VA Design Patterns Briefing and VistA Evolution Update

November 17, 2014Dr. Aaron DrewSenior Enterprise Solutions ArchitectOffice of Information and Technology (OI&T)U.S. Department of Veterans Affairs (VA)

VA Design Patterns Briefing and VistA Evolution Update Overview

• Two topics– VA Design Patterns– VistA Evolution Update

• In the interest of time, please direct all questions to: – design-patterns@osehra.org

• Answers will be provided to participants following this meeting

Open source Memo (signed by Mr. Stephen Warren on 4 Nov 2014)• Establishes requirements for VA to thoroughly evaluate Open Source Software

(OSS) solutions when acquiring software and to consider the use of OSS development practices within VA.

A white paper on impact of VA design patterns on open source community was also requested – the core of this paper was a survey of the open source community. Methodology:• 8 multiple choice questions with a comments box and 2 short answer questions• Sent to approximately 2,600 members of the OSEHRA mail group; 18 surveys

receivedBased on the survey results:• The open source community understands why the VA is using design patterns,

however, there are questions about the implementation of these design patterns.

Open Source Memo and Survey

The community understands why VA is using design patterns...

But there is some skepticism as to their value...

• Potential Solution 1: Sandbox environment – Establish an open source sandbox that will provide implementations of SOA

services for testing.

• Potential Solution 2: Crowd-source capabilities – Couple open-source innovation with VA’s deep institutional VistA knowledge

base by promoting collaborative development.

• Potential Solution 3: Engagement between VA/Open Source Community – Continue to engage with the open source community through white papers,

town halls, and regular briefings.

Enabling and Empowering Open Source Innovation

• Please direct all questions to: design-patterns@osehra.org

VA Design Patterns Briefing and VistA Evolution Update Overview

VistA Evolution Program Clinical Overview

Dr. Walter Paul NicholDeputy Chief Informatics OfficerVeterans Health Administration (VHA)

VA Blueprint for Excellence

99/8/2014

Anticipate and meet the unique health care needs of enrolled Veterans1

Deliver high quality, Veteran-centered care rivaling the private sector

Leverage IT, analytics, and delivery models to optimize health

Develop a Veterans First culture, and inspire employees to highest performance

Foster continuous learning, responsible risk taking, and personal accountability

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9/8/2014

Advance personalized, proactive, patient-driven care6

Lead the nation in research and treatment of service related conditions

Become a model Integrated Health Services Network

Operate with integrity, transparency and accountability

Modernize health records (HR), procurement, payment, IT and infrastructure to be agile and efficient

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PERFORMANCE INNOVATION SERVICE ACCOUNTABILITY

NDAA 2014

VistA Evolution Delivers and Maintains a VistA-based product that Facilitates High-quality Healthcare, Benefits and Services to our Service Members and Veterans.

VistA provides VA with a solid EHR foundation. VistA 4 is about improving our foundation so we can build a modular HIT product to more rapidly and

specifically meet the needs of patients and those providing services to them

VistA Evolution improves the lives of VeteransVistA Evolution satisfies Interoperability, EHR

Certification, and Care Coordination requirements

PERFORMANCE INNOVATION SERVICE ACCOUNTABILITY

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Our FY15 priority is to develop and achieve ONC 2014 EHR Certification for the enterprise Electronic Health Management Platform (eHMP)

Prioritize VistA Evolution and Interoperability work, aligned with a compelling Strategy to benefit Veterans

Strategic Alignment

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Number OnePriority for

VistA Evolution in FY15

ONC 2014 EHR Certification

Why ONC Certification is a Top Priority

Direct value to Veterans (a few examples)• Improves interoperability of key health information with non-VA providers• Allows Veterans to fill VA-ordered prescriptions at retail pharmacies • Automated scorecards to monitor and improve performance on clinical care, such as

screening for smoking and colorectal cancer • Improved capability to reconcile medication list data from multiple sources• New capability to reconcile problem list and medication allergy list data from multiple

sources• Improved clinical decision support including usage of HL7 InfoButton technology• More secure online access to MyHealtheVet

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Direct value to part-time VA doctors in the CMS incentive program• Providers must have at least 50% of their total encounters occurring at facilities with a certified

EHR in order to be eligible for CMS incentives• Providers attesting to MU will need to be less than 50% at VA until we have a certified EHR Allows VA to maintain credibility as a leader in Health IT• All Major EHR products in the commercial market are ONC Certified today• Catalyst to create a solid foundation for an open standard/open architecture EHR platform

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VistA Evolution Triple Aim: Team-Based, Veteran-Centric, Quality-Driven

Veteran-Centric

Team-BasedQuality -Driven

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VistA Evolution Program• User experience that makes it easier and more pleasurable to get work done.

– Faster response– Shorter time to acquire needed information– Enhanced clinical decision support – Improved speed of documentation.

