs. The methodology was first defined to follow a top-down (from Strategic Goals and Objectives) and a bottom-up approach (from the VistA Roadmap and Capabilities), so the list of indicators would be consistent at all levels. The process for defining new KPIs was based on an agile methodology, through the work of VHA stakeholders. The KPIs were proposed (the first list was developed from the VHA Strategic Plan), reviewed and validated in continuous process with the participation of subject matter experts from VHA. In this validation process, the mapping with the latest version of the Roadmap was also done. After a series of discussions with VHA SMEs, 10 KPIs were developed that were linked to the VHA Strategic Goals and the VHA 10 Points for the Blueprint for Excellence.

2.7.2. Phase 2 - Program-level Metric Development Develop Program Metrics from Global KPIs: Phase 2, also developed within VHA, focused on developing the underlying measurable and feasible program metrics that will be used for measuring the success of each of the program-level KPIs. In total, approximately 60-70 metrics are being selected in the last iteration. In order to develop the metrics, time was spent researching industry measurement best standards related to the program-level KPIs and metrics. Multiple literature sources were identified to validate and support the metrics. Once the metrics were validated against the literature sources, they were also reviewed and validated by VHA SMEs.

Determine the Information Sources for Metrics: After validation with the SMEs, baseline calculation methods and sources of data from a functional/system point of view are being identified for the metrics.

Determine the Program Metric Targets and Achievement Dates: Performance targets, and achievement dates for the Measurement Plan have been also set for most of the metrics. These performance targets will need to be reviewed and complemented in later phases.


2.7.3. Phase 3 - Technical-level Specification

Develop Technical Metrics and Map to Program Metrics: This phase of the KPI development is a primary responsibility of OI&T and will focus on defining the technical metrics and mapping these metrics to the 60-70 program-level metrics developed by VHA, which are also mapped to the program level metrics for all 10 KPIS. The organizational process dependence of the program metrics will be teased out so that the technical metrics reflect direct correspondence to performance architecture and system design. A crosswalk matrix will be created that outlines all the relationships between the technical metrics and the program level metrics along with the rationales for the mapping.

2.7.4. Phase 4 – Measurement Plan and Operations Measurement protocols: OI&T will document and outline the site locations, starting date and frequency of collection for every program metric. A comprehensive, validated measurement and monitoring plan will be developed with involved stakeholders in order to properly measure the evolution of each of the program and technical metrics during or throughout r the VistA Evolution Program.

Automated design plan: The first step of this phase will involve detailing the functional requirements needed in order to collect the data for the technical and program metrics. The whole process for data collection will be specified in order to ensure that data will be available in accordance with the previously defined measurement protocol. Secondly, in the content of the monitoring plan, the automated design plan will include gap analysis requirements so that actual performance can be compared with desired performance.

Reporting toolkit: This document will outline the daily duties and management responsibilities for collecting the metrics and the architecture design of the systems that will be needed in order to collect and automatically report on program metrics, with a focus on the technical metrics.


3. VistA 4 Product Overview

3.1. VistA Introduction The mission of VHA is to provide the highest quality care to Veterans throughout their lifetime. The VHA manages the largest federal healthcare delivery system in the United States, employing 180,000 medical personnel to care for over eight million Veterans through multiple care venues: over 150 VA Medical Centers (VAMC), and more than 800 clinics, and 135 nursing homes throughout the continental U.S., Alaska, Hawaii, Philippines, Virgin Islands, Puerto Rico, American Samoa and Guam. VistA is uniquely designed to meet VHA’s mission by providing a single integrated information system for all Veterans health information in a single national information system, spanning a multitude of hospitals, clinics and long term care facilities. VistA has provided this functionality for over thirty years, and is the most proven and highly regarded national scale EHR system in the world. Because most VA hospitals are affiliated with academic medical centers, VHA has the largest role in medical education in the United States. Over 60% of all physicians in the U.S. trained at some trained within VHA and are experienced in using VistA, making VistA the most familiar and widely used EHR in the U.S.

3.2. VistA 4 Vision Upon completion in 2018, VistA 4 will be an interoperable, effective, safe, and efficient healthcare platform that improves the lives of Veterans, Servicemembers, and their dependents. VistA 4 will support VA’s vision to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are patient-centered and evidence-based. Notably, VistA 4 targets care coordination, a model of health care delivery in which teams of clinicians and patients collaborate to improve the health of the Veteran, according to clear patient-driven goals. Care coordination also promotes quality improvement in healthcare processes for all patients. VistA 4 will increase the satisfaction of VistA users, and the use of SOA principles will reduce the risks, time, and cost associated with acquiring new product functionality. Overseeing the delivery of this product, the VistA Evolution Program will ensure compliance with regulatory and statutory requirements.

VistA 4 will rely upon infrastructure, data models, and services that support an open, modular, and extensible EHR platform. This open platform will encourage collaboration with industry, Federal health peers, and the open source community, allowing VA to provide high-quality solutions with both shortened times to market and lowered development costs. The resulting system will be flexible and agile, easily accommodating new technology advances to achieve optimal results. Upon implementation and integration of VistA 4, VA will be well positioned to interoperate with DoD, using modern, flexible technologies and standards. This ensures the ability to improve the health status of Veterans, Servicemembers, and their dependents through the delivery of a longitudinal integrated health record that supports the continuum of care.

Clinical Information Systems Adoption Best Practices and Lessons Learned The clinical perspective is critical to ensure a successful workflow design, and is vital to the overall success of any new clinical system. Clinicians need to be involved from day one. It is essential to have clinical informaticists on the product management team to represent the provider perspective.


The product vision for VistA 4 includes:

• An EHR that is interoperable with the DoD EHR, and which has achieved ONC 2014 Edition EHR certification;

• A modernized EHR to enhance patient-centered, team-based, and evidence-based quality-driven care by giving health care providers a complete picture of a patient’s care and treatment history;

• A user experience that integrates information for improved quality of clinician and patient understanding;

• Sharable Clinical Decision Support (CDS) to promote best clinical practices tailored to the patient's clinical condition and health-related goals;

• Capabilities for clinicians, managers, and researchers to define and manage patient populations;

• Management of activities that improve human and material resource utilization and clarify plans of care for all members of the team including the patient;

• Explicit incorporation of patient goals in the care plan, to support patient-defined terms of success, and;

• Enterprise-wide deployment. This pathway supports the Institute of Health Improvement’s (IHI) Triple Aim of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing per capita costs of health care.


4. Generation 3 EHR In a 2007 report, Gartner identified five generations of CPR systems. This report detailed how CPR systems would evolve through time; from simple systems used merely as replacements for paper records, to complex clinical systems that provide decision support, capable of not only catching potential errors and alerting clinicians but also of guiding clinicians in the implementation of improved treatment methodologies (Handler and Hieb).

The five generations detailed in that report are as follows:

• Generation 1 systems allow the clinician electronic access of clinical data that may have been scattered across several paper record systems;

• Generation 2 systems build upon on the Generation 1 functionality by offering documentation capabilities;

• Generation 3 systems further help the clinician with basic care management and decision support;

• Generation 4 system incorporates greater decision support capability and intuitive workflow capabilities; and

• Generation 5 systems are envisioned as true ‘colleagues’ that can assist the clinician in all facets of care

Per Section 713 of the FY 2014 NDAA, enhancements to VistA must result in an EHR that at...the point of deployment...must be at a generation 3 level or better for a health information technology system. When evaluating CPRs to determine which Generation they belong in, Gartner assesses nine (previously ten) core capabilities, which are listed below. The enhancements outlined in the Roadmap which represent significant upgrades to these capabilities are also described below.

System Management: The VistA Evolution Program will oversee the transformation of VistA so that it adheres to a SOA design pattern. This will result in a vendor-agnostic technology platform that is highly responsive to changing clinical needs: new functionality can be added as new services, old functionality can be changed by modifying or replacing existing services.

As part of Generation 3 system management functionality, VistA 4 will incorporate security controls to properly protect information systems. The use of a robust Identity and Access Management (IAM) architecture will provide support for both coarse and fine grain access controls, enforceable from various points within VistA. Additionally, the use of an integrated MVI, and well-designed network security, will ensure a high degree of security and proper privacy controls for access by Veterans.

VistA 4 will also provide application programming interface (API) support for outside applications. The VistA API Exposure 2.0 project will integrate data from legacy clinical packages with the modernized VistA 4 enabling users to manage, read and write data so that future decisions and actions are based on comprehensive information. Additionally, the enterprise Health Management Platform, which integrates data from multiple data sources, will contain a modular, user configurable interface that can connect VistA data to third-party graphical use interfaces (GUI).

Interoperability


A prime goal of the VistA Evolution Program is cross-Agency (DoD/VA) interoperability. The DoD and VA vision is to enable seamless integration of DoD and VA electronic health record data, achieving improved joint visibility of health status for Veterans, Servicemembers, and their dependents. Seamless integration of health data will provide current and historical information that remains with our Veterans, Servicemembers, and their dependents. Interoperability supports the electronic exchange of health-related financial data, patient-created wellness data, and other health information among caregivers and other authorized parties, thereby better enabling clinicians to view and comprehend multi-sourced patient data. Improving cross-Departmental interoperability and interoperability with industry will provide access to a patient's comprehensive health history from all providers and organizations in one place and in an integrated manner.

Over the past 15 years, DoD and VA have transitioned from a paper based sharing of information to the digital exchange of information. An example of this information sharing is shown in Figure 1. Currently, more than 5.3 million records are jointly accessible and more than 1.5 million pieces of health data are shared daily between the Departments. Initial work has also been completed to execute a health information exchange that allows for the exchange of data with the private sector.

Figure 1. Example of VA-DoD Data Sharing Progress The Departments are not in this data sharing evolution alone. Sharing health information is becoming a bigger issue and goal within the entire healthcare industry. The Departments currently coordinate and collaborate with governance bodies, such as ONC, and other external standards organizations. A majority of the care provided to the nation’s Veterans, Servicemembers and their dependents occurs in the civilian healthcare industry, and adherence and collaboration with national groups is a key part of interoperability outside of the Departments.


Clinical Data Repository Enterprise FileMan’s (Feature Set 3) goal is to create a federated database management system (DBMS) that allow for one instance of VistA to retrieve data from another at the data level. By standardization of VistA applications and their corresponding database, FileMan will allow an enterprise-wide view of patient data. Enterprise FileMan will utilize modern internet database interface capabilities, including secure web services, web interfaces, and web data management capabilities.

Clinical Decision Support The Enterprise Health Management Platform (eHMP), to be deployed enterprise-wide in Feature Set 4, will deliver core CDS functionality to manage common, rule-based evaluations of patient and administrative data using OpenCDS and the JBoss Business Rules Management System. As part of this implementation eHMP will provide a general, standards-based framework for invoking CDS services. The eHMP user will be able to manually or automatically identify and gather patients into cohorts that can be referred to logically within rules. The eHMP CDS capability will not only meet clinical requirements but will also satisfy ONC CDS test requirements. eHMP will deploy a formal rule repository to support CDS artifact development, storage, run-time deployment and governance. This will ensure that CDS artifacts can be retrieved from an appropriate repository at runtime. Furthermore, it will allow for auditing of CDS functionality, as well as delivery of audit and operational metric visualization.

Controlled Medical Vocabulary Common vocabularies and terminologies help standardize the meaning behind shared data, allowing human users and clinical systems to comprehend the data and readily determine how the data may be used for their specific needs. In the near term, the need for consistent and reproducible vocabulary standards across the enterprise is being handled by mapping VA’s local terminology to the appropriate national standard terminologies. In the long term, direct use of the mature national standard vocabularies themselves will ensure increased interoperability, with lower cost and higher levels of safety.

Clinical Workflow eHMP, the eventual user interface replacement for CPRS, will add patient management support for models of care, including multi-patient team boards, condition-based actionable worksheets, team communication through instant messaging and team tasking. eHMP will also provide an additional support for tracking of medical goals and the linking of medical goals to specific interventions and measures in a comprehensive medical plan, as well as separable rules engine to support rapid development and maintenance of workflows and clinical and administrative processes.

Through eHMP, VistA 4 will have a user interface that allows users to easily navigate data to explore past and projected data relationships for easy understanding. This interface will support decisions and actions by allowing users to create steps in the care plan from any related data object. For example, a user will be able to click on a medication to reorder it or to change the medication, with context-based decision support.

Clinical Documentation and Data Capture The architectural approach to building eHMP and the supporting data cache, VistA Exchange (Vx), is centered on gathering clinical data from across VA, DoD and relevant third-parties. VistA Exchange has a patient data synchronization process that gathers data and stores it in the cache for VistA 4 Product Roadmap February 26, version 3.11 22

viewing via eHMP. When a clinician wishes to document an episode of care, including writing orders, capturing care plans, recording vitals, etc., that information will be recorded in the system of record (VistA).

By definition, eHMP will present a holistic view of detailed patient information to support team-based care to the Veteran from a consistent set of information, regardless of where in the VA system the Veteran receives that care. Clinical information captured at the point of care is, by design, made available to all authorized provides across the enterprise.

Clinical Results Display The eHMP Graphical User Interface (GUI) is created using a responsive design that allows authorized users to configure their patient data screens, and save multiple variations thereof, to facilitate rapid presentation of key information depending upon the care setting. For example, a Primary Practice physician may desire a different presentation of data than an Oncologist. eHMP also provides variation in data presentation at the individual data area (e.g., Labs, Vitals) such that the data can be presented at a very high level (a “gist” view) or a very detailed view.

Order Management eHMP will create a new Orders management service that will expand and improve upon the current VistA ordering module. This new service will maintain the enterprise list of ‘order-ables’, as well as local medication formularies, order sets and quick orders. eHMP will provide the front-end user application that utilizes this new service providing an efficient mechanism for the provider to manage all orders as part of a logical workflow.

Clinical Knowledge Management Previously, Clinical Knowledge Management was defined by Gartner as a core capability. However, in a 2010 report, Gartner stated that it no longer finds clinical knowledge management the sole responsibility of the CPR system itself, but as an ancillary capability that should be provided by the CPR’s ability to interact with outside tools, which may contain specialized clinical knowledge repositories.6

4.1. Technology Direction Today, VistA is a collection of many point-to-point technology systems that together form the larger VistA clinical care system. Rapid, coordinated enhancements to these standalone components to meet the evolving clinical needs of the VA can prove challenging. To address this, VA will transform VistA into a federated platform that leverages SOA. SOA can integrate systems as a collection of loosely coupled services, which are abstracted from underlying program complexities. By separating the presentation layer from the data and business logic layers using a messaging layer, applications can access independent services without knowledge of internal implementation structure. The resulting platform, built upon the separation of services and flexible design patterns, allows for rapid and efficient enterprise-wide enhancements. This architecture is depicted below in Figure 2.

6 See Handler, Thomas J. (2010). Modifying the Enterprise CPR System Generation Model. Gartner, 2010.


Figure 2. VistA 4 Conceptual Architecture

The VistA 4 architecture focuses on non-domain specific technical architecture that enables domain specific functionality. For example, the functionality known as interoperability (data exchange) requires the following non-domain specific technology capabilities in order to work:

1) A verifiable trust relationship between parties [security];

2) A network infrastructure to connect the two parties [transport: network]; and

3) The ability to send and receive a message [transport: messaging protocol].

The necessary domain specific capabilities of interoperability are:

1) The format of the payload [data: model]; and

2) The semantics of the payload [data: vocabulary].

Email is an interoperable non-domain specific technology capability. The payload for email is free text and therefore data is not available for computations, graphs, etc. The key to interoperability is the agreement on a data model and vocabulary such that the payload can be computed, graphed and combined usefully with other data within the system to provide better care. Success in interoperability requires both domain and non-domain capabilities; however, today, using World Wide Web Consortium (W3C) standards, technical capabilities can be implemented without regard to the domain specifics.

By evolving the architecture of VistA 4, specific clinical functionality will be easier to implement and less costly to maintain. Moving VistA to a SOA framework will also improve VA’s ability to upgrade VistA’s capabilities in response to clinical needs.

VistA 4 will enable key clinical capabilities using the SOA framework to stimulate innovation and reduce system redundancies. This includes a new web-based user interface, a data management VistA 4 Product Roadmap February 26, version 3.11 24

services capability, and CDS. VistA 4 will ensure that while patient information becomes more easily accessible, the right information assurance controls will be in place to restrict access to authorized users. A new messaging middleware solution will be deployed to enable these new capabilities, such as an intelligent-filtering/text-search and context consistent platform, which are currently unavailable in VistA. The deployment environment for VistA 4 will adhere to TIC compliant policy, involving data center consolidation and a move to virtualization of both back-end and front-end systems.


5. Interoperability There are multiple definitions and classification schema devised for interoperability. Most definitions emphasize meaningful exchange and use of information between systems. Within the Joint DoD/VA Healthcare Information Interoperability Technical Package (I2TP), interoperability is defined as “...the ability of different electronic health records systems or software to meaningfully exchange information in real time and provide useful results to one or more systems.” The VistA Evolution Program has arrived at the concept of VistA Interoperability from the NDAA definition, joined with the IEEE definition of Interoperability, as:

The ability of VistA to work with other systems or products without special effort on the part of VistA users. VA also employs the IEEE definition of interoperability by acknowledging the Health Level Seven International (HL7) interoperability framework, which identifies the following three different “types” of interoperability:

• Technical interoperability: Addresses how computers exchange data. This exchange is accomplished with messaging protocols and data formats, and is sometimes called syntactic interoperability.

• Semantic interoperability: Addresses how computers interpret the meaning of data. Semantic interoperability allows EHRs to unambiguously and consistently determine the meaning of data for data presentation and decision support. Determining the meaning of data is accomplished through assigning unique numeric identifiers to medical concepts using standard terminologies such as the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT). Semantic interoperability assumes technical interoperability as a pre-requisite for success.

• Process interoperability: Addresses how computers are leveraged to support complex care plans and clinical workflows. Process interoperability supports continuity of workflow between different EHRs by providing the right information, at the correct level of interoperability and at the right point in the clinical process. Process interoperability requires technical interoperability, and is made more robust by semantic interoperability.

Beyond the definition and classifications, there are three implementation components VistA Evolution also considers in order to successfully manage and exchange data. VistA Evolution continues to define, agree upon, and implement the following components for successful interoperability:

1. Content: Data Domains and Terminology Standards;

a. Data Domains: Functional groupings of data that is to be shared

b. Terminology: Vocabulary used for each domain within the content structure

2. Content Structure: The syntax or the way data content is to be formatted; and

3. Exchange Method: The means of electronically transferring data via specific transport and security protocols, standards and approaches in a way that preserves syntax, semantics and security of the data.


5.1. Data and Terminology Standardization

The DoD/VA Interagency Program Office (IPO) is responsible for establishing, monitoring and approving the clinical and technical standards profile and processes to create seamless integration of health data between DoD and VA EHR systems. The IPO represents and leads DoD and VA efforts with ONC and other national and international standards organizations. The IPO also collaborates with the ICIB to identify standards.

The HSP contains the agreed-upon, cross-Agency standards to which both VA and DoD will adhere, at the direction of the IPO. IPO guidance for standards is provided in the Healthcare Information Interoperability Technical Package (I2TP). The VistA Evolution Program data standards will conform to the HSP and I2TP; as new standards are added, the VistA Evolution Program will proactively respond to and adopt the new standards. Current I2TP-designated data domains and associated terminology standards are listed in Appendix F: Data Domain and National Standards.

Table 2. Data Domains and Terminology Standards Priority Data Domain National Standard Terminology

1 Allergies (multiple types) Drug Allergens- RxNorm (Interim: UMLS)

2 Medications RxNorm

3 Immunizations CVX- Vaccines Administered 4 Problem Lists SNOMED CT 5 Vital Signs LOINC vitals subset 6 Documents (many types) LOINC Document Types 7 Results - Lab Chemistry &

Hematology LOINC

8 Results – Lab Anatomic Pathology

LOINC

9 Results – Lab Microbiology LOINC

10 Results – Radiology Reports Target: LOINC (Interim: CPT4)

11 Encounter Data – Appointments

Encounter DXs - SNOMED CT

12 Encounter Data – Admissions Encounter DXs - SNOMED CT 13 Procedures CPT4/HCPCS

14 Demographics Ethnicity and Race - OMB/CDC race codes Preferred language -ISO 639-2 alpha - 3 codes

15 Social History SNOMED CT (including smoking status subset)

16 Family History SNOMED CT 17 Scanned & Imported Paper

Records & Non-Radiology Images

LOINC (for Document type)

18 Plan of Care-Pending Orders (multiple types)

Med Orders: RxNorm Lab Orders: LOINC Rad Orders: LOINC

(interim CPT4) Consult Orders: None


19 Radiology Images DICOM (a format, not a terminology) 20 Payers ASC X12N Health Insurance Types 21 Functional Status SNOMED CT (emerging)

22 Providers Provider Type: NUCC Taxonomy 23 Advance Directives (metadata

only) Advanced Directive Type: SNOMED CT

24 Medical Equipment Device Type: UMDNS (emerging) 25 Questionnaires

(General & Standard Instruments)

LOINC (Document Type)

Terminology Standardization is a key part of semantic interoperability. There are multiple aspects to Data and Terminology standardization efforts within VA, including the historical VistA lexicon, current data mapping efforts, and longer term conversion to native use of national standards (to obviate the need for mapping), as well as more sophisticated modeling and terminology development efforts.

