OpenVista Electronic Health Record System Request for Information Response

Final Project
Independent Masters Capstone
Winter Quarter, 2012
Roy Hoppe
OpenVistA1
Electronic Health Record System
Request for Information Response

Independent Masters Capstone Roy Hoppe
OpenVistA1
2
INTRODUCTION
RJH Consulting is preparing a report devoted to a review and
comparative analysis of the OpenVistA1
electronic health records (EHR) 5
system
for your facility as per your request. This report will form the foundation for
recommendations to the OpenVistA1
EHR5
for Accountable Care Organizations2
(ACOs) that are interested in investing and implementing EHR5
technology. This
report will be based on information received from your RFI. In addition, the
comparative analysis of OpenVista1
EHR5
system will be supported by insight
from Meaningful Use3
metrics and the findings of interviews conducted with
stakeholders with your ACO2
.
PURPOSE
This Request for Information is proprietary to RJH Consulting. It is
drafted and disseminated for the sole purpose of generating information on
OpenVistA1
’s EHR5
system in order to promote the quality and connection to
help achieve Meaningful Use3
within your ACO2
.
GENERAL
BACKGROUND
Historically, EHR5
systems have been comprehensive end-to-end systems
with significant infrastructure, integration and training requirements. The latest
buzzwords in health IT are meaningful use and usability, where usability, in
particular, having initially been long overlooked is getting a lot of attention.
Most of them are architecturally complex to deploy and maintain, and rely on
proprietary software, systems and data models. However, without adequate
training and education, usability can be an issue.

OpenVistA1
3
Today, health services providers have multiple options to consider in how
they deploy an EHR5
system. The needs of small private practices are vastly
different from those of larger integrated health systems. Providers and policy
makers must consider alternative software and informatics models before
investing in systems. Planning is needed to implement an EHR5
in order to
ensure that it can continue to provide high-quality and high-value healthcare
services in an increasingly electronic and paperless world.
During this time, end users will have a slew of choices when it comes to
vendors. The non-profit Certification Commission for Health Information
Technology (CCHIT) 4
, points to over 100 certified products in its portfolio.
American National Standards Institute7
-accredited Health Level Seven (HL7)6
International is also developing a set of standards by which to evaluate EHR5
systems. This report will help your stakeholder’s jumpstart their EHR5
selection
process. In it, we'll share the results of the responses to your RFI, taking a look at
what EHR5
system and tools OpenVistA1
offers. We’ll examine features and
functions of OpenVistA1
and match them to the needs of your organization to
help align business processes with your missions and goals.
OpenVistA1
Background
The following requirements are necessary to illustrate OpenVistA1
’s
dedication to the success of your EHR5
implementation. We want to share with
you are credentials to demonstrate that we are the right choice for your
organization.
__X_ Vendor’s EHR is CCHIT4
certified
Physicians using CCHIT4
Certified EHRs5
will enhance the quality and
safety of their care and decrease their medical legal risk. Furthermore, CCHIT4
Certified Products tie directly to Health IT Meaningful Use payments, called for

OpenVistA1
4
under the American Recovery and Reinvestment Act (ARRA) 8
, whereby
facilities will be eligible to receive payments from the Centers for Medicare and
Medicaid Services (CMS) 9
for EHR5
Meaningful Use3
.
__X_ OpenVistA1
EHR caters to small to midsize medical practices
Due to the flexibility of OpenVistA1
EHR5
system, we can accommodate
small-sized ACO2
s, single or solo-run medical practice to a group of 15
practitioners; mid-size group can be 15-50 practitioners and larger groups over 50
practitioners.
__X_ OpenVistA1
will provide 2-3 references from past and current clients
We believe that references can provide an excellent way for potential
clients to see the value in our products and services by listening to the testimony
of our previous clients. This way they will find commonalities in problems and
solutions which will emphasis our commitment to quality. References available
upon request.
BUSINESS
OVERVIEW
Midland Memorial Hospital10
is a 371-bed community hospital that
operates three campuses in Midland, Texas. Midland Memorial10
provides a full
range of acute-care services including emergency medicine, cardiovascular
surgery, and advanced radiological and oncology services and serves as a regional
referral center for other communities throughout west Texas and southeast New
Mexico. The Midland Mmeorial10
“OpenVistA1
Implementation Project”
represents a formidable challenge on multiple fronts.
For example, it is the first nongovernmental, acute-care hospital in the
United States to adopt an OpenVistA1
-based EHR5
; it has a community-based
physician staff representing all major specialty areas; and they want a “best of

