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Implementing VistA Internationally:Myth-Busting Lessons From Jordan

Joseph Dal MolinPresident, e-cology corporationChairman, WorldVistA

Nuffield Trust, LondonJuly 5, 2012

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Agenda

Background and Context

Why VistA

Jordan's Leapfrog Approach

Achievements

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Background and Context

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Jordan's Health System

Population 6 million

46+ Hospitals, 800+ Clinics

Ministry of Health

Royal Medical Services

University Hospitals

King Hussein Cancer Centre

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Jordan's Health System Challenges

Significant concerns about patient safety and health outcomes

Significant waste (drugs, tests, imaging) across the system

Spiralling cost drivers e.g. chronic disease

Impossible to share medical information and provide clinical decision support

Difficult to impossible to measure clinical effectiveness and ROI of health policies and investment

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Why VistA?

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Chronic Failure of Traditional Health IT Approaches

Existing ICT solutions could not support transformation via implementation of evidence based, best practices

Proprietary solutions too expensive to implement

Lock-in

Sustainability > capacity building, code stewardship

Pitfalls experienced in other countries: UK, Canada, US

There was compelling evidence that the US Veterans Administration and VistA stood out as positive example of how

to successfully leverage IT

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VA Top Performer:VistA Enables Dramatically Lower Costs

The cost per patient has remained low and stayed steady for the VA since the system went digital. By comparison, costs for Medicare patients and the medical consumer price index have remained high and are increasing. SOURCE: The Washington Post, April 10, 2007

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VA Top Clinical Performance

INDICATORBreast Cancer Screening 87% 87% 70% 68% 51%Cervical Cancer Screening 92% 92% 80% n/a 66%

80% 79% 59% 53% n/aLDL Cholesterol <100 after AMI,PTCA,CABG 67% 66% 60% 57% 40%Diabetes: CM control HbA1c < 9.0% 98% 97% 89% 88% 81%Diabetes: LDL-C<100 69% 68% 46% 49% 34%Diabetes: eye Exam 88% 86% 57% 61% 53%Diabetes: Renal Exam 95% 93% 82% 88% 77%

80% 78% 66% 60% 57%Smoking Cessation Counseling 96% 89% 77% n/a 69%Smoking: Medications Offered 90% 84% 54% n/a 41%

96% 92% 50% n/a 41%Immunizations: Influenza 83% 84% n/a 71% n/a

95% 94% n/a 67% n/a

VA2009

VA2008

COMMERCIAL 2008

MEDICARE 2008

MEDICAID 2008

Colorectal Cancer Screening

Diabets: BP < 140/90

Smoling: Referral/Strategies

Immunizations: Pneumococcal

Source: VHA, 2009

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Model for Radical Transformation:Transition to More Effective Care Settings

Source: Perlin et al., 2004, American Journal of Managed Care

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VistA Has Produced a Huge ROI: $3.09 billion

The potential value of the VA’s health IT investments is estimated at$3.09 billion in cumulative benefits NET of investment costs.

Source: Health Affairs 29, NO. 4 (2010): 629–638

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VistA Can Scale!

File Entries Dec '09 Daily File Entry Dec '09

Orders 2.30 billion 1,23 million

Images 1.40 billion 1.70 million

TIU Documents 1.35 billion 952 thousand

Medication Admin 1.24 billion 708 thousand

Vital Signs 1,56 billion 977 thousand

Source: Dr. Ross Fletcher, Chief of Staff, Washington DC VAMC

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Jordan's Leapfrog Approach

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Leapfrog over this

Photo credit: www.ericmackonline.com

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.....to this

Photo credit: Wikipedia

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...and iterate to this

Photo credit: Marianna Day Massey, Zuma Press

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Critical Questions to Address

Can it be adapted? Will it be accepted by clinical staff? Can we learn how to enhance it? Can we build capacity to reduce cost and risk? Can we afford it and will it cost less than comparable

approaches? Will it work?