The Standards and Terminology Services (STS) group maintains the enterprise wide vocabulary standards and terminology that are currently available within VistA itself, called the VistA lexicon. The VistA Lexicon is an intermediate mapping to standard terminologies. STS Lexicon updates are captured in authoritative lexicon files that are manually distributed and incorporated into various services that perform semantic transformation and alignment. These files are updated with new terminologies and classification codes on a periodic basis. The updates facilitate the use of new terminology, while retaining backward compatibility with older coding schema.

In addition to the VistA Lexicon, additional mapping of VA data to national standards has been occurring in conjunction with the IPO. See Figure 3 for example terminology mappings. The IPO (with VA and DoD) has identified 25 data domains for interoperability. Twenty (20) of these domains have been mapped (or provided internally to VistA in the Lexicon), one (1) is in process, and four (4) domains are currently being recorded only in free-text notes (i.e., they are not captured as structured, readily accessible data).

Figure 3. Example Terminology Mappings

Mapping is a never-ending, fragile and error-prone process. Use of the national standards natively for recording within the system is a safer, more sustainable method. Conversion of domains within


VistA to native use of national standards is a complex endeavor requiring significant resource commitment for the initial migration as well as to keep current with standards updates for the life of the product. STS has a pending contract award which will provide a much needed boost in funding for terminology tooling, mapping and analytics work. VHA is aligning resources to provide clinical expertise in support of the STS work. Lexicon improvements, interim mappings, and longer term conversion to direct use of national standards and more sophisticated information modeling and terminology management is envisioned as part of the proposed Enterprise Terminology Services (ETS) program within VistA Evolution.

5.2. Interoperability Development/Transition Schedule The realization of VistA Evolution interoperability requires all constituent components that provide aspects of the abstract capabilities illustrated in the interoperability framework be delivered and orchestrated into a unified system-of-systems. The scheduled development and delivery of constituent capabilities are illustrated in the transition chart listed below. The deployment of each new increment, and the decommissioning of replaced capabilities must be seamless with regards to the operational solution that VistA provides to the clinical community. They must also contribute to the overall enterprise requirements and architecture goals and objective of VistA Evolution. If VistA Evolution component interoperability and modernization plans do not move in alignment with clinical and IT needs to work in accordance with the enterprise plan, then critical milestones may be missed, program funding profile will become misaligned, and cost allocation challenges may ensue.

Figure 4 illustrates a high level interoperability transition schedule including interoperability milestones of the various VistA Evolution components. For a more detailed discussion of Interoperability, including efforts with the private sector, please refer to the VistA Evolution Interoperability Plan (VEIP).


Figure 5. Interoperability Timeline


6. Feature Set 1 Feature Set 1, the first phase of VistA 4, provided the foundation for the functionality that will be delivered over the next four years. In FY 2014, Feature Set 1’s core capabilities were enabled at two sites; VistA 4 Feature Set 1 is available to a group of Community Based Outpatient Clinics (CBOC) users at the Hampton VA Medical Center (VAMC), in Hampton, VA and Audie L. Murphy VA Hospital, South Texas Veterans Health Care System (STVHCS), in San Antonio, TX.

The VistA 4 Feature Set 1 included the following capabilities:

• Interoperability: Joint DoD/VA information sharing through the Joint Legacy Viewer (JLV).

• VistA Standardization, Phase 1: The two Feature Set 1 sites were standardized on the 74 VistA products of the Interagency Interoperability Core Product Set. Work on VistA Standardization consists of multiple phases, which span multiple Fiscal Years and Feature Sets, with all work scheduled for completion by the end of FY 2015.

• VistA Immunization Enhancements (VIMM), 1.0: Upgraded VistA files to allow use of standardized data and capabilities to read and write immunizations.

• Laboratory: The newly awarded System Engineering & Integration contract provides architecture, requirements design and Concept of Operations support for Laboratory. One or more Laboratory Enhancements project(s) will be initiated in Feature Set 2 to address priority funded enhancements to VistA Lab.

• Graphical User Interface (GUI) Tools: Additional functionality was added to the clinical GUI, including: Google-like searches across an entire patient record, InfoButtons that provide context-specific knowledge resources for medications and patient education, improved medication reviews for enhanced safety, tasks for team-based coordination and follow-up, and a Newsfeed for rapid, chronological review of a patient’s care and results.

• VistA 4 Application Programming Interface (API), 1.0: This release identified an initial set of VistA APIs to expose as services via standard web services programming interfaces. Further work will take place in API Exposure, 2.0 (see Section 8.7).

o Approximately 226 APIs were identified to be developed as services on the Enterprise Service Bus (ESB) and Service Registry/Service Repository. Exposing an API as a service allows an application outside of the M-Code (Massachusetts General Hospital Utility Multi-Programming System Code) environment to use a Remote Procedure Call (RPC) to invoke a VistA API. APIs, exposed as a service, provide complete, secure, and unambiguous access to information in the selected VistA packages. Full exposure of these services will take place in API Exposure 2.0.

Clinical Information Systems Adoption Best Practices and Lessons Learned

Phased deployments have proven more successful than suddenly switching entire systems on at once. Phasing deployment allows users and leadership to correct glitches on a smaller scale, while building user confidence and realizing incremental benefits. Recommended Practice: Developing and Implementing an Enterprise-wide Electronic Records Management (ERM) Proof of Concept Pilot. National Archives and Records Administration (March 2006).


• Enterprise Messaging Infrastructure (eMI): eMI, the sustainment phase of the SOA suite

project, will facilitate the delivery and use of reusable services in support of cross-Agency interoperability.

The above capabilities are reflected in the Feature Set 1 Gantt Chart in Figure 4. VistA 4 Feature Set 1 successfully delivered new user functionality, enabled industry standard capabilities, and positively impacted the quality, safety, efficiency, and satisfaction of health care for Veterans, Servicemembers, and their dependents.

Figure 4. Feature Set 1 Gantt Chart

The aforementioned major deliverables are described in more detail below:

6.1. Interoperability through JLV The DoD/VA JLV is the newest health record viewer available to users in both DoD and VA. JLV helps meet the increasing need for seamless interoperability of standards-based health data to support high quality care for our nations’ Veterans and Servicemembers. JLV addresses the FY


2014 NDAA mandate for an integrated display of data and documents between DoD and VA and serves as a transitional capability for the VistA 4 product. JLV is a waypoint on the path to the state of the art, interoperable, standards based, eHMP, under development by the VistA Evolution Program. JLV also provides several advantages over existing viewers:

• JLV is the only interagency application to provide an integrated, chronological view of real-time electronic health record information from all DoD and VA facilities where a patient has received care in a workflow configurable display.

• JLV supports FY 2014 NDAA requirements by incorporating semantically normalized data, where mappings are available. This enables clinicians to use national standard codes to compare data between systems, understand trends, and develop a more complete picture of a patient’s history.

• JLV combines data from the same clinical domain into one table, arranging it in chronological order, allowing clinicians to scan results and identify trends.

• JLV allows the user to configure displays to support various workflows (e.g., clinicians can create and save a view with tables of labs and medications, side by side, to evaluate the effectiveness of medications).

6.2. VistA Standardization, Phase 1 The VistA Standardization effort, which consists of three phases, involves 130 separate VistA instances, supporting VA Healthcare delivery, at over 150 VAMCs, and over 800 clinics. Each VistA instance is comprised of over 27,400 routines (executable modules of code), which are logically grouped into 150 ‘products.’ Of specific interest to the Interagency interoperability effort is a set of 74 products within VistA that has been deemed the Interagency Interoperability Core Product Set, representing approximately 60% of VistA. This Core Product Set is comprised of 17,400 routines; its products were prioritized for standardization.

In VistA Standardization, Phase 1, the Core Product Set was standardized at the two Feature Set 1 sites. The VistA standard and methodology used for all three phases of this effort are described below in Section 6.2.1 and Section 6.2.2, respectively.

While the work to standardize the Core Product Set for the remaining 128 VistA instances began during the Feature Set 1 time-frame, this effort (Phase 2) was not completed until the end of calendar year (CY) 2014, and is therefore included in Feature Set 2 (see Section 7.5).

6.2.1. VistA Standard The national release of Class 1 code through the Forum system comprises the set of VistA products that are the VA VistA Enterprise Standard. This Standard represents the compilation of all historical releases that can be obtained through the Forum system, as well as in a non-production instance of VistA, used to generate the Freedom of Information Act (FOIA) release of VistA. This FOIA instance of VistA is also used to maintain the OSGVISTA instance, which the VistA Standardization team uses for Clinical Advisory Technical Services (CATS) comparisons. No code is released or refactored as a result of the VistA Standardization effort; VistA Standardization instead inspects and certifies against the identified Standard.


6.2.2. Methodology

The VistA Standardization team ran CATS analysis comparing the target instances with the VA VistA Enterprise Standard, sorted out the true variance through manual inspection, and then provided each Feature Set 1 site with the identified variances for remediation. The site, through OI&T and VHA collaboration, then looked at the variance and determined if the functionality that variance provided was too critical to perform remediation back to the Standard. If nothing prevented remediation, the site restored their VistA product to the nationally released Standard with local test and release processes. If the site felt they could not restore to the standard, they submitted a Waiver Request to the VHA/OI&T joint Waiver Committee. Waivers granted always have a short or midterm pathway back to the standard, such as the variance becoming corrected through an upcoming new release that solved the issue. Alternatively, a site could even route their local modification for national release into the standard if that local modification was preferred to the old standard. Waivers denied meant the site needed to remediate back to the Standard.

6.3. VistA Immunization Enhancements (VIMM), 1.0 These VistA enhancements accommodate data required for immunization capture and interoperability, allowing for enhanced immunization-data portability for Veterans, Servicemembers, and their dependents, and fulfilling the required vocabulary standard for eventual ONC certification. The enhanced functions ensures that Veterans, Servicemembers, and their dependents receive recommended immunizations on time, and through interoperability, allow VA to keep track of immunizations received outside of VA, ultimately improving the health of Veterans, Servicemembers, and their dependents through proactive health management. In collaboration with VA Data Access Services (DAS), the Immunization project also deployed VistA software for the Data Persistence for Commercial Pharmacy Immunizations (Walgreens) project. To date, over 75 VAMCs have installed the patch, and over 400 Veterans a day are receiving immunizations transmitted from Walgreens. These encounters are populating the Veteran’s VistA EHR for more accurate treatment and greater quality of care.

6.4. Laboratory Following award of the Systems Engineering & Integration contract, the VistA Evolution Program identified four high value Laboratory enhancements: Auto-verification, which will optimize resource utilization by setting lab-established boundaries for test results, eliminating the need for laboratory personnel to approve results before they are sent to the attending clinician, upgrades to VistA Blood Establishment Computer Software (VBECS) to help ensure continued patient safety and quality, as well as new clinical functionality, Microbiology upgrades, and an Anatomic Pathology (AP) ordering mechanism for clinicians to provide required information to facilitate specimen processing. With orders and results now using standard terminology code sets, the enhanced Laboratory capability will better enable interoperability and clinical data exchange with internal VA systems and DoD.

Influence of Laboratory Medicine on Quality, Efficiency, and Cost of Health care Lab services account for less than 3 percent of annual health care spending, yet the results of lab tests affect an estimated 70 percent of medical decisions, highlighting the potential influence of laboratory medicine on the quality, efficiency, and cost of healthcare. The Value of Clinical Laboratory Services. American Clinical Lab Association (2011).


6.5. Graphical User Interface Tools

In Feature Set 1, VistA 4 provided an improved user experience for clinicians by enabling many ease-of-use features that enhanced system adoption, productivity, and overall user satisfaction. This initiative shapes the future of VA clinical information systems through deliberate application of health IT to help clinical delivery. The delivery of these advancements established a path forward for VA care teams, patients, and community partners to transition from an antiquated information system to a robust, customizable and flexible environment.

The current VistA system must deal with the challenge of incomplete information capture and display. This creates an incomplete patient record and additional effort is required to devise workarounds for team communication, patient provider messaging, knowledge management, clinical decision support, and clinical practice guidelines availability at the point of care. The new system will mitigate the risk of an incomplete record, as comprehensive information is critical for patient care and necessary for user acceptance. The work completed in this Feature set establishes a baseline for future enhancements and is described in further detail below:

6.5.1. Search Functionality Search functionality enables users to find information in the patient record more quickly and accurately, similarly to the familiar functions of a web search engine.

6.5.2. InfoButtons InfoButtons, located next to data, such as laboratory results, medications, problem list entries and diagnoses, allow quick access to additional information specific to that data with a simple click. Additional information may include simple attributes about the data, or a detailed set of relevant reference materials.

6.5.3. Medication Reconciliation Medication Reconciliation capabilities are designed to provide electronic validation and documentation of medication administration, reduce medication misadventures, provide an online patient medication record, and promote a safer inpatient care environment. The medication reconciliation capabilities provided allow for a clinician to view a Veteran’s medications enterprise-wide; the ability to write data back into a Veteran record will be introduced later.

6.6. VistA 4 API Exposure,1.0: The two VistA API Exposure efforts will help enable interoperability and build the foundation for the future VistA 4 architecture. This project identified an initial set of APIs, which will be later exposed as services in API Exposure, 2.0 (see Section 8.7). VistA APIs can perform the following functions: provide a read or write of data to and from VistA, serving as an “event driver”, or trigger, to notify when a noteworthy write has taken place within VistA.

Dynamic InfoButtons Clicking an InfoButton next to a particular test display could bring up the results. For a Red Blood Cell Count test, items such as a patient’s electrolytes, red blood cell count, white, and blood cell count would be shown, in addition to the normal range for those items. Another InfoButton click could display the medical journal or local VA protocol for treatment response to elevated values.


6.7. Enterprise Messaging Infrastructure (eMI)

eMI, which has been in place since August 2014, provides the necessary software and hardware that makes it easy for any system in VA to communicate with other systems inside and outside of VA. By providing a single address for systems to send their information requests, eMI’s smart routing makes it easy for systems to stay in communications. A change to the location or other similar information for an application no longer means that all systems that use it must also update their code or configurations.

eMI also provides additional value-added services, such as message conversion from one format to another, aggregation of data from multiple sources, and even business rules to allow only data that meets specific filter criteria to come through.


7. Feature Set 2 The second phase of VistA 4 delivery, Feature Set 2, will further build upon the work already delivered in Feature Set 1. Feature Set 2 will include Interoperability Enhancements, development and field deployment of eHMP 1.1 and 1.2, JLV enhancements, web-based migration of patient consent (iMed Consent), Pharmacy enhancements, and Phases 2 and 3 of VistA Standardization. The products included in Feature Set 2 are expected to be delivered at the end of the 4th quarter of FY 2015.

High-level descriptions of the VistA 4 Feature Set 2 are as follows:

• eHMP and Interoperability Enhancements: eHMP capabilities will include the front-end clinical GUI application and presentation infrastructure environment for the future clinical application. It will gradually replace VA’s Computerized Patient Record System (CPRS) as the front-end interface for future VistA clinical applications and enhanced/modernized legacy packages. This capability is dependent on the development of the VistA Exchange to provide middle layer functionality, such as messaging and transformation. Vista Exchange is a data management and messaging engine that will provide aggregated and normalized data, along with a data cache that will significantly enhance performance and reduce redundant network traffic.

o The cornerstone of Feature Set 2 will be the achievement of eHMP development and deployment of versions 1.1 and 1.2.

o Additionally, there are several initiatives taking place in Feature Set 2 that will enable VistA to achieve interoperability requirements by December 31, 2016. These initiatives include the Enterprise Health Management Platform, VistA Exchange, and the establishment of DoD/VA Gateways.

• JLV Enhancements: There are three major releases and one patch planned for FY 2015.

• iMed Consent Web Migration: iMed Consent Web Migration will help improve the efficiency of clinicians managing the electronic informed consent process. The software allows the preparation of an electronic Informed Consent form, which can be easily signed using electronic signature pads, freeing up clinicians’ time to focus on the patient encounter.

• Enhancements to Pharmacy: Medication Order Check Healthcare Application (MOCHA) v2.1 provides maximum daily dose medication order checks; Pharmacy Enterprise Customization System (PECS) v6.0 provides VA customization of order checks provided by a commercial drug knowledge database. Additional enhancements include updates to the Pharmacy Product System, the National Drug File, and Safety Updates for Medication and Prescription Management.

• VistA Standardization, Phase 2 and 3: The remaining 128 of 130 production instances of VistA were standardized on the Core Product Set for VistA Standardization, Phase 2 (note that this was completed at the end of CY 2014). VistA Standardization, Phase 3 builds off of the foundational work accomplished in Phase 1 and Phase 2, by standardizing the remaining 40% of applications beyond the core VistA applications.


7.1. Interoperability Enhancements

One of the VistA Evolution Program’s primary goals is to enhance VistA to meaningfully exchange and use healthcare data and information with other systems. This goal is in alignment with Section 713 of the FY 2014 NDAA, mandating that the VA achieve interoperability with DoD’s EHR systems by no later than December 31, 2016. This mandate, and its additional requirements, are explained further in Section 5. In order for VistA to successfully fulfil this mandate, there are several initiatives that will occur in Feature Set 2, in advance of Feature Set 3. This section explains the deliverables that collectively comprise these Feature Set 2 Interoperability Enhancements.

7.1.1. Enterprise Health Management Platform (eHMP) eHMP is the front-end clinical GUI application and presentation infrastructure environment for the future clinical application. eHMP will gradually replace VA’s CPRS as the front-end interface for future VistA clinical applications and enhanced/modernized legacy packages. It will also replace other VA interoperability-oriented viewers, including VistAWeb and JLV.

eHMP capabilities will be delivered incrementally from FY 2014 to FY 2016 and beyond. In FY 2014 and 2015, eHMP version 1.1, the Viewer Edition, will be delivered and will include the following delivery milestones:

• Delivery in several VA test sites capabilities that satisfy ONC meaningful use criteria; and

• Delivery in VA production sites, of a read-only view of data from available heterogeneous data sources, much like the current JLV.

In FY 2015, eHMP version 1.1 and 1.2, will be delivered. Version 1.1 will include the following features: Longitudinal clinical data views (DoD/VA), including coversheet, activities, documents and medication review, list and view of C32 narratives, text search, and access controls. Additionally version 1.1 will comply with Clinical Context Object Workgroup (CCOW) standards.

Version 1.2 will include user-defined screens, gist views, global Timeline Date Filter, filter, medication review sparkline, patient photograph, receive/display/incorporate Community Health (VLER), auditing, text search improvements, condition-based analysis workspaces health summaries, on-line help and user analytics.

CPRS capabilities will not be fully subsumed until the year 2020. VA will discontinue use of the JLV and VistA Web once eHMP capability, scalability, and deployment is sufficient to supplant them.

7.1.2. VistA Exchange eHMP is dependent on the development of the VistA Exchange to provide middle layer functionality, such as messaging and transformation.

Vista Exchange is a data management and messaging engine that will provide aggregated and normalized data, along with a data cache that will significantly enhance performance and reduce redundant network traffic. VistA Exchange will provide a longitudinal health record, the enterprise Virtual Patient Record (eVPR), which natively integrates data from all VistA instances, as well as data from the DoD and third party providers when appropriate.

Vx is part of eHMP Release 1.0, which was delivered and deployed to the Austin Information Technology Center (AITC) Enterprise Development Environment (EDE) in September of 2014. Vx


Connectivity has been tested against a local VistA and JMeadows (to retrieve DoD and external partner data), but is not connected directly to any external interfaces, as of October of 2014. As of December 2014, Vx is bypassing JMeadows, connecting to the DoD Adaptor to retrieve DoD data, and to Data Access Services (DAS) to retrieve external eHealth Exchange partner data via the VLER Health Exchange services. The current plan is to deploy Vx into three regional primary locations including Sacramento, Warner Robbins, and St. Louis. Each location has a corresponding backup location including Denver, St. Louis, and Warner Robbins, respectively.

Terminology normalization is an important feature of eHMP. In 2015, Vx will rely on an internal mapping of non-standard to standard clinical terminology (similar to JLV). This mapping will be maintained manually according to the authoritative data mappings provided by the IPO. The longer term vision is to utilize an enterprise wide terminology service for managing and propagating clinical terminology mapping.

