VETERANS HEALTH ADMINISTRATION

Quality Improvement using the VA Electronic Health RecordMatthew Bidwell Goetz, MDChief, Infectious DiseasesVA Greater Los Angeles HCS

VETERANS HEALTH ADMINISTRATION

VHA and quality of care

• VA is now recognized nationally for quality

• Transformation into a quality institution occurred in conjunction with other changes

– Reorganization to a primary care-focused system

– Quality measurement and accountability

– Independent data gathering programs

– Public availability of performance data

– Institution of an integrated, comprehensive EHR

VETERANS HEALTH ADMINISTRATION

How did the EHR help improve quality?

• 100% access to records

• Availability of remote data (other VAs) and DoD data

• Ability to identify patients by disease or other characteristics (coding, use of data elements)

• Ability to use data to create reports, provide feedback

• Decision support tools at point of care including reminders to providers

VETERANS HEALTH ADMINISTRATION

Examples of Summary Reports

VETERANS HEALTH ADMINISTRATION

Secure, web-based national registries for use by all VA primary care providers

VETERANS HEALTH ADMINISTRATION

Group comparisons

VETERANS HEALTH ADMINISTRATION

Care Managers can produce customized, team-level reports

VETERANS HEALTH ADMINISTRATION

Provider access to information on patients not meeting indicators

VETERANS HEALTH ADMINISTRATION

Quality Measures in the VA

VETERANS HEALTH ADMINISTRATION

Use of the Computerized Patient Record System (CPRS) for Management of Individual Patients

VETERANS HEALTH ADMINISTRATION

Selected views of CPRSCover Page

Imaging and Procedure Reports Laboratory Reports

Clinician Notes

VETERANS HEALTH ADMINISTRATION

CRPS: customized patient-specific reports

VETERANS HEALTH ADMINISTRATION

GLA HIV Viral Loads, Includes patients not on treatment

0tan

15a5

6651

5

0tan

15a5

6651

5

0tan

16a5

6651

6

0tan

16a5

6651

6

0tan

17a5

6651

7

0tan

17a5

6651

7

0tan

18a5

6651

8

0tan

18a5

6651

8

0tan

19a5

6651

9

0tan

19a5

6651

9

0tan

20a5

6652

0

0tan

20a5

6652

0

0tan

21a5

6652

1

0tan

21a5

6652

1

0tan

22a5

6652

2

0tan

22a5

6652

2

0tan

23a5

6652

3

0tan

23a5

6652

3

0tan

24a5

6652

4

0tan

24a5

6652

4

0tan

25a5

6652

5

0tan

25a5

6652

5

0tan

26a5

6652

6

0tan

26a5

6652

6

0tan

27a5

6652

7

0tan

27a5

6652

7

0tan

28a5

6652

8

0tan

28a5

6652

8

0tan

29a5

6652

9

0tan

29a5

6652

9

0tan

30a5

6653

0

0tan

30a5

6653

00%

10%20%30%40%50%60%70%80%90%

100%

<50 50 - 400 400 - < 1,000 1,000 - <100,000 >100,000

Viral Load

VETERANS HEALTH ADMINISTRATION

System-Wide Quality Improvement in HIV - Testing

Facilitation by the VA Electronic Health Record (EHR) and the Functionality of CPRS

VETERANS HEALTH ADMINISTRATION

How did the VA EHR and CPRS help HIV testing initiatives?

• Able to identify patients not previously tested and avoid

repeatedly offering tests the previously tested

• Able to use data to create reports, provide feedback

• Decision support tools at point of care

VETERANS HEALTH ADMINISTRATION

Using CPRS – based decision support (Clinical Reminders)

• Used for a wide variety of purposes in the VA– Screening for depression, traumatic brain injury– Screening for Tobacco & alcohol use– Hypertension identification and management– Diabetes monitoring– Vaccination rates– Etc.

• Contributes to attainment of performance standards

VETERANS HEALTH ADMINISTRATION

Examples of Clinical Reminders

• Sample reminders for an HIV-infected patient

• OI prophylaxis

• Hepatitis screening

• Primary care indicators

• Reminders can be determined by the status of the patient

• Reminders can be customized at each facility

VETERANS HEALTH ADMINISTRATION

Provider – specific reminder completion rates

VETERANS HEALTH ADMINISTRATION

Relative Increase in Testing50% 390% 556%

Pre- vs Post-Intervention Routine HIV TestingMulti- VISN QI Project – Adjusted Rates

0tan29a566029

0tan2a56602

0tan4a56604

0tan6a56606

0tan29a566029

0tan2a56602

0tan4a56604

0tan6a56606

0tan29a566029

0tan2a56602

0tan4a56604

0tan6a566060%

5%

10%

15%

20%

25%

30%

Pre-Intervention Post-Intervention

HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH

HIV

Tes

ting

Rate

Control Sites Local CentralNo Implementation Implementation Implementation

VETERANS HEALTH ADMINISTRATION0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

HIV

Tes

ts (t

hous

ands

)

VA-Wide Changes in HIV Testing vs Use of HIV Testing Clinical Reminder

Sites without Clinical Reminder Sites with Clinical Reminder

2009 2010

VETERANS HEALTH ADMINISTRATION

Acknowledgements

• VA HSR&D: QUERI core funds, SDP 06-001, SDP 08-002

• VA Clinical Public Health: moral, financial and logistical support

• QUERI-HIV/HEP colleagues: Steve Asch, Allen Gifford, Jane Burgess, Tuyen Hoang, Hersch Knapp, Henry Anaya and many, many others

• Slides on the development of clinical dashboards – Caroline Goldzweig