NHLBI Workshop

Data Needs for Cardiovascular Events, Management, and Outcomes

Veterans Health Administration - Dr. Robert Jesse

The Veterans Affairs (VA) Health Care System

• Largest integrated health care system in U.S.
  • 21 regions
  • 163 hospitals (1,139 total facilities)
    • 75 hospitals with cardiac cath facilities
    • 44 hospitals with onsite PCI/CABG capability
      
• System challenges include comprehensive and consistent regional cardiac care delivery

Veterans Health Administration (VHA): Computerized Patient Record System (CPRS)

• Every medical center has the Computerized Patient Record System
• 65% Medical Centers have "filmless" images

What Does CPRS Provide?

• Legibility
• Computerized physician order entry
• Real-time clinical reminders
• Recall - limited search functions

What Does CPRS Not Provide?

• National aggregate of clinical data
• Disease specific data sets
• Certain defined data fields are lacking (i.e. LVEF)
• Forced data entry
• Robust search function
  

Optimizing the Electronic Medical Records (EMR) -- What Do We Need?

• Forced entry for key data elements
• Care coordination and disease management functionality
• Comprehensive critical pathway support
• Computerized decision support and other 'E-health' strategies
• Audit and feedback with benchmarking

CART-CL (Cardiovascular Assessment Reporting and Tracking System for Cath Labs)

• National VHA Cath Lab database, including software for data entry and report generation for all 75 VA Cath Labs
• Features and Function
  
  • Core data elements and data standards
  • Integrated into regular clinical care
    
    • Fully integrated into existing electronic medical record
    • Creates standardized pre-cath, cath, & PCI reports
      
  • Centralized national data repository
    • Not '75 databases for 75 cath labs'
      
  • National QI program - feedback to sites with benchmarking
    • VA to join ACC-NCDR

Performance Measures -- Improving Outcomes in VHA

• EPRP (External Peer Review Program)
  • Chart Abstraction (100% of AMI diagnosis)
  • Performance measures and supporting data
    
• IHD-QUERI (Ischemic Heart Disease Quality Enhancing Research Initiative)
  • Chart Abstraction (100% of AMI diagnosis)
  • Performance measures and supporting data

The Matrix for Quality Assessment: Event capture and timelines

The Matrix for Quality Assessment: Antecedent Care

VHA Performance Measures

• ECG within 10 minutes of arrival (or 15 mins prior)
• Troponin value returned within 60 mins of order
• Reperfusion therapy in all eligible STEMI patients
• Primary PCI 'door to balloon' within 120 mins
• Thrombolysis 'door to needle' within 30 mins
• Cardiologist involvement within 24 hours (all AMI)
• Cath prior to discharge (all moderate/high risk ACS)
• Cardiologist f/u within 60 days (all ACS discharges)
• BP <140/90 mmHg; LDL <100 mgDL; Tobacco counseling
• LDL measured and at goal w/in 2 years prior to ACS event
  

What's on the Horizon?

• Re-hosting of CPRS
  • Oracle-based
  • JAVA scripting
    
• National Clinical Data Repository
  • A single clinical database
• Broad use of CART-like functions
  • Disease/condition based data entry and clinical support to optimize care.
• The true Evidence-Based Medical Record

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