In 2015, Vx will also rely on VLER Health Exchange to receive content from external partners. VLER Health Exchange will also be migrated to utilize the Vx as the source of VA data provided to the external partners. During FY 2015, VLER Health Exchange will be upgraded to produce the new Consolidated Clinical Document Architecture (CCDA) format that is called for in ONC regulations. CCDA is an HL7 standard that provides a common architecture, coding, semantic framework and markup language for the creation of select electronic clinical documents.

7.1.3. DoD/VA Gateways DoD/VA Gateways will provide the connectivity bridge and security that all current legacy and future interoperability data will traverse between DoD and VA. As DoD and VA deploy new joint interoperability capabilities, the four DoD/VA gateways will allow more timely and secure sharing of health data. DoD is the prime solution developer on this effort, working with VA.

Upgrades and enhancements to the four DoD/VA Gateways are complete, and the medical data sharing traffic has been transitioned from the current Secure Internet/ Nonsecure Internet Protocol (IP) Router Network (NIPRNet) to the VA/DoD Gateways. The Departments are currently in process of testing gateway failover, which was completed on January 21st, 2015. Once gateway failover testing is complete, project closure will take place. A noteworthy risk is that the communications between the departments may lapse in the case of gateway failures. Resources from both VA and DoD are working to improve the communication processes.

7.2. Joint Legacy Viewer (JLV) Enhancements The Joint Legacy Viewer (JLV) provides an integrated read-only view of DoD and VA health information within a single application for clinicians in both the DoD and VA. The JLV integrated view supports faster and more comprehensive understanding of patient health status through improved usability and system efficiency. It reduces the need for clinicians to access multiple applications to obtain patient information.

JLV was deployed in a phased, data driven approach that offered the application incrementally to select users across the VA enterprise based upon current utilization of interagency data. JLV is now available at all VA facilities. Expansion was monitored to stay within system capacity and performance constraints. eHMP will incorporate JLV functionality and will eventually replace JLV, which is fulfilling these key interoperability needs in the interim. The eHMP viewer version will


include JLV base functionality but also include other improvements of the baseline full-featured system, including improved application performance.

The DoD Defense Medical Information Exchange (DMIX) is currently managing the development of JLV, along with enhancements to DoD data services supporting JLV (and other VA application consumers of DoD data), as well as consolidation of the multiple data viewers that DoD has currently deployed (with JLV serving as the baseline for this consolidation). There are three major releases and one patch planned for FY 2015. The schedules for the patch and releases and their intended capabilities are listed below:

Table 3. JLV Patch Schedule

Increment Development Timespan Capability

Release 1 10/06/2014 – 12/20/2014 Immunization Patch

Release 2 10/30/2014 – 03/21/2015 New & Updated Domains

Release 3 01/02/2015 – 06/19/2015 DoD Healthcare Management System Modernization (DHMSM) Preparation/DoD Viewer Consolidation

Release 4 03/23/2014 – 09/26/2015 DoD Adaptor Consolidation/Bidirectional Health Information Exchange (BHIE) Framework Disconnect

7.3. iMed Consent Platform Migration iMedConsent is currently a Windows client/server software application. It is a Commercial-Off-the-Shelf (COTS) product that has been in use since the fourth quarter of FY 2005. This migration will convert the current application from a client/server to a web-based framework. The iMedConsent software package provides VHA physicians with essential tools to ensure that Veterans receive consistent, legible, high-quality information regarding the health care options proposed by the health care team. iMedConsent integrates informed consent into the electronic medical records process and reduces lost or misplaced forms. This improves patient safety by decreasing delayed or postponed procedures. Additionally, the use of iMedConsent empowers the Veteran to make informed choices regarding their health care. Patients who are more active and involved in their health have better health outcomes and are more satisfied with their health care experience.


The National Center for Ethics in Health Care has requested that iMedConsent be migrated to a centralized platform to permit updates to be more responsive to ensure consistency in consent throughout the enterprise. This will provide consent form updates to all sites in a shortened timeframe, allowing all sites to have the latest version of all nationally standardized forms.

7.4. Enhancements to Pharmacy The VHA Pharmacy Benefits Management Office successfully implemented the Pharmacy Re-engineering (PRE) Medication Order Check Healthcare Application ((MOCHA) v2.0 software nation-wide on July 9, 2014. This clinical decision support system provides customized Maximum Single Dose Order Checks to providers and pharmacists based on active ingredient, dosage form, and route of administration, in conjunction with patient-specific data elements. Practitioners are advised in real time with a warning message and recommended maximum dosage when dosages exceed established norms.

7.4.1. Medication Order Check Healthcare Application 2.1 Following on PRE MOCHA v2.0, MOCHA 2.1 and 2.2 will serve as the VA medication clinical decision support system to provide drug interaction, duplicate drug, duplicate therapy, and maximum dose alerts when a provider enters a medication order. In FY 2015 the enhancements to this system will improve patient safety by refining the current alert system (2.0) and adding an alert for maximum daily dose for simple orders (2.1). The MOCHA system meets the current ONC Meaningful Use Requirements.

7.4.2. Pharmacy Enterprise Customization System (PECS)

The PECS component provides tools to allow customization of COTS drug database information used in production order checks, provided by MOCHA, to increase patient safety. This will also reduce false alert fatigue to pharmacists, and improve order checks to use unique VA expert pharmacist knowledge, instead of just COTS data. In FY 2015 version 6.0 of PECS will be completed. PECS 6.0 will upgrade VA to First Databank’s latest version (4.0). PECS 6.0 will also make the system Personal Identity Verification (PIV) card compliant in addition to other technical changes to make the system easier to use and manage.

7.4.3. Pharmacy Product System (PPS)/National Drug File (NDF) Project (PPS-N and PPS-L)

The PPS/NDF system is the largest open source drug file in the USA. The Pharmacy Product System-National (PPS-N) is a Web-based application that provides the ability to manage pharmacy-specific data across the VA enterprise, ensuring that all facilities are using the same base data for their operations. It allows approved national VA personnel to easily, quickly, and safely manage the

MOCHA Improves Both Patient Safety and Clinician Efficiency

MOCHA v2.0 delivers substantial advancements in patient safety, medication ordering efficiency, and pharmacy workload efficiencies. Prior to MOCHA v2.0, it was estimated that 1% of all medication orders entered in the CPRS exceeded maximum single dose recommendations, with total medication orders for all sites estimated at 8.75 million per month. Fortunately, many of these orders did not ultimately result in adverse drug events (ADEs) due to the diligence of pharmacists reviewing and correcting near-miss events. However, this situation created additional workload for pharmacists and put patients at risk.


VA National Formulary which directs which products (such as medications and supplies) are to be purchased and used by the VA hospital system.

There are two major projects for FY 2015; these include PPS-N 3.0 and PPS-L 1.0 Foundations

7.4.3.1. PPS-N 3.0 PPS-N 3.0 will completely automate the updating of PPS/NDF information at sites; PPS/NDF updates will occur weekly with the option to do daily updates. This will improve VA ability to respond to clinical and market changes. PPS-N 3.0 will also add support for hazardous waste drugs,, and length of clinical effect, which will be used to pinpoint duplicate therapy alerts on expired medications. PPS-N 3.0 will also allow RxNorm information to be directly updated in PPS daily.

7.4.3.2. PPS-L 1.0 Foundations PPS-L 1.0 Foundations, will upgrade the existing PPS-L code to a Technical Reference Model (TRM) compliant code, and will add data tables necessary to support a host of local attributes like orderable items, medication instructions, intravenous (IV) additives and solutions.

7.4.3.3. Safety Updates for Medication and Prescription Management (SUMPM) The SUMPM project (previously known as Pharmacy Legacy Enhancements) specifically addresses enhancement requests related to Pharmacy Legacy applications. These enhancements are approved and assigned by Health Provider Systems (HPS) Enterprise System Manager (ESM). The enhancements provided by this project address patient safety issues, legislative/regulatory changes, and user/site requested changes that enhance productivity, reduce costs, and/or improve the ability to provide care. Enhancements to be delivered under SUMPM for FY 2015 are:

• Change the pharmacy package to allow greater than 90-day fill for outpatient prescriptions and greater than 90-day interval for administration frequency of inpatient and clinic orders, where appropriate for a given medication.

o The development of this interface will provide for process improvements with the administration and tracking of pharmaceuticals being dispensed by the automated dispensing units. This will lead to reduced waste and provide savings to VA.

• The State Prescription Drug Monitoring Programs (SPMP) software was released in late FY 2014 and is currently being activated as part of a phased schedule to address site-specific support needs. The activation schedule is planned through approximately March 2015.

7.5. VistA Standardization, Phase 2 The standardization of the Core Product Set for the remaining 128 of 130 production instances of VistA was the focus of VistA Standardization, Phase 2. This effort utilized the methodology described in Section 6.2.2. Seven increments (Increments 4 through 10), compromising 20 sites each, with each increment being about 5 months long, but overlapping other increments, allowed for an increment completion every 2 months. This overlapping increment methodology was used to maximize use of resources. Overlapping allowed for resource leveling, and was made possible by the fact that waves of sites were not sequentially dependent upon each other. As of the end of FY


2014, increments 4 through 8 were completed on time; increments 9 and 10 were completed as of the end of CY 2014.

7.6. VistA Standardization, Phase 3 Phase 3 builds off the foundational work of VistA Standardization, Phases 1 and 2 by standardizing the remaining 40% of the products within VistA. The outcome of VistA Standardization Phase 3 will be the standardization of all MUMPS VistA code across all VistA instances. Standardized executable code is essential to allowing VistA Evolution and its applications to be launched nationally to every site.

Phase 3 will consist of four increments (Increments 11 through 14), comprising different numbers of sites in each increment. The Increments began in Q2 of FY 2015; all Increments are on track to complete on schedule in Q4 of FY 2015.


8. Feature Set 3 Feature Set 3, the third VistA 4 Increment, has eight major deliverables: continued eHMP development, an interoperable EHR, VistA Scheduling Enhancements, Enhancements to Pharmacy, VistA Service Assembler (VSA), Immunization enhancements, API Exposure, 2.0, and FileMan Modernization. VistA 4 will use open standards and open architecture to achieve seamless interoperability with DoD to ensure that authorized beneficiary and medical data are accessible, usable, shared, and secure to meet the needs of VA patients, health care providers, and other stakeholders. Interoperability with DoD EHR systems, with an integrated display of data, will be achieved no later than December 31, 2016, and the evolution of the VistA 4 product will continue through the end of FY 2017.

• eHMP: FY2016 will continue with development of new patient centric features and the deployment of eHMP version 1.3 and 2.0.

o Certification of ONC 2014 Edition EHR Criterion: Achieving modular certification of the 2014 edition ONC EHR criterion at the time of eHMP code deployment will provide for the continued coordinated efforts to improve healthcare at the national level. By participating in the EHR certification, VA is supporting the ONC goals to improve quality, safety, and efficiency, care coordination and maintain privacy and security.

• Interoperable EHR: FY 2016 will establish VistA baseline as an interoperable EHR, providing the exchange and use of computable data with DoD and external partners.

• VistA Scheduling Enhancements (VSE): VSE consists of three enhancement that will allow VA schedulers to view a consolidated list of Veteran appointment requests, view resource availability, book Veteran appointments from the same screen and monitor scheduling data and track metrics related to outpatient scheduling across VA hospitals nationwide.

• Enhancements to Pharmacy: In-bound e-Prescribing will allow for inbound electronic prescriptions (e-prescriptions or eRxs) from an external provider to be processed in the VistA Outpatient Pharmacy (OP) package. The functionality will also include the capability to electronically transfer a prescription from a VA pharmacy to a different pharmacy, as well as electronically receive a transferred prescription from a different pharmacy.

• VistA Service Assembler: VSA, Phase 2 will further develop the VSA set of utilities, identify and produce multiple sample VistA SOA business services, and provide organization initiatives with a VSA solution leveraging existing VistA application functionality and data exposure methods.

• VistA Immunizations Enhancements, 2.0: This feature completes the upgrade of the VistA Immunizations capability for full compliance with national standards, while enhancing the usability and capabilities for VistA users.

• API Exposure, 2.0: The VistA API Exposure 2.0 project will expose up to 250 APIs and associated RPCs in VistA clinical applications.

• FileMan Modernization: FileMan modernization (culminating in FileMan 23) will provide enhanced database utilities, time zone support, data access methods, and data standardization which will permit Fileman-based querying and aggregation of structured


data between all VistA databases, allowing for a Fileman-based enterprise-wide view of patient data. eHMP Development

8.1. eHMP Development eHMP represents a multi-year effort to evolve a modern, service-oriented enterprise Health Application; thus, development work will continue during Feature Set 3. The eHMP platform includes VistA Exchange, the front end GUI, and certain clinical knowledge enrichment and decision support services. The eHMP front-end will incorporate capabilities currently provided by JLV and the Health Management Platform (HMP).

During Feature Set 3 eHMP will develop the following features:

• Structured data management • Basic orders • Patient goal management • Patient self-description • Image viewer • Scanned document search • CDS (e.g., Immunizations) • Basic task management • Medication Reconciliation • Alert Management • Basic care team & plans • Women’s Health / Family, Military & Social History • Complete outpatient encounter • After Visit Summary/Patient Education • Patient List Creation • Multi-patient views • Advance Directives • Secure Messaging • Enterprise orders selection/management services • Advanced task/team management • Goal-based care plans • Concept relationship management • Advanced CDS • Clinical Reconciliation • Outbound ePrescribing

8.2. Interoperable EHR Interoperability is a core requirement in the VistA modernization effort. Feature Set 3 is focused on the delivery of interoperability enabling capabilities that also meet FY 2014 NDAA directives.


Feature Set 3 will complete the VistA Evolution baseline for an Interoperable EHR. eHMP and VistA Exchange will be updated to include all remaining data domains (for which there are structured data sources) with national standard terminologies. New and updated data services and new UI capabilities will also be completed.

8.3. Scheduling (VistA Scheduling Enhancements) Scheduling is a critical contact point for patients accessing their VA health benefits. The legacy scheduling system currently in use by VA, initially implemented in 1985, is inadequate to meet VA’s current requirements. A multi-phased plan to upgrade VA’s scheduling capability as quickly and cost effectively as possible is currently underway. The first phase, VSE, which will be delivered as part of Feature Set 3,is focused on rapidly delivering capabilities that will have direct impact on the lives of Veterans and their dependents. VSE will provide near term relief to VA’s scheduling issues by enhancing the legacy scheduling system, while the next phase, the Medical Appointment Scheduling System (MASS), to be delivered in Feature Set 4, will feature a complete replacement of the legacy system and all VSE additions.

VSE will provide three primary enhancements to the existing legacy scheduling system: a single queue for scheduling requests, an aggregated view of clinic profile scheduling grids, and a management dashboard that will incorporate reporting functions described below.

8.3.1. Single Queue of Request Lists The scheduling process begins with a request for an appointment. This request can be made by either the patient or by someone acting on their behalf, such as a family member. An appointment request is then placed on a work list that captures these requests. Currently, schedulers work from and manage multiple work lists as part of their overall workload. The need to coordinate multiple work lists is challenging, error-prone and inefficient. Such inefficiencies are compounded by the fact that over 50,000 employees use the scheduling application to make approximately ninety-seven (97) million outpatient appointments each year.

A single queue for appointment requests will improve schedulers’ ability to effectively sort, filter and manage scheduling resources. Moreover, consolidation of all appointment request lists in a single queue will allow the scheduler to view all open appointment requests collectively, and decrease the time it takes to match an available resource with the patient’s request.

8.3.2. Aggregated View of Clinic Profile Scheduling Grids The current scheduling system requires schedulers to manually navigate and search through multiple clinic profile scheduling grids to verify resource availability aligned with the patients’ appointment request. Schedulers must navigate back and forth through multiple screens, adding an additional layer of inefficiency. Additionally, the lack of transparency into resource schedules makes it difficult to manage clinical resources. An aggregated view of clinic profile scheduling grids will allow schedulers to view resource availability and schedule the appointment for the Veteran from the same screen, decreasing the time it takes to match an available resource with the patient’s request.


8.3.3. Resource Management Dashboard

VA has mandated reporting requirements and must respond to Congressional inquiries from many different constituents. In addition to the challenges faced by any government organization subject to Congressional oversight, VA also faces the same challenges as other large health care providers.

To quickly adapt to the changing needs of the enterprise, VA personnel must be able to monitor and aggregate data through reports and dashboards to track relevant metrics. Existing scheduling reports are inadequate for this task. Existing reports are typically historical and not timely, and are incomplete which affects accuracy. Additionally, they do not capture or reflect key aspects of resource/supply and Veterans’ requests/demand. Due to the large amount of data, the need to report at multiple levels in the organization (facility, VISN, and national levels), and the range/reach of the business, the current process for reporting metrics is ineffective in managing day-to-day scheduling resources.

An upgraded resource management dashboard will allow the enterprise to use VistA scheduling data more effectively, provide greater visibility for scheduling operations, and better manage scheduling resources. The planned dashboard will display pertinent resource management metrics in a single view, allowing individual facilities and staff at various levels within the organization to measure and track supply, demand, and efficiency metrics related to outpatient scheduling operations. While the near-term dashboard is constrained by the VistA instance and the availability of data within the given VistA instance, the long- term goal is to develop a comprehensive dashboard that will display metrics at the facility, Veterans Integrated Service Network (VISN) and National level.

8.4. Enhancements to Pharmacy In-Bound e-Prescribing through the adoption of the National Council for Prescription Drug Programs (NCPDP) standards and the use of RXnorm terminology will enhance existing functionality in the VistA OP package and increase safety and convenience for the Veteran. It will provide the ability to receive inbound electronic prescriptions (e-prescriptions or eRxs) from an external provider with the ability to fill, dispense and process the prescriptions in VistA. The functionality will also include the capability to electronically transfer a prescription between VA pharmacies, as well as transfer prescriptions to an external pharmacy.

Solution development for e-Prescribing will occur during FY 2015 with delivery as part of Feature Set 3. The delivery is scheduled to begin during FY 2016 and will continue throughout FY 2018. The existing milestones and their delivery dates for e-Prescribing are as follows:

Table 4. Pharmacy e-Prescribing Milestones

Milestone Delivery Date

Operational Readiness (OR) FY 2016 Q1- October

Initial Operating Capability (IOC) FY 2016 Q2- January

National Deployment (ND) FY 2016 Q2- March


8.4.1. Continued Pharmacy Safety Updates

Further work on the SUMPM project will modify the algorithm to associate the appropriate IV additive to the correct orderable item, based on additive strength.

The Pharmacy Interface Automation – Automated Dispensing Units will deliver a bi-directional interface between the VistA Inpatient Medication Package and Pharmacy Automated Dispensing Units that are used in both inpatient and outpatient care settings

The Inpatient Medication Administration – The Transdermal Integrated Project Team (IPT) will work as a cross-functional team of decision makers to achieve consensus on the project regarding requirements, scope, strategy, procurement, implementation, testing, and deployment for the identified initiative. This initiative will enhance the safety and accuracy of medication administration for items such as transdermal patches, in which there is an action to remove the medication at a defined period of time after it is applied.

8.5. VistA Service Assembler VSA Phase 2 will further develop the VSA set of utilities, and will identify and produce multiple sample VistA SOA business services, by leveraging existing VistA application functionality and data exposure methods. VA objectives prioritize the implementation of SOA as an Enterprise design. The VSA solution provides the ability to automate the generation of “service” needs across major initiatives, provide for standardization of technical characteristics and maintainability, as well as address the organizational challenge of approaching disparate technologies relevant to legacy systems and SOA.

Continued development of VSA will further enhance VSA design time utilities and run time capability. Full VSA preparation is dependent on the availability of eMI infrastructure being available during development, testing, and deployment, as well as major initiatives providing sufficient “service needs” and the supporting information to facilitate adequate capability development. Lastly, VSA is not fully resourced, which has created risk to the current increment schedule. Currently, VSA is scheduled to be deployed in three Increments from 20FY2015 through Q3 of FY 2016 with the intended capabilities. The schedules and intended capabilities for each Increment are as follows:

Table 5. VistA Service Assembler, Increments

Increment Timespan Capability

Increment 1: 11/03/2014 – 05/02/2015 VSA 1.0 National Production deployment

Increment 2: 05/02/2015 – 11/02/2015 VSA 1.1 ESB/eMI IAM Production deployment

Increment 3: 11/03/2015 – 05/02/2016 VSA Infrastructure Build Out

8.6. VistA Immunization Enhancements (VIMM), 2.0 VistA Immunization Enhancements (VIMM) 2.0 will modify the existing Immunization functions delivered in Feature Set 1 to enable VA clinicians to quickly and reliably document and exchange standardized immunization information on Veterans and their dependents with both DoD and


external health care partners. Enhancements will accommodate standardized data required for immunization capture and interoperability, allowing for improved immunization-data portability for Veterans, Servicemembers, and their dependents, and fulfill the required vocabulary standard for the 2014 EHR certification.