OpenVistA1
5
breed” software environment that leverages investments in current solutions that
needed to be interfaced to OpenVistA1
. The contract for the project is awarded to
Medsphere Systems15
Corporation.
BUSINESS
OBJECTIVES
Since wellness and patient-centered care is at the core of this particular
medical practice, practitioners and staff eagerly wants to adapt an EHR5
that has
standard core features in addition to including extra components to enhance
quality, disease management and population care management. To that end, the
Midland Memorial’s10
staff hopes to continue providing quality service by way of
excellent patient satisfaction scores and improved Healthcare Effectiveness Data
and Information Set (HEDIS)11
results in the coming years. The selected EHR5
technology will assist the practice in achieving this goal.
GUIDING
PRINCIPLES AND
MAJOR PROJECT
OBJECTIVES
• Enhance patient safety, increase clinical efficiency/ improve healthcare quality.
• Standardize the delivery of care across the continuum (acute, ambulatory, and
rehabilitation) and multiple geography locations of care (hospitals and clinics).
• Reduce medical errors and wasteful costs associated with the delivery of health
care.
• Build upon the proven success and experience of the VA in the implementation
of its comprehensive OpenVistA1
EHR5
for Midland Memorial10
.
• Leverage the OpenVistA1
EHR5
as a differentiating factor in helping recruit and
retain patients, physicians and staff.
• Leverage the OpenVistA1
to reduce Midland Memorial10
overall systems
lifecycle costs.

OpenVistA1
6
PROJECT
HISTORY
Midland Memorial Hospital10
has determined to replace their “sun
setting” pharmacy and laboratory systems. This review prompted IT steering
committee members to rethink their best-of-breed strategy and take the
opportunity to evaluate a single, integrated solution to meet their clinical,
administrative, and financial needs. During the course of their evaluation of
traditional healthcare IT companies, they were unable to overcome the $20
million price barrier to implement the comprehensive solution they envisioned.
They became aware of OpenVistA1
through their interaction with the Big Springs
VA Medical Center12
and the realization that there were multiple commercial
vendors supporting the OpenVistA1
solution.
Midland Memorial10
next engaged in a rigorous 12-month evaluation of
the technology, product and Health IT service providers. After attending several
national conferences, completing multiple site visits, and a series of intense
product demonstrations to its staff, Midland Memorial10
decides to move forward
with a comprehensive enterprise assessment of the issues related to implementing
the OpenVistA1
solution. After the completion of the assessment, Midland
Memorial’s10
IT steering committee unanimously approves the recommendation
to begin the OpenVistA1
project.
With OpenVistA1
serving as the platform of innovation, a six-month
software development effort ensues to ensure that the product will meet some of
the unique functional specifications of Midland Memorial10
. A primary objective
of this effort is to complete the required interfaces to share patient demographic
information, the event points where charges can be captured, and the seamless

OpenVistA1
7
sharing of information among 13 disparate information systems Midland
Memorial10
wants to retain. This process is successfully completed by a talented
team of OpenVistA1
engineers who had a thorough knowledge of the system and
leveraged standard VA design concepts, improved existing software tools, and
developed new integration utilities to accomplish the work. These efforts prove
highly successful and set the stage for the next step, the clinical configuration of
the system.
Clinical configuration of the system begins with the training of six newly
hired registered nurses who form the core of Midland Memorial’s10
clinical
information technology (IT) team. These individuals, under the direction of a
Midland nurse informaticist, are training to become “super users” of the graphical
user interface to OpenVistA1
, known as the Computerized Patient Record System
(CPRS) 13
. This training gives them the knowledge needed to create templates,
order sets and clinical reminders; set clinical rules; and configure other
OpenVistA1
clinical modules. Staff from Medsphere15
augments their staff
during the design, configuration, training and deployment of the OpenVistA1
system. The goal of the training program is designed to allow Midland
Memorial10
to become a self-sufficient organization that would not be dependent
on a vendor for many of the ongoing operational and maintenance tasks.
Multiple committees convene, under the direction of the IT steering
committee, to ensure a smooth transition to the OpenVistA1
EHR5
. These multi-
disciplinary subcommittees include Computerized Provider Order Entry, Bar
Code Medication Administration, Forms, Pharmacy, