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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

Primary Prevention
Secondary Prevention
Initial Presentation
Discharge
Follow-up
Assessment Risk
AMI
60 days
Evaluation Testing
ECG, Tn
Therapy
ASA, BB

BB, ACE,
ASA, Statin

Education Counseling
Smoking Cessation
Clinical Events
PCI, Lytics

The Matrix for Quality Assessment: Antecedent Care

Primary Prevention
Secondary Prevention
Initial Presentation
Discharge
Follow-up
Assessment Risk
Lipids, DM, HTN
ACS
Evaluation Testing
Therapy
Education Counseling
A Plan
Clinical Events

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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