VIMM 2.0 will be delivered in four increments from FY 2014 to FY 2016. The goals of each Increment are as follows:

• Increment 1: Push CVX (Vaccine Administered) and Manufacturers of Vaccines (MVX) updates from the Centers for Disease Control (CDC) Immunization Information System (IIS) to VistA. In order for VistA to obtain the updates, new unidirectional interfaces are being established between the CDC’s IIS and DAS and between DAS and STS. The existing integration between STS and VistA is being utilized to incorporate the CVX/MVX content in VistA from STS.

• Increment 2: o Demonstrate access, record, update immunization information and transmission to

immunization registries criteria

o Support FY 2015 flu season

o Expose STS on eMI

• Increment 3: Intake immunization data from external partners outside VA and transmit VA data to other healthcare system and agencies. DAS will ultimately enable external partners to read immunizations from VA and push immunizations to VA. VistA successfully established an immunization data exchange with Walgreens during Feature Set 1. The internal partnerships with which VistA exchanges immunization data with will expand due to the work completed during Increment 3.

• Increment 4: Provide CDS via recommended immunization treatments, alerts/reminders and ad hoc reporting.

The schedules for each Increment are as follows:

Table 6. VIMM 2.0 Increment Schedule

Increment Timespan Goals

Increment 1: Standardization

09/16/2014 – 03/13/2015 Obtain the CVX/MVX codes from CDC

Increment 2: Meaningful Use

03/15/2015 – 09/11/2015 • Demonstrate access, record, update immunization information and transmission to immunization registries criteria

• Support FY 2015 flu season • Expose STS on eMI

Increment 3: Interoperability

09/14/2015 – 03/11/2016 Intake immunization data from external partners outside VA and transmit VA data to other healthcare systems and agencies

Increment 4: CDS

03/14/2016 – 09/16/2016 Provide CDS via recommended immunization treatments, alerts/reminders and ad hoc reporting


VIMM 2.0 is intended to utilize VSA. A delay in the delivery of VSA may impede ability to support the FY 2015 flu season.

8.7. VistA 4 API Exposure, 2.0 VistA API Exposure, 2.0 will expose up to 250 APIs and RPCs in VistA clinical applications. This project will take a foundational suite of VistA application packages, and work to integrate these applications with the DoD/VA interoperability infrastructure. VistA 4 APIs can provide a read or write of data to and from VistA that serves as an “event driver”, or trigger, to notify when a noteworthy write has taken place within VistA.

This allows integration of data from legacy clinical packages, listed in Table 7, below, with the EHR to enable users to manage (read and write) data so that future decisions and actions are based on comprehensive information. These services will be compliant with OneVA Enterprise Architecture, accessible through eMI, and secured using IAM Services.

Table 7. Legacy VistA Clinical Packages Main Data Stores VistA Package

Allergies Adverse Reaction Tracking GMRA

Problem List GMPL

Vitals GMRV

Clinical Warnings and Directives CWAD

Immunization Information PCE

Imaging MAG

8.8. FileMan Modernization The VistA architecture includes a DBMS called File Manager (FileMan), and applications built on top of FileMan. FileMan provides structure for the data in VistA’s database, and is the interface to VistA’s data. Planned future enhancements to FileMan will allow for the querying and aggregation of structured data between all VistA databases. Upgrades to FileMan will allow for the federation of records from multiple systems to create a virtual database, with support for table-driven record movement and deletion.

Following a provision phase, the FileMan modernization planning phase began on 11/20/2014. This planning phase concluded on 1/27/2015. The actual upgrades are scheduled to be delivered in four increments, beginning on 3/31/2015; they are expected to be completed by 12/30/2016. Three of the four increments are scheduled to be delivered during Feature Set 3, with the first increment being delivered in Feature Set 2. The schedules and intended capabilities for each Increment are as follows:

Table 8. FileMan Increment Schedule

Increment Timespan Capability

Increment 1: 3/31/2015 - 06/01/2015 Updated Lexicon, meta-data


Increment 2: 06/02/2015 - 12/01/2015 FileMan security update, time zone support

Increment 3: 12/03/2015 – 06/02/2016 Application APIs and Lexicon enhancements

Increment 4: 06/03/2016 – 12/02/2016 Application APIs and Lexicon enhancements


9. Feature Set 4 The final Feature Set, Feature Set 4, completes the VistA 4 evolution. Upon completion of Feature Set 4, VistA 4 will be interoperable with the DoD EHR, will have a complete implementation of the certified ONC EHR product, achieve or exceed industry standards, and be deployed consistently across the VA care setting enterprise. Feature Set 4 will be completed in FY 2018 with five major deliverables.

The maturation process for VistA 4 will leverage the foundation of the enhanced graphical user interface, standards-based data, and core clinical applications laid during previous increments, with continued attention and commitment to the core principles discussed in Section 1. Provided there exists sufficient funding, the functional focus areas for the final increment of VistA 4 will include:

• Medical Appointment Scheduling System (MASS): MASS will feature a COTS replacement of the legacy scheduling system that provides a much broader range of features than can be derived from the legacy system. This application will remedy excessive VA patient wait times and enhance the Veteran health care experience.

• eHMP Full Deployment: eHMP will continue to expand to full deployment during Feature Set 4. The features of eHMP are being developed in Feature set 2 and 3.

• Veteran’s Authorization and Preferences (VAP): The VAP application provides management and tracking of authorizations and forms required for VA processing, to allow sharing of health information. A series of enhancements will be delivered for VAP, which is currently in operation.

• Women’s Health: Women’s health will utilize a robust, user friendly, graphical user interface, and will incorporate all of the current women’s health functionality existing or being developed today; successful delivery of this project will result in a full-featured women’s health solution; much of this capability will be delivered through the new eHMP user interface.

• Enhancements to Ancillary Systems: Ancillary system enhancements will provide improved patient safety, meet regulatory requirements, and enable a more robust CDS for clinicians, resulting in an improved health care experience for Veterans. The resulting VistA 4 application suite and underlying technical architecture will represent a state-of-the-art enterprise EHR solution. Additional clinical capabilities will continue to evolve, and inevitably become available, over the lifecycle of the VistA product.

9.1. Scheduling (Medical Appointment Scheduling System) One of the critical goals of the Scheduling project is to improve resource utilization by balancing the supply of clinicians with increasing demand. Another paramount concern is to meet the need to accommodate scheduling alternate modes of care delivery, including TeleHealth, rural health care, home health care and electronic access to allow patients to work collaboratively as integral members of the health care team.

The current VistA scheduling application lacks many key functions necessary to meet these pressing needs. The new scheduling solution will move from a scheduling system based on separate clinics to one that is focused on available clinical resources and the individual patient. The second


phase of the scheduling project, Medical Appointment Scheduling System (MASS), will deliver a comprehensive scheduling solution to support VA’s mission.

The MASS phase of the project will feature replacement of the legacy scheduling system with a commercial system which provides a much broader range of features than can be derived from the legacy system. Whereas VSE is a development effort to enhance the service that can be derived from the legacy scheduling system, MASS represents a replacement of the existing scheduling system with new capability. Having learned from the Replacement Scheduling Application project, VA is not attempting to deliver MASS as a custom-built development project. Rather, the MASS program is anchored on the acquisition of an existing, proven commercial scheduling system. The Request for Proposal (RFP) for the MASS acquisition was released in the first quarter of FY 2015. Within two years of award, in FY 2017, the core capabilities required to address VA’s scheduling needs will be deployed enterprise-wide. Within four years of award, additional capabilities will be introduced to expand scheduling functionality, provide greater flexibility and configurability to the system, and enable easier customization.

The replacement system will be extensible, configurable, and flexible to support VA’s mission well into the future. In addition to being a feature-rich solution, MASS will move VA’s scheduling solution into an SOA, in compliance with the OneVA Architecture, ensuring that the implemented system will be cost effective and adaptable as VA’s needs evolve. The MASS system will replace both the legacy VistA scheduling system and the VSE phase when completed.

By procuring a commercial scheduling solution that interfaces with VistA, MASS will result in an outpatient scheduling application that supports defined appointment processes and a patient-centric view of appointments, regardless of location of care. This application, nested within VA interfaces and integration points, will remedy excessive VA patient wait times and enhance the health care experience, beginning with the initial patient contact. MASS will transform VA’s scheduling process by enabling cross location scheduling, resource-centric scheduling, supply-to-demand matching, and by substantially reducing the amount of time required to schedule an appointment. Additionally, MASS will enable new models of care, such as TeleHealth, moving VA to a Veteran-centric care model.

Below is a representative sample of the business needs which will be addressed by MASS:

• Improved Veteran service through appropriate, timely, and efficient appointment and visit scheduling

• Web enablement to allow patients to request or view information via the Internet

• Improved utilization of provider and clinic resources to include equipment and rooms

• Accurate, maintainable system and user documentation

• A formalized repository of scheduling business rules maintainable without developer intervention to promote standardization of business practices across the enterprise

• Web based graphical user interfaces (GUIs)

• Open connectivity promoting regular upgrades and enhancements

• Improved IT support, emphasizing the shift to ambulatory care

• Linkage with CPRS and other VistA packages to provide a seamless interface to clinicians and clerical staff alike


MASS represents the future of VA scheduling. As a transformative technology, it will enable VA to be more responsive, and more efficient, in meeting the health care needs of our Veterans and their dependents. When completed, MASS will not only have a major impact on VA’s ability to respond to the health care needs of our Veterans and their dependents, it will also enable a wide range of new delivery models, such as Veteran self-scheduling, mobile and web scheduling and provide VA with the ability to manage and schedule its resources with a precision not previously available.

9.2. Full Deployment of eHMP The eHMP capabilities previously described will be released for full deployment during Feature Set 4.

This eHMP platform will include VistA Exchange, the eHMP user interface, and certain clinical knowledge enrichment and decision support services. eHMP will eventually replace CPRS as VA’s primary point of care application.

eHMP Services is the name for the middle tier components that include VistA Exchange, Data Annotation Service, Clinical Decision Support, Clinical Workflow, Context Persistence, Concept Relationship Service, Orders Selection Service, Documentation and Text Search Service, Orders Management Service and Business Rules Management Service.

The development work under the eHMP project is planned to deliver the initial version of the eHMP user interface to access patient data cached in VistA Exchange by November 30, 2014, with continued agile development. Other capabilities include introduction of initial capabilities that will assist clinicians’ use of the system including enhanced patient search (when searching for a patient not registered in the user’s local VistA site), free text search (finding entries in patient records based on user entered criteria) and context persistence (returning to the same patient when moving from one workstation to another).

9.3. Veteran Authorization and Preferences (VAP) The VAP application provides management and tracking of authorizations and forms required to be completed by the Veteran or Servicemember, and their family members, for VA processing. These authorizations/forms authorize or restrict the Release of Information (ROI) for health care, benefits, and other VA-related services. Through the VAP user interface, VA staff, if authorized, can manage consent directives on behalf of a Veteran. VAP facilitates sharing pertinent health information, or restriction or revocation of that information, between trusted external partners. Additionally, VAP provides the capability to store and retrieve Veteran preferences for sharing information with the Social Security Administration (SSA) for the purpose of “coverage” and adjudication of benefits. VAP upgrades will consist of:

• The ability for users of the VAP system to create and print letters to alert Veterans or Servicemembers of expiring authorizations;

• Further safeguards to ensure authorizations are up to date;

• Ensuring conformance to mandated cross-Agency requirements for identity management;

eHMP eHMP is the name of the overarching system, which includes both the front end application, called the eHMP Clinical Practice Environment (eHMP CPE), and the middle tier components, called eHMP Services.


• Streamlining the ability to add partner systems; and

• A re-design of business and technical architectural to improve performance and reliability.

9.4. Specialty Clinical Applications The functionality described for the GUI, decision support, care-management support, enhancements to the pharmacy systems, and medical device integration will be combined to support many specialty workflows. Supported specialty workflows include but are not limited to: women’s health, emergency-department care, surgical care, dental care, eye care, dermatology, disability evaluation, consults and referral management, anesthesia documentation, mental health, nutrition care, genomics, intensive care nursing and medicine, and occupational health. The general approach in VistA 4 will be to deliver technical components that require minimal engineering to support specialty workflows. In no case will a complete suite of new technical applications be needed; however some cases may require significant engineering. The sections below give examples of approaches to selected specialty workflows.

9.4.1. Women’s Health Currently there is no unified system to follow the care of women Veteran’s within the VHA. Lack of a unified system of treatment for female Veterans makes for an inefficient process that risks delays in diagnosis and treatment. While some progress has been made with current development projects, there is a pressing need to unify those projects into a single women’s health management platform.

This project will create a new women’s health management platform that utilizes a robust, user friendly, graphical user interface. The system will incorporate all of the current women’s health functionality existing or being developed in VistA today, and expand upon it to create a full-featured women’s health IT solution. The system will integrate and enhance the functionality of the System for Mammography Results Tracking and the Breast Care Registry (BCR) to include the ability to identify, monitor and track normal and abnormal test results for gynecologic, the new System for Mammography and Reproductive Health Tracking; enhance the Notification of Teratogenic Drugs (TDrugs) project; and disseminate nationally the Maternity Tracker Innovations project. The solution would expand the gender characterization of Veterans to include aspects of gender identity and phenotype, in addition to biological sex. It will ensure that a full set of reproductive health data elements (e.g. last menstrual period, expected due date, Menopause status and others) exists in VistA for use across all projects. Data will be available for viewing at the level of the patient, provider’s panel, patient-aligned care team (PACT)), or aggregate patient level (all patients). Reporting functionality will allow for the building of data cubes and multi-functional analysis for more robust clinical reports. Moreover this platform will have the ability to track and incorporate results of health care and diagnostic testing done outside VA.

This solution will enhance the health care team’s (physicians, nurses, pharmacists, women’s health Program Managers, maternity care coordinators, etc.) ability to track, manage, treat, and communicate with female Veterans about their health and health care. Enhanced patient-provider communication will support timely provision of preventive care, management of abnormal tests, diagnosis, and treatment. In addition, improvements in clinical decision support will improve patient safety during the care of female Veterans.


9.5. Enhancements to Ancillary Systems

The ancillary system business owners and clinical users will benefit from the continued incremental enhancements to the existing VistA ancillary systems, including radiology, laboratory, and pharmacy. These enhanced service capabilities will provide improved patient safety, meet regulatory requirements, including Digital Imaging and Communications in Medicine (DICOM) for radiology and multiple accrediting bodies for VA laboratory (Joint Commission, AABB, and the College of American Pathologists), and enable a more robust CDS for clinicians, allowing them to provide improved care for Veterans, Servicemembers, and their dependents.

9.5.1. Radiology VistA 4 will update the radiology package to transition radiology operations from a paper-based to a paper-light practice. These enhancements will address the current clinical workflow demand with emphasis on increased efficiency, improved documentation, and enhanced patient safety.

The VistA 4 radiology GUI project and imaging enhancements will leverage some of the innovative work undertaken by community VistA users for a new radiology user interface. This GUI may be used as a model user interface for the following radiology functions: enter order, schedule study, register patient, case edit study, protocol study; display status of patients who are in the department; display key management parameters: unscheduled orders, incomplete studies, un-dictated studies.

Key functionalities targeted for the radiology interface include scheduling exams from a list of orders. This user interface will enhance functionality of the scheduling application to allow auto-populating in the radiology application of the scheduled appointment time, eliminating the need for duplicate entry. Additional new capabilities will consist of:

• Ability to assign orders for imaging studies to radiologists so they can be protocoled;

• Select acquisition protocols for ordered and scheduled imaging studies with rationale for selection;

• Communicate imaging instructions to technologists;

• Communicate patient communications from clerk to radiologist and technologist, and;

• Enter radiation dosage. As listed above, VistA 4 radiology will include best practices functionality such as support for electronic protocols and a dashboard display of the patient’s status, which will facilitate communication between radiologists and technologists. Incorporating protocols within radiology procedures will ensure the clear communication of important safety information such as allergies and renal functions. Radiology CDS capabilities will improve ordering guidelines to follow appropriateness criteria, as defined by the American College of Radiologists. VistA 4 Imaging will build upon current image management capabilities to support enterprise image distribution and viewing. Such enhancements include the ability to import studies from external entities, improved image viewing functions, support for structured DICOM reports and integration and tracking of

Radiology and Imaging Clinical Decision Support

Imaging best practice protocols combined with clinical decision support CDS at the time of order entry helps remind providers of evidence-based and local guidelines, reduces unnecessary testing and provides patient safety checks throughout the procedure.


radiation dose metrics. These features will also enable imaging interoperability with our partners, including DoD.

The VistA 4 Radiology and Imaging System enhancements will improve the efficiency, quality of care and Veteran safety through efficient workflows, timely processing of orders, improved communications among staff, more complete documentation and support for optimal scanning protocols.

These enhancements will benefit clinicians by allowing simultaneous availability of patient images and data while planning and providing care, resulting in less time locating images and improved communication among radiology clinicians and specialist.

9.5.1.1. VistA Imaging (in support of Radiology) VistA Imaging has helped VA medical facilities achieve an enterprise-wide paperless and filmless Electronic Health Record. VistA Imaging has captured and stored more than 2 billion images nationwide using 4.9 Petabytes (PB) of Tier 1 storage.

VA’s VistA Imaging systems provide the following services to VA health care professionals and their patients:

• Tracks/manages more than 1.3 million unique patients every month

• Captures seventy (70) million new images each month

• Provides views of fifty (50) million to one hundred (100) million images per month both locally and remotely

Current requirements for the system require that a patient’s images be retained for seventy-five (75) years after the last episode of patient care. With the current rate of growth (Average 15% per year) of both the number of images and the image size, the storage requirements must be reviewed on a regular basis to determine the best solution to meet the system’s expanding storage needs.

Tier I: Current State

Local VistA Imaging System Tier I configurations contain clustered file servers with Storage Area Network (SAN) attached Redundant Array of Independent Disks (RAID) to hold locally acquired medical images for approximately five (5) years. Acquired images are also immediately copied to a local Tier II storage system. Image files and the file copy tasks are managed by a site’s VistA Imaging application called the Background Processor.

The current VistA Imaging systems are installed locally in various sized VA medical facilities, grouped into twenty-one (21) geographical VISNs, all of which acquire, store and retrieve medical image files in the course of their daily operations. Currently, the most active large VA medical facility utilizes approximately one (1) Terabyte of storage per month, which is over twice what a typical large sized facility consumes. Some large VA medical facilities may be considered small, as they consume less than fifty (50) GB per month.

Image display workstations receive images for redisplay from local or remote VistA Imaging site Tier I, as well as from DoD image file sources. VA Image requests for images held in Tier II storage are managed by the Background Processor (BP) application, which copies the image from the Tier II storage system(s) to the Tier I RAID storage system.


• Current system: 85% of systems exceed 5 year useful life and 65% will no longer be

serviced by manufacturer.

Tier I: Future State

• Fully implemented within 12 months of award • Will run on a new operating system, will be hosted by servers (versus desktops), • All Tier 1 Systems standardized across all 4 Regions • Increases Reliability and Supportability • Allows all sites the capacity to store 5 years of studies on Tier 1 storage.

o Decreases image retrieval time which improves patient care

• Leverages latest technology to improve performance and disaster recovery

o New Tier 1 System uses High availability storage

o Leverages Microsoft HyperV virtualization

Meets the VA Virtual First requirement reducing cost and power consumption

Reduces recovery time during unplanned outages

Increases System Uptime

Lessens the burdens of the Microsoft operating system restrictions for VistA Imaging and will allow VI to move to future OS levels in a more seamless fashion

• Reduces the risk for critical patient data loss for End of Life (EOL)/End of Service (EOS) VistA Imaging Systems

Tier II

• Fully implemented by December 30, 2017 • Will reduce overall storage cost, by moving to a true deep archive system and helps disaster

recovery by moving data to a regional data center (versus by VISN), by using less power, space, and less equipment cost.

• Requires less FTE to manage; four regional centers versus 21 VISN o Flattens imaging footprint.

9.5.2. Laboratory The Enterprise-wide Feature Set 4 laboratory enhancements for completion are:

• Auto-verification, which will optimize resource utilization by setting lab-established boundaries for test results, eliminating the need for laboratory personnel to approve results before they are sent to the attending clinician.

• Upgrades to VistA Blood Establishment Computer Software (VBECS) to help ensure continued patient safety and quality, as well as new clinical functionality.

• Microbiology upgrades.


• An Anatomic Pathology (AP) ordering mechanism for clinicians to provide required

information to facilitate specimen processing.

