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Ehrin J. Armstrong, MD MScDirector of Interventional Cardiology
Denver VA Medical CenterAssociate Professor of MedicineUniversity of Colorado Denver
Integrating Structured Data Sets andSupporting Data Extraction
Interoperability: the Veterans’Administration
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The VA Health Care System
Largest integrated health care system in U.S.Currently serve 7.9 million veterans 153 hospitals (1,139 total facilities)
• 79 hospitals with cardiac cath facilities• 44 hospitals with onsite PCI/CABG capability
Most Comprehensive EMR in the Country
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VHA Cardiovascular Assessment, Reportingand Tracking (CART) Program
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CART characteristics
Cath labs 79
Coronary procedures 362,287
Angiograms 274,893
PCIs 87,394
Health care providers 810
Patients 249,034
PCIs performed for ACS (2014) 57.5%
Severity of CAD noted on cath (2014) 3 vessel 12.1%
2 vessel 13.1%
1 vessel 17.3%
Non-obstructive 20.5%
Normal 12.1%
Procedural complications (2014) MAE 0.06%
Other 5.0%
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VHA CART Data Elements
• CART Data is standardized using ACC clinicaldefinitions.
• CART Data is also linked to longitudinal patient caredata, including clinic visits, hospitalizations, andpharmacy prescriptions.
• CART Data is organized to generate real-time accessto knowledge.
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The Conventional Approach
“Medical Record”
“Abstractors”
“Errors in Translation”
Home
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The CART Transactional Concept
• Transactional Quality and Management:– a healthcare redesign process through which clinical
practices are both enhanced and ensured real-time.
– If specific data are needed for patient care, to improvequality and increase patient safety, these data should beavailable and accessible at the point of care and notabstracted after the fact
Robert Jesse, VA Acting Principal Deputy Undersecretary for Health
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The CART Transactional Concept
• Clinical tool that improves efficiency of care– Integration with CPRS– Efficient Report Generation
• Faster than dictation• VHA-wide standardization• Report completion in real-time
• Integration of data collection into the transaction of care– No duplicate data entry– Used as part of regular clinical care– Pre-procedure, diagnostic procedure, &
PCI report– No new personnel– Core of American College of Cardiology
data elements and standards
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The CART Transactional Approach
“Medical Record”
“Abstractors”
“Errors in translation”
“CART CL”
Assessment
PCI ReportSQL
Quality and Management
Health Services Research
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Data Resources at Austin InformationTechnology Center
• VA National Patient Care Databases (NPCD)– Medical SAS Datasets (MedSAS)
• Decision Support System (DSS)• Vital Status Files• VHA Service Support Center (VSSC)• Corporate Data Warehouse (CDW)• Resident Assessment Instrument/Minimum Dataset
(RAI-MDS)• Real SSN
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CART Supports Quality Management
RecommendedAction
RecommendedAction
CommitteeReview
CommitteeReview
AutomaticNotificationAutomatic
Notification
ResolutionResolution30
days
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CART Supports Device Surveillance
• Discussions Initiated in 2006• CART-CL as Sentinel Patient
Safety Network for cath labdevice surveillance
• CART-CL modified to captureunexpected problems withdevices
• Monthly reports informallyexchanged with FDA (noPHI) in 2007
FDA 3500A
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Device Surveillance
• Unexpected device problems (UDP) reportedimmediately at time of procedure.
Tsai et al, Med Care 2013;51:S57-S61
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Device Surveillance with CART
Tsai et al, Med Care 2013;51:S57-S61
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Current Limitations
• CART data input is limited to the cath lab.– Does not currently capture procedures by radiologists,
vascular surgeons.
• Peripheral vascular CART module still in testing.– Many peripheral procedures entered in CART, but lack
standardization.– Upcoming CART PVI module will contain data elements in
concordance with NCDR-PVI registry.
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Ehrin J. Armstrong, MD MScDirector of Interventional Cardiology
Denver VA Medical CenterAssociate Professor of MedicineUniversity of Colorado Denver
Thank You
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CART Supports Research + Longitudinal Data
CART-CLDatabase(Analytic)
VA Processes of Care(e.g. medications, risk factor
management, visits)
VA Outcomes of Care(e.g. mortality, MI, risk factor
control)
External Care and Outcomes(e.g. CMS)