• Studies show EHRs increase work by 75 to 90 minutes a day.

• Coordinated care:– Patient-centric, team-based, and quality driven healthcare– Veteran-driven goals drive the plan– Task-based communication (including orders) improves speed and clarity of

communication while automatically tracking into care plan (may save 30 minutes a day)

• Lays foundation for many new workflows to support specialty care areas such as women's health and mental health, as well as population health, etc.

VistA Evolution Program• Enhanced DoD Interoperability: Architectural work underway to improve performance and reduce

maintenance for components supporting DoD interoperability.

• Advanced Indexing and Enablement of Clinical Data Enrichment: VistA Exchange leverages the eVPR cache to create a universal index for search. This allows for the addition of external clinical enrichment features (e.g., natural language processing, tagging, and annotations).

• Web-Based Computerized Patient Record System (CPRS): A web-based alternative to CPRS is being developed. First release of the this new User Interface (UI) will be December 2014. This UI is leveraging designs, functionality, and capabilities of the hi2 Health Management Platform (HMP) UI.

• Decoupling of Ancillaries from Core Clinical Functionality Through Open Standards: An open, standards-based services for Orders Management and Order Selection will be created. This will allow orders to be managed as enterprise activities, and will decouple the generation of the clinical record from ancillary fulfillment, thus facilitating the selection and integration for Commercial-Off-the-Shelf (COTS) ancillary products such as Laboratory and Pharmacy (the ancillary product acquisitions are outside of the scope of eHMP project).

• Other Evolutionary Generation 3 EHR Capabilities: This would include services for Clinical Workflow and Activity Management, Decision Support, and Concept Relationship.

VistA Evolution Program Update

• The VistA Evolution Program will enhance VistA’s core architecture to achieve interoperability with DoD.

• Further work will augment VistA’s clinical capabilities to support a patient-centric, team-based healthcare delivery model. The Program’s end product, VistA 4, will deliver cross-agency interoperability, a robust health IT architecture to enable future innovation, and cutting-edge clinical capabilities, allowing VistA to serve as a cornerstone for the delivery of care and benefits to Veterans, Service members, and their dependents.

VistA Evolution Program

Feature Set 1 (Delivered September 30, 2014)

Feature Set 2 (To Be Delivered By September 30, 2015)

• Interoperability (through JLV)• VistA Standardization, Phase 1• Vista Immunization Enhancements (VIMM, 1.0)• Laboratory• Graphical User Interface (GUI) Tools• VistA 4 Application Programming Interface (API),

Initial Release

• ONC 2014 EHR Certification• VistA Scheduling Enhancements• VistA API Exposure, 2.0• iMed Consent Web Migration• Enhancements to Pharmacy (MOCHA, PECS, PPS-

N, PPS-L, SUMPM)• VistA Standardization, Phase 2

Feature Set 3 (To Be Delivered By December 31, 2016)

Feature Set 4 (To Be Delivered By September 30, 2018)

• Interoperable EHR• Broad eHMP Deployment• Enhancements to Pharmacy (In-bound e-

Prescribing) • VistA Standardization, Phase 3• VistA Service Assembler • VistA Immunization Enhancements (VIMM, 2.0)

• Medical Appoint Scheduling System (MASS) – broad deployment

• Enterprise-wide eHMP Deployment• Veteran’s Authorization and Preferences (VAP)• Women’s Health• Enhancements to Ancillary Systems (Radiology,

Laboratory)• FileMan Modernization

VistA Evolution Program

JLV/eHMP/VistA Exchange• Mr. Keith Michael, eHMP Lead Architect/Product Manager• Ms. Betsy Green , eHMP Project Manager

FileMan Standardization and Modernization• Mr. Russell Holt, FileMan Portfolio Manager

Enterprise Messaging Infrastructure (eMI)• Dr. Patrick Pearcy, Director, Veteran Facing Applications and

Service Integration

VistA Evolution Program Update: Select Projects

Mr. Keith Michael, eHMP Lead Architect/Product ManagerMs. Betsy Green , eHMP Project Manager

VistA Evolution Program Update: JLV/eHMP/VistA Exchange

• JLV is the newest health record viewer available to users in both DoD and VA to meet increasing needs for seamless interoperability of standards-based health data supporting high quality care for our nations’ Veterans and Service members. JLV is the only application providing an integrated, chronological view of electronic health record information from all VA and DoD facilities at which a patient has received care, in a user-configurable display.