Enhancements to VistA Laboratory will support interoperability of laboratory data with internal VA systems, DoD, and other health care partners. These enhancements will leverage standards and interoperability guidelines to exchange orders and results within and across department and commercial reference labs.

9.5.3. Pharmacy Medication Order Check 2.2 Following on MOCHA 2.1, additional MOCHA enhancements will include maximum daily dose for complex orders (2.2).


10. VistA 4 Product Enablers

10.1. VA Infrastructure Current and future VistA 4 components require infrastructure support such as data centers, platforms, storage, networks, client technologies, and messaging / middleware. Current and projected infrastructure needs are known for legacy VistA systems, and future VistA 4 system deployments are undergoing design, requirements analysis, and analysis on operational impacts. Infrastructure planning to support VistA 4 and other systems, including future deployments, can be described as a holistic plan. The overall plan supports different deployment options for various new VistA 4 deployment needs. This section of the VistA 4 Product Roadmap describes the known infrastructure planning to support the presumed VistA 4 Feature Set 4 deployment options for use, when specific infrastructure needs are known.

As an overall summary, the deployment environment must adhere to the Office of Management and Budget (OMB) Mandate 08-05 and the TIC Reference Architecture 2.0, with mechanisms and provisions in place to assess the most appropriate environment deployment option. This can include VA-only private cloud offerings that are TIC compliant, in which case VA standards and policies for virtualized platforms apply and are described. If hosted external to the VA, TIC compliance require the external private cloud hosting VA data and systems be physically and logically air gapped from all other non-VA data and systems. Additionally, the external enclave must connect to VA via Internal Business Partner Extranet (iBPE) connections, and all access to and traffic between VA and the external enclave must transit the iBPE connection. No other connections to the external enclave are permitted for TIC compliance. Platform and server configurations and standards and storage configurations and standards support the TIC compliant offerings. These are all described along with the specific legacy VistA configurations, which are moving toward VA standards. Legacy VistA and other applications are in the process of migrating to a smaller quantity of data centers, in accordance to data center consolidation policies and plans that are described. The networks supporting these data centers and interconnections between them are described, including the planned changes for the VistA 4 Feature Set 4 timeframe. Emerging client technologies may affect VistA 4 designs, and the infrastructure to support this, including future plans, are described. Finally, the messaging and middleware infrastructure needed to support both Legacy VistA and future VistA 4 deployments are described.

10.1.1. Current VA TIC Cloud Initiatives VA will provide TIC compliant services with initial delivery as a part of Feature Set 1 in FY 2014 and full delivery as part of Feature Set 2 in FY 2015.

10.1.2. Virtualization Some VA standards that support and enforce the use of virtualization are:

• All internally developed applications shall be designed to run in virtual environments without the need for modification;


• All newly implemented projects and applications must be fully supported on virtualized platforms;

• As existing systems and applications reach the end of their useful life, they are to be migrated to virtualized platforms, and;

• Current non-virtualized projects and applications should be scheduled for virtualization re-platforming as staff and infrastructure resources allow.

These standards have been, and continue to be used for system deployments, including VistA 4 deployments. Although non-virtualized deployments exist (e.g., some legacy VistA systems), through technical refreshes, redesigns, and solution replacements, all deployments will follow the same standards and guidelines to support virtualization.

10.1.3. Virtualization of Database Back End Next Generation The VistA 4 Feature Set 4 platform will include virtualization of the back end servers. The successful evolution of the VistA front end has demonstrated a viable virtual platform; however challenges remain with front-end systems direct access to data. As a result of this issue, the virtualization of the back end systems requires careful planning and testing. Several options exist for Virtual Machine (VM) access to the SAN. Selection of the best option is critical and must be addressed with care to ensure data integrity and that performance measures are met.

The current deployment of virtual front-end (vFE) servers includes performance analysis and capacity planning of the virtual infrastructure. Currently, VistA front-end systems migrated into regional data centers are 33% vFE systems, and full virtualization progress is ongoing. These tools and reports, and experience implementing a full vFE for all VistA systems, will be leveraged for virtual back-end (vBE) development and deployment. The schedule for these components is being re-assessed, and no definitive dates are available at this time.

10.1.4. Caché Mirroring Enhanced Disaster Recovery The current disaster recovery implementation for VistA relies on InterSystems Caché Shadow Journal processing, which is an asynchronous data replication method. Another capability contained within Feature Set 4 includes the technology known as Caché Mirroring. Caché Mirroring on the production back end will introduce asynchronous mirroring to the disaster recovery instances. The asynchronous mechanisms used by Caché Mirroring as compared to Caché Shadow Journal provide improvements in maintaining the integrity of the disaster recovery database due to the improved timestamps and checkpoints used by Caché Mirroring. High bandwidth comparison utilities can be modified to a reduced functionality, which may free up WAN bandwidth. Caché Mirroring will not be implemented in a VistA production environment until Caché 2014.1 is released to VA by InterSystems and thorough testing is performed by VA. Once the mirroring feature is fully tested, the Linux database back-end architecture will be re-engineered to migrate from Linux clustering to Caché Mirroring.

10.1.5. Storage The VistA product is fully deployed to all VAMCs. The evolution of VistA, through the VistA 4 product, is based on an open architecture to enable the system to provide and consume services, allow agile modification, and provide the ability to create, store, and exchange interoperable data

VistA 4 Product Roadmap February 26, 3.11 61

according to established industry standards. The value of medical information contained in data for patient care and medical research is the usability of that data; therefore data is no longer purged from VistA, requiring a large, flexible storage infrastructure that can expand with VistA, while performing within the constraints of a good user experience for response time.

Previous VistA environments were implemented and managed locally at VAMCs. With the consolidation efforts, new VistA storage environments are located at National Data Center Program (NDCP) data centers. These data centers are more robust and provide greater /more consistent administrative functionality to the consolidated VistA environment. By leveraging these data centers, VA is more prepared to meet high availability and disaster recovery scenarios. Additionally, their use will provide improved and consistent recovery point objectives/recovery time objectives Service Level Agreements across VHA. The consolidated VistA storage environments of Region 2 and Region 3 are engineered to meet VA TRM requirements.

10.1.6. VistA Data Center Consolidation VA chartered the NDCP in 2009 to address the OMB Federal Data Center Consolidation Initiative (FDCCI) requirements to reduce the federal data center footprint and improve management of IT assets throughout all agencies. In alignment with Federal Data Center Consolidation Initiative Best Practices, VA’s objectives for data center consolidation and optimization, used for the VA data center consolidation effort, are:

• Consolidate data centers where possible to increase efficiency and effectively reduce ongoing operational costs;

• Shift IT data center operations to less costly, more efficient, sustainable infrastructures;

• Provide sustainable data center infrastructures with disaster recovery/continuation of operations capabilities that are appropriately sized and commensurate with the requirements of the IT systems being operated;

• Provide scalable data center infrastructures that can be cost effectively adapted to meet future IT system needs;

• Optimize space, IT asset utilization, and processing capacity to minimize environmental impacts and achieve maximum operational efficiencies;

• Provide automated and standardized security hardening of hardware and software platforms across data centers; and

• Provide automated and standardized monitoring of data center assets and IT system availability and performance to improve trending capability for predicting future needs and for measuring impacts of change.

Figure 5 below provides a map of the four regional data centers and areas that they support across the VA.


Figure 5. Regional Diagram for Data Center Consolidation

10.1.7. NDCP VistA Migrations OI&T completed 12 successful NDCP migrations of VistA systems from VAMCs into Defense Information Systems Agency (DISA) / Defense Enterprise Computing Centers (DECCs), for a total of 25 successful migrations to date. The consolidation effort results in more efficient and effective operations and more reliable systems due to a standard, lower cost platform, new operating system, high availability, unified support strategy and disaster recovery for each site migrated to data center hosting.

Region 2 and Region 3 VistA and related systems are being migrated to DoD DECCs. As they are migrated, they are upgraded from VMS to Linux. Region 1 and Region 4 VistA and related systems were collocated in the Regional Data Centers in Sacramento, Denver, Philadelphia, and Brooklyn in circa 2006. While it was originally hoped they could be consolidated in DoD DECCs as well, no funding for that project has been made available and it is unlikely funding will be provided in the foreseeable future.

Some VistA-related systems will always remain in the medical centers (e.g. VistA Read Only) as needed in the event of a disaster to provide continued patient support at the sites.

In Regions 2 and 3, there are 70 sites to be migrated from their medical center locations to the DoD DECCs:

• 29 in Region 2

• 41 in Region 3 As of 9/15/14, 25 of the 70 sites have been migrated:

• 14 from Region 2

• 11 from Region 3

FY 12, 13 & 14 Migrations:


Table 9. FY 12 Migrations Region Site Name VISN Migration Date

R02 St. Cloud V23 9/15/12 End of Fiscal Year 2012

Table 10. FY 13 Migrations Region Site Name VISN Migration Date

R02 Black Hills V23 9/15/12 R02 Sioux Falls V23 12/08/12 End of Calendar Year R02 Fargo V23 1/12/13 R02 Minneapolis V23 4/27/13 R03 Columbus, OH V10 5/04/13 R03 Augusta, GA V07 5/18/13 R02 Iron Mountain V12 6/08/13 R02 Little Rock V16 06/22/13 R03 Fayetteville, NC V06 08/10/13 R02 South Texas V17 08/24/13 R02 Valley Coastal Bend V17 08/24/13 End of Fiscal Year 2013

Table 11. FY 14 Migrations Region Site Name VISN Migration Date R03 Huntington V09 11/16/13 R02 Tomah V12 11/16/13 R02 Central Texas V17 12/07/13 R03 Tennessee Valley V09 12/07/13 End of Calendar Year R03 Hampton V06 1/25/14 R02 Central Alabama V07 2/08/14 R03 Tuscaloosa V07 3/01/14 R03 Atlanta V07 4/26/14 R02 Madison V12 5/03/14 R02 Houston V16 6/07/14 R03 Orlando V08 7/12/14 R02 Milwaukee V12 08/16/14 R03 Birmingham V7 08/23/14 End of Fiscal Year 2014

Table 12. FY15 Migrations Region Site Name VISN Migration Date R02 Omaha/Central Iowa HCS V23 10/18/14 R03 Asheville V6 11/01/14 R02 New Orleans V16 12/06/14 R03 West Palm Beach V08 12/13/14 End of Calendar Year R02 North Texas HCS V17 1/13/15


R03 Dublin V07 2/07/15 R03 Beckley V06 3/14/15 R02 Alexandria V16 3/21/15 R02 Biloxi* V16 4/18/15 R03 Northern Indiana HCS* V11 4/18/15 R03 Louisville* V09 5/16/15 *Date confirmed by site. Executive level approval will be sought 3 weeks prior to scheduled migration date.

Table 13. Remaining VistA Migrations Region 2 Region 3

Site Migration Date

Site Migration Date

Site Migration Date

Chicago* 7/18/15* Ann Arbor TBD Gainesville TBD Fayetteville** 11/7/15** Battle Creek TBD Indianapolis TBD Hines* 9/19/15 Bay Pines TBD Lexington TBD Jackson* 8/29/15* Charleston* 8/23/15* Memphis TBD Kansas City TBD Chillicothe TBD Miami TBD Muskogee** 12/12/15** Cincinnati TBD Mountain Home TBD Tampa* 9/19/15 * Cleveland TBD Richmond TBD North Chicago** 10/3/15** Columbia, SC TBD Saginaw TBD Oklahoma City TBD Danville TBD Salem* 6/20/15* Shreveport* 6/6/15* Dayton TBD Salisbury TBD St. Louis TBD Detroit TBD San Juan TBD Durham* 7/25/15* *Denotes tentative migration dates in FY15, not yet confirmed by site. Sites and proposed dates subject to change. **Denotes tentative migration dates in FY16, closing out calendar year 2015, not yet confirmed by site. Sites and proposed dates subject to change.

10.1.8. VistA System Data Center Infrastructure Background VA seeks to continuously improve the data center infrastructure and architecture for VistA while protecting the mission critical health services and functions directly supported by this IT system without interruption. The following timeline, in Table 14, depicts the iterative improvements implemented to date, aimed at full virtualization of this mission critical system:

Table 14. VistA Data Center Consolidation Timeline Through 2013 Consolidation Timeline

2004 Commencement of system redesign to a regional infrastructure model for R1/4 VistA

2006 Completion of Region 1/4 VistA migrations to the regional infrastructure model

2009 Commencement of system redesign to a regional infrastructure model for R2/3 VistA

2010 OMB directive for FDCCI 2011 Change in design direction from a regional infrastructure model to a standardized

enterprise infrastructure model for R2/3 VistA as a result of FDCCI Best Practices recommendations and preparation for inter-connectivity with DoD health record systems

2012 Interagency agreement with DoD space hosting services for Region 2/3 VistA and


related systems 2012 Commencement of Region 2/3 VistA migrations to a standardized enterprise model

with virtualized front ends

2013 Commencement of VistA testing in preparation for future migration of all VistA systems to a virtualized platform

Schedules are being re-assessed to meet the timetable identified for Feature Set 4 for VistA system migrations to regional data centers. Following a pause in migrations, Region 2/3 migrations are resuming in FY 2014, and will continue after FY 2014.

10.1.9. Wide Area Network (WAN) VA Telecom Enterprise Systems Engineering has proposed and documented a new design called VA Next Gen WAN. This design will begin implementation in FY 2015, with an estimate time-frame for completion of 24 months. It will provide a major upgrade to the existing WAN. Through the deployments of various new technologies, such as Voice Over Internet Protocol, Administrative and Clinical Video, and IPv6, the effort will both provide the flexibility necessary to accommodate various application and initiatives to include eBenefits, Telehealth, VistA Modernization, and other VA business initiatives, and align with several OMB mandates. The focus of the new design is flexibility and a flat architecture that leverages the Multiprotocol Label Switching (MPLS) WAN transport technology presently deployed across VA. The new design will remove the legacy hierarchal core, distribution, and access layers in favor of a single MPLS Virtual Routing and Forwarding “Flat” design.

The proposed OneVA architecture implements a fully integrated next-generation WAN architecture that:

• Optimizes VA’s current WAN topology around four National Data Centers located in Philadelphia, Chicago, Denver, and Austin (TX);

• Defines two network layers across a common MPLS infrastructure, to ensure WAN performance nationwide and improve security;

• Identifies an essential set of WAN services associated to each network, ensuring availability, capacity and scalability.

The overall simplicity created by the VA Next Gen WAN is a foundational element that allows VA IT to focus on mission-based, value-added services, and avoid duplicative infrastructure. The following figures show the conceptual architecture for the future WAN.

Figure 6, below shows the future VA WAN topology with the One-VA MPLS clouds. One of these clouds uses AT&T as the service provider, and the other uses CenturyLink. As indicated in the diagram, all major nodes and some small nodes (CBOCs, branch offices, etc.), including VISN Data Centers, Regional Data Centers, National Data Centers, VAMCs currently connected to Region or VISN WANs, and other large VA sites currently directly connected to the VA Backbone clouds, as well as the four ICTIC sites, will be directly connected to these two service provider clouds.


Figure 6. Next Generation WAN topology

10.1.10. WAN Acceleration Since October 2012, the VA WAN Acceleration infrastructure is currently undergoing an augmentation that will transform it from approximately 22 percent coverage of major facilities to nearly 100 percent coverage of major facilities. The $15M project is adding new equipment onto VA's WAN infrastructure to optimize the available bandwidth. For the purposes of the project, major facilities were defined to be those with greater than 250 employees.

The initial installation, configuration and turn-up of the infrastructure was completed in the second region. The initial results of this implementation indicate a 50-75 percent data reduction for the traffic that was eligible to be optimized. Since September 2014, implementation efforts continued in the other regions. The enhanced infrastructure will enable VA to contain escalating telecommunication costs associated with its increasing business needs while helping to ensure performance of existing critical applications across the WAN.

10.1.11. Target VistA 4 LAN Data centers are evolving toward architectures in which networks, computer systems, and storage devices act in unison. To achieve this, data centers need an end-to-end architecture that is efficient, adaptable, and scalable. As the VA OI&T organization migrates from fragmented, older data centers to more cost-effective and agile ones, a sound architecture that can serve as the


foundation for the evolution to a next-generation data center must first be developed. This line of reasoning is what VA has used and will use in the future for the data centers’ Local Area Network (LAN) infrastructure and the supporting access LAN infrastructure for client access to those data centers.

The following is a list of targets for future LAN considerations:

• LAN access switches that provide high-speed connectivity, applications, and communications systems that efficiently and securely manage bandwidth-intensive data, voice, video, and wireless applications;

• Application Intelligence to help networks recognize many types of applications and secure and prioritize those applications to provide the best user experience;

• Unified Network Services - combining the best elements of wireless and wired networking allow you to consistently connect to any resource or person with any device;

• 10 Gigabit Ethernet technology and Power over Ethernet technology to support new applications and devices. Power over Ethernet Plus helps ensure compatibility with future versions for deployment of next generation high power devices;

• Nonstop Communications - features such as redundant hardware, and non-stop forwarding and tasteful switch over technology to support more reliable connections;

• A higher available failover design for the LAN infrastructure called Multi-Chassis link aggregation, used to increase operational efficiency;

• Strengthened controls over wired and wireless access to VA’s network. Secure LAN Access switches that provide end-to-end security using identity-based policy and threat intelligence capabilities, and;

• An open reference framework for programmability and control, through an open source software defined network (SDN) solution. Such a framework will maintain the flexibility and choice to allow organizations to easily deploy SDNs, yet still mitigate many of the risks of adopting early stage technologies and integrating with existing infrastructure investments.

10.1.12. Client Virtualization VA OI&T Service Delivery and Engineering (SDE) is working toward a national procurement of a “block” of hardware technologies that will effectively commoditize the back end computing, network, storage, and end user devices that go with the paradigm shift of moving from physical personal computers on the floor to data center-based virtual desktops. The possible long term vision involves hosting desktops in a VA only private cloud that is TIC, where VA no longer buys physical Government Furnished Equipment (GFE), but just a set number of “desktop operating system” instances from a service provider.

10.1.13. Messaging / Middleware In November 2013, VA OI&T ASD conducted an in-depth review of current messaging approaches, SOA design patterns, and tools (i.e., software) in use by the Department with the end goal of reducing the operational cost of the messaging infrastructure, reducing the complexity of


the current multiple messaging tools and increasing the reliability, security and stability of message transport both within the Department and to external partners. As a result of this review, ASD has determined that a SOA-based “Messaging Design” pattern and the use of the interagency procured ESB and other interagency procured SOA Suite components (hereinafter referred to collectively as the ESB) will be utilized by the Department for VistA Evolution and other projects requiring messaging.

One of the first activities benefiting from this decision is the transition of the current VistA interface engine (VIE) to the ESB. In 2002, VHA purchased several components of a commercial interface engine middleware suite to provide a common enterprise application messaging platform for the communication of information between clinical, administrative and managerial applications within the Department’s VistA. Enterprise application messaging continues to be a mission-critical operation requiring assured message delivery between VistA and both internal and external healthcare applications. At the time of purchase, the adoption and implementation of the VIE met VA’s need for an interface engine which could support multiple initiatives, and provide the common messaging platform for the communication of information.

While the need to provide enterprise messaging as described above remains; unfortunately, the current implementation of VIE has reached end of life and requires replacement. The Department plans to transition the end-of-life VIE messaging product to the ESB with initial planning being developed to meet an estimated transition/completion date of March 2017. The ESB will continue to provide that assured communication between the current VIE supported user with little or no modification required by the individual applications that VIE currently communicates with. Use of the ESB will allow a phased transition of applications and services to the ESB with immediate roll-back to use of VIE if a problem is identified.

The transition of VIE to ESB requires:

• Analysis and forecasting of messaging volumes, growth, and the degree to which applications require advanced capabilities of middleware/messaging and enterprise service bus technologies;

• Physical location of the messaging servers/technologies and the VistA databases with which they communicate must be fully understood in order to successfully locate and transition the current messaging technologies to the ESB with the least impact on existing or future network capacity;

• Current and future network capacity and trend information will remain a variable which must be understood and reviewed at known intervals with metrics collected and reviewed (i.e., capacity planning in order to ensure that the adoption and operation of a messaging/ESB technology does not result in an adverse impact to the network or result in unsatisfactory performance), and;

• The inclusion of the current VIE National Administration team in the transition discussion and activities as the department migrates to the new messaging/ESB to include:

Application architecture;

• Continuity of Operations, Disaster recovery; and,

• Message persistence to include Recovery Point and Recover Time objectives


• Identified eMI risks are as follows: o If eMI adoption and deployment plans are not well understood by the full VA

development community, then the probability of duplication in capability development, monitoring, testing and security activities increases

o If the eMI capabilities, including the SBSA, VSA, and enterprise IAM services are not achieved in a timely manner, then the schedule, speed, reliability, security, and capacity of data services and access to longitudinal health record data will be compromised. The current eMI project plan is for four (“4”), six (“6”) month eMI development increments starting in November 2014. The target date for eMI deployment, with full VA authority to operate (ATO) is currently March 2016.

