Joseph Dal Molin: Implementing VistA internationally: Myth-busting lessons from Jordan
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Transcript of Joseph Dal Molin: Implementing VistA internationally: Myth-busting lessons from Jordan
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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)