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Iterative Implementation Model

Assessment Phase First Iteration National Implementation Strategy Pilot Site Selection Establish Public Sector Non-Profit Proof of Concept Seed Site Implementation Evaluation Second Iteration National Implementation Strategy

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Technology Strategy

Follow VA development standards Minimal (Minspec) changes to WorldVistA EHR

– Arab language support for Registration, Medication Labels, Patient information

– Registration gui– Scheduling gui

Test centralized and decentralized architecture Collaborate with community

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Establish local capacity and sustainability in parallel to seed site implementation

Minimum specifications for customization and adaptation Implementation path is bottom up, evolutionary and guided by

learning Create contagious buy-in and support Early validation of clinical and financial business case

Benefits of Phased Implementation Approach

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Asessment = Road Trip

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Assessing the Health Ecosystem

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What We Found:High Leverage Opportunities

The following areas represented up to 30% annual “hard” cost savings which in total have the potential to fund national deployment of WorldVistA EHR.

Medication management – stop polypharmacy Estimated savings 30 – 50 m JD per year Clinical benefits of avoiding errors and interactions Better data for purchasing decisions – id. Substitutes and cost

savingsImaging

Cost of PACS software savings Cost of film savings Telemedicine support – savings through remote consultation

Laboratory Avoid duplication of tests

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What We Found:Business Process Transformation

Supply chain – drugs, other consumables availability Unit dose packaging Standardized bar coding of medications Electronic signature Controlled substances Integration with national unique identifier database Alignment of roles and responsibilities, e.g. nurses and

nursing assistants with best practices

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Scope of Implementation

National roll-out to 46 hospitals and 1000 clinics

Pilot Sites– King Hussein Cancer Centre– Prince Hamzah Hospital (MoH)– Amman Comprehensive Clinic

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Selected WorldVistA EHR

Deliverable of HHS/CMS funded VistA Office EHR initiative Certified

– CCHIT certified 2007– Meaningful Use Full Inpatient and Ambulatory Certification, 2011

Enhancements Pediatrics – growth charts, demographics Women's health Registration E-Prescribing CCR/CCD export and import HTML 5 web interface

Implementations – Jordan, Mexico, US hospitals and primary care

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Achievements

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Achievements:Affordable, Sustainable, It Works!

Established a new, health stakeholder run, non-profit Established 98% self-reliance in 18 months Successful adaptation and configuration Confirmed affordability Successful go-live of full implementation, including imaging

and bar code medication administration in late Fall 2011 Given green light for national implementation

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Achievements:Community Based, Rapid, Open Innovation

Collaborative Successes IHS Graphical scheduling interface WHO standard based pediatric growth charts EDIS – emergency room package Support for internationalization

Current Innovations Web enabling of VistA – EWD and HTML5 Harvard SMART program – “App” development platform

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Achievement: Patient Number One

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Thank You!

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WorldVistA and the VistA Community

Incorporated in 2002 as 501c 3 Established the open source VistA community Ported VistA to full open source software stack: Linux + GT.M 2005 CMS funded VistA Office EHR initiative 2007 CCHIT and 2011 Full Inpatient and Ambulatory

Meaningful Use Certification 2007 Jordan adopts WorldVistA EHR for national deployment 2007 Wired Magazine Rave Award for Medicine

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International Deployments

WorldVistA EHR Jordan – 2 live, planned 44 inpatient, 800 ambulatory Mexico - Instituto Mexicano del Seguro Social (50+ hospitals) Thailand – Queen Sirikit Medical Center Cardiovascular Clinic India – Rajiv Ghandi Cancer Center, Max Health, hospital

network FOIA VistA

American Samoa (FOIA) Egypt, Cairo - National Cancer Institute (FOIA) Uganda, Kampala - Nakasero Blood Bank (FOIA) Nigeria - Obafemi Awolowo University and eight (8) Teaching

Hospitals (FOIA) Pakistan - SKM Cancer Hospital and Research Centre (FOIA)