10.2. Security The implementation of VistA 4 will meet all Federal information security requirements and will utilize approved VA Office of Information Technology ProPath System Development Lifecycle (SDLC) process and the VA Office of Information Security’s Software Assurance (SwA) Program. These will improve both patient identity security and information system security. Additional security will be achieved through VA’s Information Security Continuous Monitoring (ISCM) and Information Security Risk Management (ISRM) programs to manage information system risk as called for in NIST SP 800-137 guidance.

VistA 4 will enhance patient data security by using improved Technical Controls, which will include SwA, ISCM, ISRM, and data encryption, both in transit and at rest.

10.2.1. Security Requirements and Policies The implementation of VistA 4 will meet all Federal information assurance requirements including:

• Federal Information Security Management Act (FISMA);

• Health Insurance Portability and Accountability Act (HIPAA);

• Applicable National Institute of Standards and Technology standards and special publications;

• VA Directive and Handbook 6500, Managing Information Risk: VA Information Security Program; and,

• Risk Management Framework for VA Information Systems – Tier 3: VA Information Security Program respectively.

The E-Government Act, Pub. L. 107-347, 116 Stat. 2899 (2002), recognizes the importance of information and information systems to the economic and national security interests of the United States. Title III of the E-Government Act, FISMA, tasked all Federal agencies with the responsibility of developing, documenting, and implementing agency-wide information security programs, and providing risk-based information security for the information and information systems that support their operations and assets.

The transformation of the current VistA system to the VistA 4 product will utilize approved VA OI&T DLCSDLC, obtain appropriate VA OI&T management Authorization to Operate through


the Assessment and Authorization process prior to implementation within VA, and will be continuously monitored to ensure that the security controls and security posture remains effective throughout its lifecycle.

In addition to following Certification Program Office and Assessment and Authorization processes to support FISMA compliance in accordance with VA Handbook 6500.3 as described above, there have been notable recent security-related enhancements to VA systems development processes that the VistA 4 Product will benefit from, compared to the current system. These enhancements are specific to building security into application source code during the development of applications at VA, to increase the level of confidence that software developed for use at VA is free from vulnerabilities. There are two areas where recent security-related enhancements to VA systems development processes have been made:

1. The first area is ProPath; which is a set of process maps that help make standard, repeatable systems development processes at the VA easier, and

2. The second area is the establishment by the Office of Information Security of an agency-wide Software Assurance Program.

Security-related enhancements, which have been made to ProPath include systems development product build processes activities BLD-2 (Perform Product Component Test) and Assessment and Authorization (AAA) 6.6 (Complete Security Controls Assessment). Updates to BLD-2 make performing code reviews a regular activity during development. Updates to AAA 6.6 make passing an independent code review a requirement to obtain an Authority to Operate, in addition to any other NIST 800-53 compliance requirements. The overarching goal of the Software Assurance Program is to increase the level of confidence that software developed for use at VA is free from vulnerabilities. Recent program activities include working with OI&T to make the aforementioned enhancements to ProPath. Recent activities also include the augmentation of Network and Security Operations Center Assessment and Authorization reviews with source code reviews. Another recent example is taking first steps to deploy secure software development tools (specifically, static analysis tools) agency-wide so that code reviews can be performed during development.

NIST Special Publication (SP) 800-53 Revision 4, Recommended Security Controls for Federal Information Systems, contains a list of security controls that are recommended for protecting Federal information systems based on the system’s Federal Information Processing Standards 199 security categorization.

Security controls are implemented to protect information systems. The selection and employment of appropriate security controls for an information system are important tasks that can have major implications on the operations and assets of the VistA 4 Product.

Security controls are the management, operational, and technical safeguards or countermeasures prescribed for an information system to protect the confidentiality, integrity, and availability of the system and its information as defined below:

• Management Controls: The security controls (i.e., safeguards or countermeasures) for an information system that focus on the management of risk and the management of information system security;


• Operational Controls: The security controls (i.e., safeguards or countermeasures) for an information system that are primarily implemented and executed by people (as opposed to systems), and;

• Technical Controls: The security controls (i.e., safeguards or countermeasures) for an information system that are primarily implemented and executed by the information system through mechanisms contained in the hardware, software, or firmware components of the system. Because this document is capturing the design of the VistA 4 system, the technical controls will be discussed and expanded on in the following section.

10.2.2. Technical Controls The federal laws, regulations, and policies that establish specific requirements for the confidentiality, integrity, or availability of the data processed, stored, transmitted, and received by VistA 4 are represented in the NIST SP 800-53 eighteen control families listed below in Table 15.

Table 15. Security Control Classes, Families, and Identifiers IDENTIFIER FAMILY CLASS

AC Access Control Technical AT Awareness and Training Operational AU Audit and Accountability Technical CA Security Assessment and Authorization

Management Management

CM Configuration Management Operational CP Contingency Planning Operational IA Identification and Authentication Technical IR Incident Response Operational MA Maintenance Operational MP Media Protection Operational PE Physical and Environmental Protection Operational PL Planning Management PM Program Management Management PS Personnel Security Operational RA Risk Assessment Management SA System and Services Acquisition Management SC System and Communications Protection Technical SI System and Information Integrity Operational

Specifically related to the Service Oriented Architecture and web services aspects of VistA 4, following NIST guidance (SP800-95), the following security actions are considered during development:

• Replication of Data and Services to Improve Availability - Since Web services are susceptible to Denial-of-Service (DoS) attacks, it is important to replicate data and applications in a vigorous manner. Replication and redundancy can ensure access to critical data in the event of a fault. It will also enable the system to react in a coordinated way to deal with disruptions;

• Logging of Transactions to Improve Non-repudiation and Accountability - Non-repudiation and accountability require logging mechanisms involved in the entire web


service transaction. As of early 2007, there are few implemented logging standards that can be used across an entire SOA. In particular, the level of logging provided by various Universal Description Discovery and Integration (UDDI) registries, identity providers, and individual web services varies greatly. Where the provided information is not sufficient to maintain accountability and non-repudiation, it may be necessary to introduce additional software or services into the SOA to support these security requirements;

• Threat Modeling and Secure Software Design Techniques to Protect from Attacks - The objective of secure software design techniques is to ensure that the design and implementation of web services software does not contain defects that can be exploited. Threat modeling and risk analysis techniques should be used to protect the web services application from attacks. Used effectively, threat modeling can find security strengths and weaknesses, discover vulnerabilities, and provide feedback into the security life cycle of the application. Software security testing should include security-oriented code reviews and penetration testing. By using threat modeling and secure software design techniques, web services can be implemented to withstand a variety of attacks;

• Performance Analysis and Simulation Techniques for End to End Quality of Service (QoS) and Quality of Protection - Queuing networks and simulation techniques have long played critical roles in designing, developing and managing complex information systems. Similar techniques can be used for quality assured and highly available web services. In addition to QoS of a single service, end-to-end QoS is critical for most composite services. For example, enterprise systems with several business partners must complete business processes in a timely manner to meet real time market conditions. The dynamic and compositional nature of web services makes end-to-end QoS management a major challenge for service-oriented distributed systems;

• Digitally Sign UDDI Entries to Verify the Author of Registered Entries - UDDI registries openly provide details about the purpose of a web service as well as how to gain access. Web services use UDDI registries to discover and dynamically bind to web services at run time. Should an attacker compromise a UDDI entry, it would be possible for requesters to bind to a malicious provider. Therefore, it is important to digitally sign UDDI entries so as to verify the publisher of these entries, and;

• Enhancement of Existing Security Mechanisms and Infrastructure - Web services rely on many existing Internet protocols and often coexist with other network applications on VA’s network. As such, many web service security standards, tools, and techniques require that traditional security mechanisms, such as firewalls, intrusion prevention systems, and secured operating systems, are in effect before implementation or deployment of web services applications.

10.2.3. Web Service Security VA understands that because a web service relies on some of the same underlying HTTP and web-based architecture as common web applications, it is susceptible to similar threats and vulnerabilities. Web services security is based on several important concepts, including:


• Identification and Authentication - Verifying the identity and/or location (when applicable) of a user, process, or device, often as a prerequisite to allowing access to resources in an information system;

• Authorization - The permission to use a computer resource, granted, directly or indirectly, by an application or system owner;

• Integrity - The property that data has not been altered in an unauthorized manner while in storage, during processing, or in transit by ensuring proper encryption protocols;

• Non-Repudiation - Assurance that the sender of information is provided with proof of delivery and the recipient is provided with proof of the sender’s identity, so neither can later deny having processed the information;

• Confidentiality - Preserving authorized restrictions on information access and disclosure, including means for protecting personal privacy and proprietary information, and;

• Privacy - Restricting access to subscriber or relying party information in accordance with Federal law and organization policy.

• All of the above will be thoroughly addressed in the new design making improvements, where possible, over the legacy VistA system.

VA also understands the importance of secure messaging and that web services rely on the Internet for communication. Because the typically used Simple Object Access Protocol (SOAP) was not designed built-in security control, SOAP messages can be viewed or modified by attackers as the messages traverse the Internet. There are several options available for securing Web service messages:

• HTTP over SSL/TLS (HTTPS) - It is trivial to modify a Web service to support HTTPS, because SOAP messages are transmitted using HTTP;

• XML Encryption and XML Signature - These XML security standards developed by the Worldwide Web Consortium allow XML content to be signed and encrypted. Because all SOAP messages are written in XML, web service developers can sign or encrypt any portion of the SOAP message using these standards, but there is no standard mechanism for informing recipients how these standards were applied to the message, and;

• WS-Security - WS-Security was developed to provide SOAP extensions that define mechanisms for using XML Encryption and XML Signature to secure SOAP messages.

Each secure messaging option has its own strengths and weaknesses and VA will implement the best options based on the risk analysis performed balanced against needs and performance.

The VA will target the implementation to be modeled after the industry-standard web services stack as shown below in Figure 7:


Figure 7. Industry-standard Web Services Stack

Standards at the network, transport and XML security layers are used to secure messages as they are transmitted over the network. The security standards IPsec, SSL/TLS (Secure Sockets Layer/Transport Layer Security), XML Encryption and XML Signature each operate on SOAP messages at a different level.

Above the XML Security layer, there are two types of standards: standards built on top of SOAP and standalone standards. Message security standards WS-Security and WS-SecureConversation define how to use XML Signature, XML Encryption and credentials to secure SOAP at the message layer while reliable messaging standards define the protocols and constructs necessary to ensure that messages will be received. The access control standards are not unique to web services; eXtensible Access Control Markup Language (XACML) can define the access policy for any system and Security Assertion Markup Language (SAML) can be used to define assertions in any environment. The policy layer’s WS-Policy defines a grammar to communicate the policy requirements of a web service.

Security management specifications define other web services to manage credentials, such as public key infrastructure (PKI) certificates within the SOA. Identity management standards take advantage of access control standards, policy standards and SOAP standards to offer services for distributing and managing user identities and credentials within the SOA.

VA understands that when resources are made publicly available, it is important to ensure that they are adequately protected. Usually, web services are intended to be accessible only to


authorized requesters, requiring mechanisms for access control. To perform access control, web services need to identify and authenticate one another. Several different methods are available, including transport layer authentication, token authentication via the WS-Security specification using SAML assertions or other tokens, and the SOAP authentication header. Authorizations for web services are often done through custom implementations, but the XACML is an Organization for the Advancement of Structured Information Standards (OASIS) standard available for performing authorization decisions, eliminating the time and cost associated with developing and testing a custom solution.

In conclusion, VA will select the best of breed practices, from those described above, for implementing and securing SOA/Web Services throughout the lifecycle of the VistA 4 product.

10.3. External Collaborations/Enabling Innovations The open source and standards community has significantly contributed to VistA in the past and has much to contribute to its future development. It is in the interest of VA to leverage their contributions to create enhanced functionality, interoperability, standards adoption, and a more flexible technical architecture. The partnerships across VA, DoD, and the community of health IT industry innovators, health systems, universities, and open source providers shall create a common vision of what needs to happen by creating a community that will drive VistA’s Open Source codebase modernization. This is the core of VA’s approach to the development of VistA 4 and interoperability. The plan to achieve this goal is to develop a common understanding between VA, DoD, and the community stakeholder triangle through discussions, pilots, and proofs of concepts. The practical goal is to greatly increase the quality and reduce the time for VA to create and execute a plan for VA HIT modernization.

VA is committed to working collaboratively with the open source community for the benefit of all Veterans. In June of 2011, VA began an open source Initiative for VistA. The former Secretary of VA, the Honorable Eric Shinseki, announced an open source strategy “to engage the public and private sectors in the rapid advancement of our EHR software.”7 This strategy is central to the care VA delivers to Veterans, Servicemembers, and their dependents, as well as the joint EHR collaboration with DoD. In support of this new strategy, VA has taken considerable steps to promote external collaborations and innovative activities with the external community including:

• Establishment of an Open Source Tiger team to define a process to bring in open source contributions into VA;

• Establishment and participation in the Open Source Electronic Health Record Alliance (OSEHRA);

• Creation of new policy in the form of VA Directive 6402 to re-enforce VA’s dedication to external collaboration and innovation with the external community;

7 Department of Veterans Affairs. VA Launches Open Source Custodian. 30 April 2011. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2153


• Use of Open Source certification of VA code base for the 74 core VistA products;

• Creation of two new Program Offices dedicated to the promotion of external collaboration with the open source and open standards as well as private health systems provider communities.

10.3.1. Founding of the Open Source Electronic Health Record Alliance Under FOIA, VistA has always been available from VA as “public domain” software. To date, VistA has been implemented to some extent by many non-VA healthcare facilities, including international healthcare entities. With its widespread use, there is a considerable community of VistA developers across the world that can collaborate to enhance VistA. In 2011, VA established OSEHRA to:

Build and support an open source community of users, developers, service providers, and researchers engaged in advancing electronic health record software and related health information technology. OSEHRA’s mission includes the creation of a vendor-neutral community for the creation, evolution, promotion and support of an open source Electronic Health Record. This community will operate with the transparency and agility that characterize open source software initiatives. This entails not only the development of a community of software experts, clinicians, and implementers, but also a robust ecosystem of complementary products, capabilities and services.8

Through this establishment, VA encouraged an ecosystem to promote open development of VistA and encourage collaborative innovation with some of the best minds in government, industry and academia. This collaboration and commitment to innovation is anticipated to pioneer new software developments that can address the unique challenges of future iterations of VistA.

10.3.2. VA Open Source Tiger Team During the open source Tiger Team activities, VA successfully adopted parts of the open source HealtheMe product through MyHealtheVet. VA is currently actively pursuing pilots for the VA intake of additional open source contributions. Two products that have been certified by OSEHRA are actively seeking funding for active project teams to move them forward through the remainder of the VA intake process.

10.3.3. VA Policy Creation and Open Source Certification As a part of VA Directive 6402 the VA announced that all current VistA software supported at the national level will be certified by OSEHRA.

The VistA code set will be certified and stored by the custodial agent Open Source Electronic Health Record Alliance (OSEHRA). This partnership with OSEHRA is a key element of VA’s effort to innovate in the Electronic Health Record software arena,

8 http://www.osehra.org/page/about-us


including both VistA and our joint effort with the Department of Defense (DoD) to merge the agency’s systems to support common clinical processes and implement an Integrated Electronic Health Record (iEHR) as directed by the Executive Branch. This move towards an iEHR requires rigorous and consistent software configuration at all VAMCs.

10.3.4. Collaboration with OSEHRA Workgroups VA has also taken steps to collaborate with the open source community by initiating and/or engaging in various OSEHRA workgroups. OSEHRA workgroups are defined for the purpose of collaborating around a specific topic. There are many workgroups that VA is participating in for the purpose of defining requirements for a functional capability. Clinicians, informaticists and developers engage to define and potentially build a product that will meet the needs of the open source community at large. VA is positioning itself to play a strong role in this community and as a result will be able to take advantage of the many community contributions. As VA embarks upon modernization of its VistA software, the VA is leveraging community contributions as well as collaborating with the open source community. VA will do this by openly sharing VistA roadmap artifacts, seeking community input, jointly defining requirements, and producing world-class software that will enhance the care of Veterans, Servicemembers, and their dependents worldwide.

10.3.5. VA Established the Open Source and Open Standards Community IT Engagement Program

The Open Source and Open Standards Community IT Engagement Program (CITE) supports the reengineering and refactoring of VistA EHR components and assembling the core capabilities for VistA 4 in a market context. VHA Office of Informatics and Analytics (OIA) is striving to accelerate the market for open, extensible, modular EHRs, which is expected to lower costs and increase quality of EHR components in the future. Moreover, VHA OIA recognizes that it needs to draw on rapidly improving the HIT market to maintain functional parity as VistA 4 is developed. The goal of this effort is to support the VHA & OI&T executive management teams and their goals and objectives preparing VA for the next generation of VistA by acting as a conduit for information exchange between VHA, OI&T, and the community as outlined in Figure 8, below.


Figure 8. Information exchange between VHA, OI&T, and the community

The CITE Mission focuses on the following:

1. Community Involvement: Engage in meaningful dialogue with the community on the future direction of interoperable open electronic health solutions.

2. Community Developed Solutions: Prepare the marketplace to respond to the future iterations of VistA.

3. VistA Evolution Program Support: Identify best practices with open standards and technologies, and incorporate open source products and services from the community back into VA.

Table 16, below, shows the activities that will be undertaken by CITE.

Table 16. CITE Activities

CITE Effort Description

Intake Pathways In coordination with VHA’s Strategic Investment Management Office’s (SIM) Open Source Office, develop a high-level plan, with OI&T and VistA Evolution stakeholders, for the expedited integration, development, and testing of non-OI&T developed code into VA VistA Enterprise Standard. It is anticipated that this effort will enhance quality of patient care and decrease the lifecycle development cost to the enterprise.

Communication and Engagement Strategy

Create and execute a communication and community engagement strategy including an Industry Day event, targeted at Standards Development Organizations, Open Source Community and Health Systems innovators. Provide bi-directional external VE updates and collaboration opportunities. Create Industry Day for members of the outside community to learn about the VistA Evolution Program, and invite them to bring solutions and services to the VA.


Market Research Provide organizational and domain support in the evaluation of community developed solutions, technologies or services as outlined by the VistA 4 Product Roadmap.

Voice of Industry Workgroup

Develop “Voice of Industry” collaboration resource where industry informatics thought leaders provide best practice domain insight and share industry lessons learned with the VA VistA Evolution Program leaders. This resource will ensure community innovation efforts are evaluated as part of the VistA Evolution program.

Governance Guidance Obtain key guidance from the Office of General Counsel (OGC) to define an engagement protocol for approaching the “Community”. Ensure compliance with the Federal Acquisition Regulation, Corporation Control Act, and Federal Advisory Committee Act. Provide a reference guide for utilizing Collaborative Research and Development Agreements (CRADA).

10.3.6. VA Established the Open Source Management Office The goal of the Open Source Management Office is to support VHA’s engagement with the Open Source community, enabling collaboration with OI&T and community experts to foster the development of world-class healthcare software that will empower clinicians to better serve our Veterans, Servicemembers, and their dependents. The Open Source Management Office works closely with CITE to address topics and issues to enable VistA 4 to achieve Feature Set 4 deployment.


11. Summary Successful implementation of this Product Roadmap will deliver a modernized, interoperable EHR, VistA 4. The evolution of VistA will establish seamless, electronic sharing of interoperable health care data with DoD, and other healthcare partners, in a real-time, computable manner, using existing data standards, with the objective of achieving one unified, lifetime health record for each Veteran, Servicemember, and their dependents. The open source, open standard, and SOA-based approach will reduce risk and cost, and increase quality and speed of HIT acquisitions and deployments. The modernization of VistA will improve quality, safety, efficiency, equity, and satisfaction in health care for Veterans, Servicemembers, and their dependents.


12. Appendix A: Data Standards 12.1.1. Core Medical Vocabulary Standards

Semantic interoperability refers to information exchanged between systems having shared meaning, so computers and software applications can appropriately compare or compute on information from multiple sources. In the medical domain, this is accomplished in part through standard medical code systems. A code system is a collection of concepts with definitions (vocabulary) usually organized hierarchically (taxonomy). Different coding systems are used for different medical subdomains: for example, VA National Drug File/Pharmacy Product System (VA NDF/PPS), RxNorm for drugs, Logical Observation Identifiers Names and Codes (LOINC) for laboratory and clinical observations, Current Procedural Terminology (CPT) for medical procedures, and Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) for diagnoses condition(s and symptoms.