• JLV is a waypoint on the path to the state-of-the-art, interoperable, standards based VistA 4 enterprise Health Management Platform (eHMP)

Joint Legacy Viewer (JLV)

The eHMP project is a multi-year effort to evolve a modern, service oriented enterprise health application platform. It will provide ‘native federation’ of a complete enterprise Virtual Patient Record (eVPR), including information model binding, terminology normalization, knowledge enrichment, and search indexing for all available longitudinal patient record data aggregated from VA, DoD, and exchange partner sources.

eHMP is the name of the overarching system encompassing both the front end application and middle tier components called eHMP Services

– eHMP Services is the name for the middle tier components that include

Enterprise Health Management Platform (eHMP) Overview

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• VistA Exchange (Virtualization of Patient Record)

• Clinical Decision Support• Context Persistence • Orders Selection Service • Orders Management Service

• Data Annotation Service • Clinical Workflow• Concept Relationship Service• Documentation and Text Search Service• Business Rules Management System

• Will eventually replace the Computerized Patient Record System (CPRS) as VA’s primary point of care application.

• Will show information in a single view, which will allow clinicians to use comprehensive patient data and images more easily, instead of a siloed approach which can sometimes hinder the exchange of information. This foundational delivery will also integrate several functionalities into the DoD/VA interoperability infrastructure to support the VistA Evolution Program’s interoperability commitment. These additions will give clinicians simplified access to Veterans’ complete patient history from both DoD and VA shown in a single reliable and secure interface.

• Consists of a middle tier that enables enhanced clinical information exchange through various components that find, standardize, and interpret many sets of information, to include demographics, lab and immunization results, visit management, problem/medication list, and more.

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Enterprise Health Management Platform (eHMP) Overview

Components– Application Development Kit (ADK): Client-side

• JavaScript : Language• Backbone.js : Library to develop SPA• Marionette : Framework for backbone.js applications• Bootstrap : Libraries for front-end development

– Resource Development Kit (RDK): Server-side• JavaScript : Language• Express.js: Web Application Framework

– Single Page Application (SPA)– HTML/JavaScript/CSS returned as “static assets” from web server– Logic performed in client instead of server– Fluid and more responsive

• No reloading and re-rending– JSON creates separation between presentation and application logic

Software Development Kit (SDK) Technical Details

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• Applet– Single unit of visual functionality

• Screen– Defined collection of applets

• Layout– Abstract arrangement of applets

• Application– Collection of screens

• Majority of web developers working within eHMP UI will spend their time developing applets.

Application Development Kit (ADK)

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• Resource– Single web service– (e.g. method @get)

• Resource Family– Collection of resources– (e.g. class)

• Resource Server– Deployable unit, includes a set of resource families and specific configuration– (e.g. war file)

• The approach to resource servers follow “microservice”– Allows for discrete instances to be independently deployed, optimized, and load

balanced

Resource Development Kit (RDK)

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Working Draft, Pre-Decisional, D

eliberative Document – In

ternal VA Use Only

Draft

Cover Sheet Mock-Up

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Mr. Russell Holt, FileMan Portfolio Manager

VistA Evolution Program Update: FileMan Modernization & Standardization

• Key features– Standardization of VistA applications and their corresponding database, including federating

application data to create an enterprise-wide view of patient data. – Population and cohort queries for applications that are fully converted to use FileMan Enterprise.– Powerful interfacing and integration capability of any VistA application to data source,

application, or external system.– Standardized, enterprise Application Programmable Interfaces (APIs) to VistA applications. These

allow interfacing of external applications to all VistA systems through one enterprise API.– Interface Modern Internet Database capabilities, including secure web services, web interfaces,

and web data management capabilities.– Standardize unified method of access for all VistA data through FileMan programmatic

interfaces.– Ensure FileMan data storage and access supports universal time zones (UTC) (FileMan will be

able to store by implementing UTC offset)– Enterprise-wide secure FileMan access expand/enhance single character use

VistA FileMan Modernization & Standardization

VistA FileMan Architecture

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FileMan “As-Is” Architecture

WebLogic

VistALink

Working Draft, Pre-Decisional, D

eliberative Document – In

ternal VA Use Only

FileMan “To-Be” Architecture

FileMan

Database(1)

Database(126

)

Enterprise

Apps

Enterprise VistA

API’s

Dr. Patrick Pearcy Director, Veteran Facing Applications and Service Integration

VistA Evolution Program Update: Enterprise Messaging Infrastructure (eMI)

• eMI is the sustainment phase of the Service-Oriented Architecture (SOA) Suite project.

– Provides the ‘transport’ for the messages between both DoD/VA and supports the associated information management systems in a standards-based, secure and reliable manner.

– Simplifies the integration of new capabilities, web services, and other technologies.

• eMI will continue to facilitate the delivery and use of reusable services in support of VA and other health partners, as dictated by the National Defense Authorization Act (NDAA).

• eMI has been in place since August 2014.

Enterprise Messaging Infrastructure (eMI)

Enterprise Messaging Infrastructure (eMI) Architecture

VistA Evolution Update

• Please direct all questions to: design-patterns@osehra.org