The HSP identifies 41 distinct medical domains and subdomains where coding systems apply. Different coding systems are used for different medical subdomains; some examples of coding systems and their area of application include, but are not limited to:

• VA National Drug File/Pharmacy Product System – for medication names used in pharmacy and related applications

• LOINC/Clinical – for document titles, clinical documentation forms, scales, and inventories

• LOINC and Radiology Lexicon (RADLEX) – for radiology document titles

• Digital Imaging and Communications in Medicine (DICOM) – for images in radiology clinical medicine (e.g., EKG, endoscopies)

• Center for Disease Control (CDC) Vaccine Administered (CVX) and Manufacturers of Vaccines (MVX) – for immunizations and vaccine manufacturers

• CDC race and ethnicity codes – for demographics

• CPT-4 and Healthcare Common Procedure Coding System (HCPCS) – for procedure documentation

• International Classification of Diseases (ICD)-9 and ICD-10 – for encounter diagnoses and clinical coding

• Unified Code for Units of Measure (UCUM) – for units of measure

• Unified Medical Language System Concept Unique Identifier (UMLS CUI) – for allergies and interlingua-translation tasks

• RxNorm and National Drug File – Reference Terminology (NDF-RT) – for drug class determination, medication representation, and translation tasks for medications

12.1.2. Information Model Standards This category of standards is concerned with representing information in EHR systems and communications related to patient care and hospital operations. Information models augment coded medical vocabularies in three ways:


• By providing the business context around medically-coded information; – The same drug code can appear in the context of a prescription, a billing

statement, a request to a pharmacy, a record of dispensing or administering the medication, as part of a medical history, or in an adverse reaction report;

• By providing additional information around an action or encounter; and

– Information such as participants (e.g., patient, practitioner, family members, organization), relevant dates and times, locations, payer information, etc.

• By capturing relationships between clinical information – Information such as a lab result being evidence for a diagnosis, a procedure being

a treatment for a condition, or an adverse reaction resulting from the administration of a medication.

Typically, information models are expressed at two levels:

• A logical model that describes the information to be exchanged, independent of any particular data management technology, typically comprised of entities and relationships with underlying definitions.

• A physical model that specifies the syntax or structure used, often referring to the message formats or model serializations.

When exchange partners use different information models, the information must be mapped from one model to the other; therefore, the use of common information models is highly desirable. The HSP identifies several information modeling standards which the VistA Evolution Program will comply with, including but not limited to:

• Health Level 7 (HL7) Consolidated CDA (formally referred to as the HL7 Implementation Guide for CDA® Release 2: IHE Health Story Consolidation) – for external exchanges of patient information related to care transitions, and other clinical contexts where the sending and receiving of structured and/or unstructured data is needed

• HL7 v2.x message profiles – for information exchange requirements such as order management, results reporting and immunization reporting

• DICOM – for medical imagery

• National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard, Implementation Guide, Version 10.6 or later – For pharmacy-related messages in support of ePrescribing and other pharmacy functions

HL7 Fast Healthcare Interoperability Resources (FHIR) Data Standard for Trial Use (DSTU) Version .80 – for representing data for internal DoD/VA information exchange (recognized as an “emerging standard”).

In addition, VA has identified additional data standards that may be required for implementation in the future:

• QRDA (formally referred to as the HL7 Implementation Guide for CDA® R2: Quality Reporting Document Architecture) – a document format that provides a standard


structure to report quality measure data to organizations that will analyze and interpret the data

• Health Quality Measures Format (HQMF) (formally referred to as the HL7 Version 3 Standard: Representation of the Health Quality Measure Format (eMeasure) DSTU, Release 2) – for representing clinical quality measures, as electronic documents

• HL7 Implementation Guide: Clinical Decision Support Knowledge Artifact Implementation Guide (also known as HeD) – for sharing clinical decision support knowledge such as clinical guidelines, rules and knowledge artifacts

• The ONC Blue Button Plus standard – for providing Veterans access to their health care data

12.1.3. Secure Data Transport Standards This category of standards is concerned with data transport and the required methods for moving electronic health record information. Below is a list of approved and emerging standards for secure data transport, to which the VistA Evolution Program will adhere. These include, but are not limited to:

• SOAP – as represented in the eHealth Exchange specifications, and supporting transport profiles, such as Cross-Enterprise Document Media Interchange (XDM), Cross-Enterprise Document Reliable Interchange (XDR), and Cross-Enterprise Document Sharing (XDS.b)

• Simple Mail Transfer Protocol (SMTP)/Secure/Multipurpose Internet Mail Extensions (SMIME), as represented by the DIRECT protocol, and supporting the XDR and XDM messaging options

• Representational State Transfer (REST)ful transport

• HL7 MLLP (Minimum Lower Layer Protocol)

12.1.4. Privacy and Security Standards VA is committed to ensuring that as the Vista Evolution Program progresses, appropriate privacy and security controls and mechanisms will continue to be implemented. VA will strive to adopt additional privacy and security standards specific to ONC EHR Certification and the regulatory framework it establishes. Privacy and security standards will focus on the following:

• Use of American Society for Testing and Materials (ASTM) E2147 (formally referred to as the Standard Specification for Audit and Disclosure Logs for Use in Health Information Systems) to comply with audit log guidelines

• Use of Network Time Protocol (NTP) to ensure time synchronization for all Vista components that enable auditing

• Support for auditing requirements associated with the viewing, downloading and transmitting of health information

• Use of encryption for data at rest and in motion. This may include use of any combination of TLS, Advanced Encryption Standard (AES), Triple Data Encryption


Algorithm Standard (3DES) and/or Secure Hash Algorithm (SHA1) to support encryption requirements.

Additional privacy and security standards will be considered where appropriate and in consultation with ONC and the IPO. Such standards may include:

• Future use of the Secure Access Markup Language (SAML) and/or OAuth 2.0 standards to support authorization

• Support for standards associated with the accounting of electronic disclosures of information as they are defined at the national level

12.1.5. Service Standards VA will strive to achieve alignment with the services vision as outlined in the ONC Standards & Interoperability (S&I) Framework standards portfolio, including consideration of the service standards already under development in the industry. This includes evaluation of the following standards for use within the Vista Evolution program, in consultation with ONC and the IPO:

• HL7 Common Terminology Service (CTS) Application Programming Interface (API) to support the maintenance and development of clinical terminology value sets

• HL7 Retrieve, Locate, Update Service (RLUS) API to support the retrieval, location and updating of patient health care records

• Health Provider Directory (HPD) Plus profile to support the identification and management of VA health care provider information


13. Appendix B: Acronyms Acronym Description

3DES Triple Data Encryption Algorithm Standard ACE Adaptive Cloud Environment ADE Adverse Drug Event AES Advanced Encryption Standard AIDE Agile Integrated Development Environment AITC Austin Information Technology Center API Application Program Interface ASD Architecture, Strategy and Design ASTM American Society for Testing and Materials BCR Breast Care Registry BP Background Processor C/MU Certification/Meaningful Use CAS Clinical Ancillary Services CATS Clinical Advisory Technical Services CBOC Community Based Outpatient Clinic CCDA Consolidated Clinical Document Architecture CCOW Clinical Context Object Workgroup CCR Continuity of Care Record CDC Centers for Disease Control CDS Clinical Decision Support CDW Corporate Data Warehouse CEHRT Certified Electronic Health Record Technology CITE Community IT Engagement Program CLIM Common Logical Information Model CMS Centers for Medicare & Medicaid Services COTS Commercial-Off-The-Shelf CPE Clinical Practice Environment CPOE Clinician Pharmacy Order Entry CPRS Computerized Patient Record System CQM Clinical Quality Measures CRADA Collaborative Research and Development Agreements CTS Common Terminology Services CVX Codes for Vaccine Administered CY Calendar Year DBMS Database Management System DECC Defense Enterprise Computing Centers DHCP Decentralized Hospital Computer Program DHMSM DoD Healthcare Management System Modernization DICOM Digital Imaging Communications in Medicine


DISA Defense Information Systems Agency DMIX Defense Medical Information Exchange DoD Department of Defense DoS Denial-of-Service DSTU Data Standard for Trial Use EA Enterprise Architecture EDE Enterprise Development Environment EHR Electronic Health Record EOL End of Life EOS End of Service ePrescribing Electronic prescriptions ESB Enterprise Service Bus ESM Enterprise System Manager ETS Enterprise Terminology Services eVPR Enterprise Virtual Patient Record FDCCI Federal Data Center Consolidation Initiative FHIR Fast Healthcare Interoperability Resources FISMA Federal Information Security Management Act FOIA Freedom of Information Act FY Fiscal Year GFE Government Furnished Equipment GUI Graphical User Interface HCPS Healthcare Common Procedure Coding System HDR Health Data Repository HEC Health Executive Council HHS Health and Human Services HIPAA Health Insurance Portability and Accountability Act HIT Health Information Technology HL7 Health Level 7 HMP Health Management Platform HPD Health Provider Directory HPS Health Provider Systems HRF Human Readable Form HSP Health Standards Profile HTTPS Hypertext Transport Protocol Secure I2TP Joint DoD/VA Healthcare Information Interoperability Technical Package IAF Interoperability Alignment Framework IAM Identity and Access Management IBPE Internal Business Partner Extranet ICD International Classification of Diseases ICIB Interagency Clinical Informatics Board ICU Intensive Care Unit


IEEE Institute of Electrical and Electronics Engineers iEHR Integrated Electronic Health Records IHI Institute of Health Improvement IIS Immunization Information System IPT Integrated Project Team ISCM Information Security Continuous Monitoring IT Information Technology IV Intravenous JLV Joint Legacy Viewer JSON Java Script Object Notation LAN Local Area Network LIS Laboratory Information System LOINC Logical Observation Identifiers Names and Codes M-Code Massachusetts General Hospital Utility Multi-Programming System Code MD FIRE Medical Device Free Interoperability Requirements for the Enterprise MDI Medical Device Integration MLLP Minimum Lower Layer Protocol MOCHA Medication Order Check Healthcare Application MPLS Multiprotocol Label Switching MU Meaningful Use MVI Master Veteran Index NDAA National Defense Authorization Act NDCP National Data Center Program NDF-RT National Drug File – Reference Terminology NIPRNet Non-secure Internet Protocol Router Network NIST National Institute of Standards and Technology O&M Operations and Maintenance OASIS Organization for the Advancement of Structured Information Standards OAuth2 Open Authorization 2 OGC Office of General Counsel OI&T Office of Information and Technology OMB Office of Management and Budget ONC Office of the National Coordinator OP Outpatient Pharmacy OSEHRA Open Source Electronic Health Record Alliance PACT Patient Aligned Care Teams PB Petabyte PECS Pharmacy Enterprise Customization System PHIN Public Health Information Network PHIS Pharmacy Hospital Information System PIV Personal Identity Verification PKI Public Key Infrastructure


PMAS Project Management Accountability System PPS Pharmacy Product System PRE Pharmacy Re-engineering QoS Quality of Service QRDA Quality Reporting Document Architecture RadLex Radiology Lexicon RAID Redundant Array of Independent Disks REST Representational State Transfer RFP Request for Proposal ROI Release of Information RPC Remote Procedure Call RxNORM Normalized naming system for generic and branded drugs SAML Security Assertion Markup Language SAN Storage Area Network SDE Service Delivery and Engineering SDN Software Defined Network SDO Standards Development Organizations SHAI Secure Hash Algorithm SIM Strategic Investment Management SLA Service Level Agreement SMART Security Management and Reporting Tool SME Subject Matter Expert SNOMED Systematized Nomenclature of Medicine SNOMED CT Systematized Nomenclature of Medicine - Clinical Terms SOA Service Oriented Architecture SOAP Simple Object Access Protocol SPMP State Prescription Drug Monitoring Programs SSA Social Security Administration SSL/TLS Secure Sockets Layer/Transport Security Layer STVHCS South Texas Veterans Health Care System SwA Software Assurance TDrugs Notification of Teratogenic Drugs TIC Trusted Internet Connection TLS Transport Layer Security TRM Technical Reference Model UCUM Unified Code for Units of Measure UDDI Universal Description Discovery and Integration UMLS CUI Unified Medical Language System Concept Unique Identifier UX User Experience VA Department of Veterans Affairs VAMC Veterans Affairs Medical Center vBE Virtual Back End


VEIP VistA Evolution Interoperability Plan VFE Virtual Front End VHA Veterans Health Administration VIE VistA Interface Engine

VIMM VistA Immunization Enhancements VISN Veterans Integrated Service Network VistA Veterans Health Information Systems and Technology Architecture VistA 4 The next iteration of the Veterans Health Information Systems and Technology

Architecture VLER Virtual Lifetime Electronic Record VM Virtual Machine VSA VistA Service Assembler Vx VistA Exchange W3C World Wide Web Consortium WAN Wide Area Network XACML Extensible Access Control Markup Language XDR External Data Representation XML Extensible Markup Language


14. Appendix C: Reference/Bibliography 1 Section 713 of the National Defense Authorization Act (NDAA) for Fiscal Year 2014,

December 10, 2013. 2 HARB Charter, February 27, 2012. 3 The Institute for Electrical and Electronic Engineering (IEEE) Standard Computer

Dictionary: A Compilation of IEEE Standard Computer glossaries (New York, NY: 1990). 4 “DoD-VA Health Architecture Alignment Gap Analysis”, MITRE, September 2013 5 “Evidence Based Medicine and the Changing Nature of Healthcare”, Institute of Medicine,

9 October, 2008 6 "Free Interoperability Requirements for the Enterprise", MD FIRE: Medical Device, MD

PnP, http://mdpnp.org/mdfire.php. 7 “Final Recommendations for RESTful Exchange Standards”, NwHIN Power Team, Health

IT Standards Committee, August 22, 2013. 8 http://www.healthit.gov/FACAS/sites/faca/files/(Baker)2013Aug_HITSC_NwHINPT_FIN

AL-Revised.pdf 9 http://trm.OI&T.va.gov/VAStandardPage.asp?tid=7020^. 11 American Clinical Lab Association. The Value of Clinical Laboratory Services (2011).

http://www.acla.com/node/355. 12 VA Directive 6402 Standardization of VistA National Software 13 Evidence Based Medicine and the Changing Nature of Healthcare, Institute of Medicine, 9

October, 2009 14 http://mdpnp.org/mdfire.php 15 National Archives and Records Administration E-Gov Electronic Records Management

Initiative (March 2006). Recommended Practice: Developing and Implementing an Enterprise-wide Electronic Records Management (ERM) Proof of Concept Pilot. http://www.archives.gov/records-mgmt/pdf/pilot-guidance.pdf

16 VistA Evolution Program Plan 17 VistA Evolution Business Requirements Document 18 Handler, Thomas, J. and Barry R. Hieb. Gartner's 2007 Criteria For An Enterprise CPR.

Gartner, 2007. 19 Obama, Barack. “Remarks by The President on Improving Veterans Health Care.” The

White House, Office of the Press Secretary. Eisenhower Executive Office Building. 9 April 2009.

20 Handler, Thomas J. (2010). Modifying the Enterprise CPR System Generation Model. Gartner, 2010.

21 Department of Veterans Affairs. VA Launches Open Source Custodian. 30 April 2011. 22 The National Quality Forum (May 2006). NQF-Endorsed Definition and Framework

for Measuring Care Coordination. http://nursingworld.org/DocumentVault/Care-Coordination-Panel-Docs/background-docs/Jun-4-Mtg-docs/NQFCare-Coordination-Definition-Framework.pdf


http://mdpnp.org/mdfire.php

http://www.healthit.gov/FACAS/sites/faca/files/(Baker)2013Aug_HITSC_NwHINPT_FINAL-Revised.pdf

http://www.healthit.gov/FACAS/sites/faca/files/(Baker)2013Aug_HITSC_NwHINPT_FINAL-Revised.pdf

http://mdpnp.org/mdfire.php

http://nursingworld.org/DocumentVault/Care-Coordination-Panel-Docs/background-docs/Jun-4-Mtg-docs/NQFCare-Coordination-Definition-Framework.pdf



15. Appendix D: Care Coordination Description Care coordination is a key element of Patient-Centered Medical Home/Patient Care Aligned Care Team for the purposes of improving quality, safety, efficiency and cost-effectiveness of care.

The National Quality Forum (NQF) has endorsed the following definition and framework for measuring care coordination.

Care Coordination is a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.9

Although the concepts and activities of care planning, care management, and care coordination are tightly related, they are neither interchangeable terms, nor equivalent activities, as shown below in Figure 9. Care management and care planning activities support and inform the larger superordinate goal of care coordination.

Figure 9. Relationship of Care Planning, Care Management, and Care

Coordination

9 http://nursingworld.org/DocumentVault/Care-Coordination-Panel-Docs/background-docs/Jun-4-Mtg-docs/NQFCare-Coordination-Definition-Framework.pdf


16. Appendix E: VistA Standardization List of Applications Product / Application Category Admission, Discharge, Transfer (ADT) / Registration Clinical Services Computerized Patient Record System Clinical Services Adverse Reaction Tracking Clinical Services Authorization/Subscription Utility Clinical Services Clinical Reminders Clinical Services Consult/Request Tracking Clinical Services Health Summary Clinical Services Problem List Clinical Services Text Integration Utilities Clinical Services Text Integration Utilities Group Notes Clinical Services Laboratory Clinical Services Anatomic Pathology Clinical Services Electronic Data Interchange Clinical Services Emerging Pathogens Initiative Clinical Services HOWDY Computerized Phlebotomy Login Process Clinical Services Point of Care Clinical Services Universal Interface Clinical Services VistA Blood Establishment Computer Software Clinical Services Clinical Lexicon Clinical Services Nutrition and Food Service Clinical Services Patient Care Encounter Clinical Services Pharmacy Clinical Services Automatic Replenishment/Ward Stock Clinical Services Bar Code Medication Administration Clinical Services Bar Code Medication Administration Backup Utility Clinical Services Benefits Management Clinical Services Consolidated Mail Outpatient Pharmacy Clinical Services Controlled Substances Clinical Services Drug Accountability/Inventory Interface Clinical Services Inpatient Medications Clinical Services IV Medications Clinical Services Unit Dose Medications Clinical Services National Drug File Clinical Services Outpatient Pharmacy Clinical Services Pharmacy Data Management Clinical Services Pharmacy Prescription Practices - Retired Clinical Services Standards & Terminology Services Clinical Services Data Standardization Clinical Services Terminology Services Clinical Services


VistA Imaging System Clinical Services Core Infrastructure Clinical Services Document and Ancillary Imaging Clinical Services Document Imaging Clinical Services Ancillary Imaging Clinical Services Vitals/Measurements Clinical Services Current Procedural Terminology Administrative - Financial Services Decision Support System Administrative - Financial Services Diagnostic Related Group Grouper Administrative - Financial Services Enrollment Application System Administrative - Financial Services Event Capture Administrative - Financial Services Hospital Inquiry Administrative - Financial Services International Classification of Diseases, Clinical Modification Administrative - Financial Services Electronic Signature HealtheVet/Enterprise Pharmacy Medication Order Check Healthcare Application HealtheVet/Enterprise VA Enrollment System HealtheVet/Enterprise Administrative Data Repository Repositories Duplicate Record Merge Infrastructure FileMan (VA) Infrastructure Common Service/Identity Management Service Infrastructure Health Level Seven (VistA Messaging) Infrastructure Health Level Seven Optimized (VistA Messaging) Infrastructure Kernel Infrastructure Kernel Toolkit Infrastructure Kernel Authentication & Authorization for Java 2 Enterprise Edition Infrastructure List Manager Infrastructure MailMan Infrastructure Master Patient Index/Patient Demographics Infrastructure Remote Procedure Call Broker Infrastructure Security and Other Common Services Program Infrastructure VistA Data Extraction Framework Infrastructure VistALink Infrastructure


17. Appendix F: Data Domain and National Standards Data Domain National Standard or Health Data Dictionary (HDD)

Allergies (med allergies) UMLS CUIs Documents (many types) LOINC Clinical Document Ontology Vaccines Administered CVX Immunizations MVX Results - Lab Chemistry & Hematology LOINC v2.40 Medications RxNorm Feb 6 2012 release Problem Lists SNOMED CT 2012 edition Vital signs LOINC Results - Lab Anatomic Pathology Titles – LOINC v2.40; Diagnoses – SNOMED CT Results - Lab Microbiology Titles – LOINC v2.40; Organisms – SNOMED CT Results - Radiology Reports None Procedures CPT4/HCPCS or ICD-10-PCS Social History SNOMED CT Family History SNOMED CT Questionnaires None Other Past Medical History (e.g., travel) Uncertain (possibly SNOMED CT) Pre- and Post-Deployment Assessments None Scanned & Imported Paper Records & non-radiology images Type – LOINC; File type – PDF-A, Text, JPEG, etc.

Radiology Images Images – DICOM PS 3-2011 metadata or JPEG2000; Titles – LOINC or RADLEX

Demographics Ethnicity & Race – OMB/CDC Race codes Preferred Language – ISO 639-2 alpha-3 codes

Encounter Data – Admissions Encounter DXs – ICD10 or SNOMED CT Encounter Data – Appointments Encounter DXs – ICD10 or SNOMED CT Payers Insurance Types – LOINC Providers (a section in c32 but not CCDA) Provider Types – NUCC Taxonomy Plan of Care – Pending Orders (multiple types) Uncertain

Medical Equipment UMDNS-SNOMED CT Functional Status SNOMED CT Additional CCDA sections (mostly inpatient) Uncertain Advance Directives (metadata only) HL7 plus LOINC


18. Appendix G: Key Performance Indicators

Technical Design/Functionality

Clinical/Program Performance

KPIs/Performance Architecture Process Design

Phas

e 1 Program KPI Identification Tasks – Fall/Winter 2014 Final Deliverables

Develop Global KPIs from Strategic Goals

Review/Recommendations Define KPIs Sign Off

• Defined Global KPIs with a low-level and high-level description

• Mapping of KPIs to Strategic Goals, Blue Print for Excellence and Veteran Needs

Phas

e 2

Program-level Metric Development Tasks – Winter 2014/5 Final Deliverables

Develop Program Metrics from Global KPIs

Review/Recommendations Develop Metrics Sign Off

• Measurable impact program metrics that lie underneath the KPIs

• Metrics description and functional calculation definitions

• Metrics Benchmarking Determine the Program Metric Targets and Achievement Dates

Review/Recommendations Set Targets/Achievement Dates Sign Off

• Specified achievement targets • Proposed dates for every program metric

Determine the Information Sources for Metrics

Review/Recommendations Identify Information Sources Sign Off

• Identified information sources with baseline measurements

Phas

e 3

Technical-level Specification Tasks – Spring/Early Summer 2015 Final Deliverables Develop Technical Metrics from Program KPIs and Metrics

Define Technical Metrics Sign Off

Review/Recommendations

• Defined technical metrics • Mapping matrix between technical

metrics and Business Needs and Requirements

• Target and dates for Technical Metrics Map Technical Metrics to Program Metrics and to Technical Systems

Develop Mapping Matrix Sign Of

Review/Recommendations • Crosswalk matrix detailing the

relationships between the technical metrics and program metrics


Complete Technical Metrics data specification

Determine Data Specs. Sign Of

Review/Recommendations • Identified systems/modules that will

provide data for measurement on technical and program metrics

Phas

e 4

Measurement Plan and Operations Tasks – Summer/Fall 2015 Final Deliverables Develop Measurement protocols for program Metrics

Review/Modifications Develop Measurement Protocol Sign Off

• Strategic Planning and Monitoring Document

• Strategic Measurement Plan

Develop Automated Measurement Design or Protocol for KPIs

Create Measurement Design

Sign Off Review/Recommendations

• Gap Analysis for Targets achievements and Monitoring Plan

• Functional Requirements Document from Program and Technical Metrics

Develop Operational Measurement and Reporting Procedure or Toolkit

Create Reporting Toolkit Sign Off

Review/Recommendations • Operational Requirements Document for

Measurement

KPI 1: Improve Access to Care

VistA 4 Feature Set 1 (Sept

30, 2014)


30, 2015)

VistA 4 Feature Set 3 (Dec

31, 2016)


30, 2018) Product Enablers

Data Standards Pg. KPI Reasoning

6.3 VistA Immunization Enhancements, 1.0

35 • Supports patient access, engagement communications with private pharmacy clinics, immunizations shots management and VA care teams.

7.3. iMed Consent Platform Migration 41

• Provides consent form updates to all sites in a shortened timeframe, allowing all sites to have the latest version of all nationally standardized forms plus supports assurance behind patient medication and administration safety

8.3 Scheduling-8.3.1: Single Queue of Request Lists

47 • Enables Access Audit and timeliness of care individual-based cases and acuity.


8.3 Scheduling-8.3.2: Aggregated View of Clinic Profile Scheduling Grids

47 • Allow schedulers to view resource availability and schedule the appointment for the Vet from the same screen.

8.3 Scheduling-8.3.3: Resource Management Dashboard

48

• Support decision-making, monitoring and reporting of relationship between scheduling and resources availability for correlating with enhanced patient satisfaction monitoring to assess satisfaction with access and experience.

8.4 Enhancement to Pharmacy 48

• Inbound e-prescribing through the adoption of NCPDP. Will enhance existing functionality in the VistA 4 outpatient pharmacy.


50 • Enables Veterans patient access to public health support from sharing immune data with CDC, i.e., treatments, alerts, reminders.

9.1 Scheduling - MASS 53

• Enables balancing supply of clinicians with demand and individual patient needs including new modes of care like telehealth.

ONC Blue Button Plus Standard

85 • Veterans having accurate personal data using standards supporting semantic interoperability across providers contributing to expanding Veterans choices.


KPI 2: Improve Care Coordination


30, 2014)


30, 2015)


31, 2016)




7.2 JLV Enhancements 40

• Supports a faster and more comprehensive understanding of patient health status with the medical history data through improved usability and system efficiency.

7.1 Interoperability Enhancements 7.1.1. eHMP

39 • Enabling communications across the departments’ providers with clinical decision making through common standards interface.

7.1 Interoperability Enhancements 7.1.2.-VistA Exchange

39

• Utilizing an enterprise wide terminology service for managing and propagating clinical terminology mapping providing accuracy of meaning for shared medical data and decision making.

7.1 Interoperability Enhancements 7.1.3 DoD/VA Gateways

40 • Will provide connectivity bridge and security that all current legacy view and future interoperability data will travel between DoD/VA gateways

8.2 Interoperable EHR 46

• Ensuring the exchange and computability of medical history data as a baseline that will be accessible, usable and shared in clinical decision making.


• Enhances public-private sector care coordination while ensuring extended checks on patient medication safety.



9.2 Broad Deployment of eHMP 55 • Giving clinicians simplified access to Veterans’

complete patient history from both DoD and VA.


KPI 2: Improve Care Coordination


30, 2014)


30, 2015)


31, 2016)




9.3 Veteran Authorization and preferences (VAP)

55

• Eliminates the need for the Veterans or approved partners of the document to print, sign, mail, or deliver a paper copy to shared users or between VA and Social Security Administration office, and creates an official government record of the document as electronically signed,


KPI 3: Improve Resource Utilization within the VA Care Delivery Cycle

VistA 4 Feature Set 1

(Sept 30, 2014)


(Sept 30, 2015)

VistA 4 Feature Set 3 (Dec 31, 2016)


(Sept 30, 2018) Product Enablers


6.2 VistA Standardization Phase 1 34

• Reducing the time for the revision and update of standards and facilitating local requests for modification to standards and their incorporation with developments systems-wide.

6.4 Laboratory 35

• Eliminating the need for laboratory personnel to approve results before they are sent to the attending clinician, supported by lab-established boundaries improving clinical decision making process.

7.4 Enhancement to Pharmacy 7.4.1. MOCHA 2.1

9.5 Enhancements to Ancillary Systems 9.5.3 MOCHA 2.2

42, 60

• Supporting patient safety, medication ordering efficiency and pharmacy workload efficiencies for improved use of medical history data within clinical decision making.

7.4 Enhancement to Pharmacy 7.4.2 PECS 42

• Reducing false safety alert fatigue to pharmacists, and improve order checks to use unique VA expert pharmacist knowledge for clinical decision making.

7.4 Enhancement to Pharmacy 7.4.3. PPS, NDF, and PPS-N and PPS-L

43, 48

• Facilitating expanded and accurate use of medical history data and decision making through the open source Web-based application that provides the ability to manage pharmacy-specific data across the VA enterprise, ensuring that all facilities are using the same base data

7.4 Enhancement to Pharmacy 7.4.3.3 SUMPM

8.4 Enhancements to Pharmacy 8.4.1 Continued Pharmacy Safety Updates

43, 48

• Supporting quality medical data and clinical decision making by facilitating process improvements with the administration and tracking of pharmaceuticals.

7.5 VistA Standardization Phase 2 43 • Creating rapid and real time interoperability with

interagency data, products and systems.

7.6 VistA Standardization, Phase 3 44

• Standardizing executable M code allowing VistA Evolution and its applications to be launched efficiently nation-wide to every site.


8.3 Scheduling-8.3.1: Single Queue of Request Lists 47 • Enables Access Audit and timeliness of care

individual-based cases and acuity.

8.3 Scheduling-8.3.2: Aggregated View of Clinic Profile Scheduling Grids

47 • Allow schedulers to view resource availability and schedule the appointment for the Vet from the same screen.

8.1 Scheduling-8.3.3: Resource Management Dashboard

48

• Support decision-making, monitoring and reporting of relationship between scheduling and resources availability for correlating with enhanced patient satisfaction monitoring to assess satisfaction with access and experience.



9.5 Enhancements to ancillary systems 9.5.1-Radiology 57

• Improving the current clinical workflow demand with emphasis on increased efficiency, improved documentation, and enhanced patient safety.

9.5 Enhancements to ancillary systems 9.5.2 Laboratory 59

• Leveraging standards and interoperability guidelines to exchange orders and results within and across department and commercial reference labs while supporting better clinical decision making.

10.1.10 WAN Acceleration 68 • Infrastructure planning to support VistA Feature Set

4 Deployment.


KPI 4: Improve Patient Outcomes through Improved Medication List Accuracy


(Sept 30, 2014)


(Sept 30, 2015)





6.5 Graphical user interface 6.5.3. Medication Reconciliation

36

• Designed to provide electronic validation and documentation of medication administration, reduce medication misadventures, provide an online patient medication record, and promote a safer inpatient care environment.


39

• Creating the integrated read-only view of DoD and VA health information within a single application for clinicians in both DoD and VA with use of medical history data.

7.4 Enhancement to Pharmacy 7.4.1. MOCHA 2.1


42, 60


7.4 Enhancement to Pharmacy 7.4.2 PECS

43 • Reducing false safety alert fatigue to pharmacists, and improve order checks to use unique VA expert pharmacist knowledge for clinical decision making.


43




43. 49

• Enhancing clinical decision making and data usage by systematically supporting pharmacy patient safety issues, legislative/regulatory changes and site user requests.

8.2 Interoperable EHR 48 • Ensuring the exchange and computability of medical history data as a baseline that will be accessible, usable and shared in clinical decision making.


• Enhances public-private sector care coordination while ensuring extended checks on patient medication safety.


KPI 5: Improve Clinical Decision Making


(Sept 30, 2014)


(Sept 30, 2015)





7.4 Enhancement to Pharmacy 7.4.1. MOCHA 2.1 and


42, 60


7.4 Enhancement to Pharmacy 7.4.2 PECS

42 • Reducing false safety alert fatigue to pharmacists, and improve order checks to use unique VA expert pharmacist knowledge for clinical decision making.


43




43, 49

• Enhancing clinical decision making and data usage by systematically supporting pharmacy patient safety issues, legislative/regulatory changes and site user requests.

8.2 Interoperable EHR 48 • Ensuring the exchange and computability of medical history data as a baseline that will be accessible, usable and shared in clinical decision making.

8.4 VistA Immunization Enhancements (VMM)2.0

50 • Enhances monitoring and provider- patient alert and resources planning for immune and vaccine related illnesses for supporting access.

9.2 Broad Deployment of eHMP

55

• Showing information in a single view which will allow clinicians to use comprehensive patient data and images more easily making medical history data available and extensible with better use of medical history data for clinical decision making.

9.5 Enhancements to ancillary systems 9.5.1-Radiology

57

• Providing best practices functionality such as support for electronic protocols and a dashboard display of the patient’s status, which will facilitate communication between radiologists and technologists supporting clinical decision making.


9.5 Enhancements to ancillary systems 9.5.2 Laboratory

59


HL 7 Common Terminology Service

85

• Enabling optimizing workflows, reducing ambiguity and enhancing knowledge transfer between VA providers, partner agencies, standards organizations, vendors and Veterans.


KPI 6 - Increase Quality and Quantity of Medical History Data Available to Supports Clinical Decision Making


(Sept 30, 2014)


(Sept 30, 2015)





6.1 Interoperability through JLV 33

• Supporting data available and quality for clinical decision making by reducing the need for clinicians to access multiple applications to obtain patient information.

6.2 VistA Standardization Phase 1

34


6.3 VistA Immunization Enhancement 1.0

35 • Supports patient access, engagement communications with private pharmacy clinics, immunizations shots management and VA care teams.

6.5 Graphical User interface-6.5.1 Search Functionality

36 • Enables users to find information in the patient record more quickly and accurately

6.5 Graphical User interface- 6.5.2. InfoButtons

36 • Allow quick access to additional information specific to that data with a simple click

6.5 Graphical user interface-6.5.3. Medication Reconciliation

36

• Designed to provide electronic validation and documentation of medication administration, reduce medication misadventures, provide an online patient medication record, and promote a safer inpatient care environment.

6.7 Enterprise Messaging Infrastructure (eMI)

36

• Facilitating transporting systems in a standards-based, secure, and reliable manner between DoD/VA and other associated EHR systems.

7.2 JLV Enhancements 40




39 • Enabling communications across the departments’ providers with clinical decision making through common standards interface.


40

• Enabling a longitudinal health record which natively integrates data from all VistA instances, as well as data from the DoD and third party providers when appropriate in support of an interoperable and quality medical data and clinical decision making.

7.1 Interoperability 7.1.3 DOD/VA Gateways



43 • Creating rapid and real time interoperability with interagency data, products and systems.

7.6 VistA Standardization, Phase 3

44 • Standardizing executable M code allowing VistA Evolution and its applications to be launched efficiently nation-wide to every site.


• Appling the use opens standards and open architecture to achieve seamless interoperability with DoD.

8.5 VistA Service Assembler 49

• Facilitating enhanced design and run time for utilities that will be used to analyze Veterans medical history and data.


49

• Generates semantically interoperable data standard for immune/vaccine data across external diverse systems where access can be improved from sharing data evidence.

8.8 FileMan Modernization 51

• Allowing for the federation of records from multiple systems to create a virtual database for use quality use with clinical decision making.


55 • Giving clinicians simplified access to Veterans’ complete patient history from both DoD and VA.



57

• Providing best practices functionality such as support for electronic protocols and a dashboard display of the patient’s status, which will facilitate communication between radiologists and technologists supporting clinical decision making.


59


HL 7 CDA 83

• Fostering interoperability of clinical data by allowing physicians to send electronic medical information to other providers without loss of meaning and enabling improvement of patient care, thus supporting accuracy of data for use with clinical decision making.

HL 7 v2.x 83

• Allowing for the interoperability different functional electronic health information systems that would process medical history data for clinical decision support applications.

DICOM 83 • Allowing for bi-directional communication with medical images required for clinical decision

NCPDP SCRIPT Standards

83 • Creating and promoting data interchange standards for pharmacy that will enhance communications across healthcare providers.

Health Quality Measures Format

84

• Supporting VistA Evolution interoperability for clinical guidelines with use of medical history data and CQMs for enhancing evidence-based clinical decision making on appropriateness of care.

HL 7 Implementation Guide

84

• Supporting quality within VistA Evolution medical history data with required clinical protocols for exchange, integration, sharing and retrieval of data with clinical decision making.

SOAP 84

• Enabling quantity and quality medical records documentation to become integral with practice workflow including patient appointment scheduling, writing out notes and, thus formulating a more complete and sharable history for clinical decision support.

Simple Mail Transfer Protocol

84

• Enabling Veterans medical history data to achieve security, privacy, data integrity, and authentication of sender and receiver sufficient to meet the data transport needs of health information exchange.


Representational State Transfer

84

• Supporting quantity and quality of medical history data models used for clinical decision making with better prototyping, testing, replicating, distributing, caching, and load-balancing for VistA Evolution system using ordinary web technology.

HL 7 MLLP 84

• Facilitating wrapping an HL7 message with a header and footer to insure through the programming where a message starts, where a message stops, and where the next message starts, supporting a minimal degree of quality assurance for transporting medical history data.


KPI 7 - Improve Resource Utilization Metrics in Patients Who Receive Care Outside the VA


(Sept 30, 2014)


(Sept 30, 2015)






34


7.2. JLV Enhancements 40

• Integrating read-only view of DoD and VA health information within a single application for clinicians in both DoD and VA will support interoperability and cross-department clinical decision making.


39



39


7.1 Interoperability 7.1.3 DoD/VA Gateways







• Using interoperability standards and terminology enables clinical decision support integration with pharmacy services.



49 • Enhances monitoring and provider- patient alert and resources planning for immune and vaccine related illnesses for supporting access.


57 • Improving the current clinical workflow demand with emphasis on increased efficiency, improved documentation, and enhanced patient safety.


59



KPI 8: Increased Health of Populations Through Appropriate Utilization of Population Health Data That Informs Clinical Decision Support Tools


(Sept 30, 2014)


(Sept 30, 2015)





6.3 VistA Immunization Enhancements, 1.0 35 • Generates data for use in population health

management.

8.6 VistA Immunization Enhancements, 2.0 49

• Generates semantically interoperable data standard for immune/vaccine data across external diverse systems where access can be improved from sharing data evidence

9.4.1 Women’s health 56

• Applying aggregate Women Veterans data for reducing risks and delays in healthcare that may impact or benefit population health.


KPI 9 -Shorten Time to Delivery of New HIT Functionality


(Sept 30, 2014)


(Sept 30, 2015)






34


6.6 VistA 4 API Exposure 1.0 36

• Allowing VistA 4 to be integrated with broader clinical information systems

6.7 Enterprise Messaging Infrastructure (eMI)

36

• Creating and data interactions through robust value-added services, such as message conversion from one format to another, aggregation of data from multiple sources, and even business rules to allow only data that meets specific filter criteria to come through.



7.6 VistA Standardization, Phase 3

44 • Standardizing executable M code allowing VistA Evolution and its applications to be launched efficiently nation-wide to every site.



8.5 VistA 4 API Exposure 2.0 51

• Using open source collaboration for incremental approaches that create an evolutionary and accountable set of projects leading to an improved architecture and API.



10.1.2 Virtualization 60

• Supporting rational planning and implementation aligned with OMB policies for re-platforming end-of-lifecycle programs to virtualization.


10.1.3 Virtualization of Database Back End Next Generation

62 • Enabling efficient applications of VistA user experience in new product development

10.1.4 Cache Mirroring Enhanced Disaster Recovery

62 • Provide improvements in maintaining the integrity and efficiency of the disaster recovery database due to the improved timestamps and checkpoints.

10.1.5 Storage 62

• Supporting open architecture to enable the system to provide and consume services, allow agile modification and provide the ability to create, store, and exchange interoperable data in real time.

10.1.6 VistA Data Center Consolidation

63 • Infrastructure planning to support VistA Feature Set 4 Deployment.

10.1.7 NDCP VistA Migrations

64 • Infrastructure planning to support VistA Feature Set 4 Deployment.

10.1.10 WAN Acceleration 67 • Infrastructure planning to support VistA Feature Set 4

Deployment.


KPI 10: Improve User Satisfaction with the Electronic Health Record A: Through Improved Clinical Features B: Through Improved IT Performance


(Sept 30, 2014)


(Sept 30, 2015)


(Dec 31, 2016)




6.1 Interoperability through JLV 33

• Supports a faster and more comprehensive understanding of patient health status with the medical history data through improved usability and system efficiency.

6.5 Graphical User interface-6.5.1 Search Functionality

36 • Enables users to find information in the patient record more quickly and accurately

6.5 Graphical User interface- 6.5.2. InfoButtons

36 • Allow quick access to additional information specific to that data with a simple click

6.5 Graphical user interface-6.5.3. Medication Reconciliation

36 • Delivers real time knowledge management supporting patient care outcomes goals related to medication safety.

7.2. JLV Enhancements 40



39



39


7.1 Interoperability 7.1.3 DoD/VA Gateways










55

• Showing information in a single view which will allow clinicians to use comprehensive patient data and images more easily making medical history data available and extensible with better use of medical history data for clinical decision making.

Quality Reporting Document Architecture

83 • Enabling Blue Button Plus with VistA Evolution data availability and usability by Veterans.

HL7 Retrieve, Locate, Update Service

85

• Aligning VistA Evolution and its SOA with the services vision as outlined in the ONC Standards & Interoperability (S&I) Framework standards portfolio, including consideration of the service standards already under development in the industry, supporting updating Veterans health records for their usability.

Health Provider Directory

85 • Enabling integration and usability of Veterans data and records aligned accurately with appropriate healthcare provider information.
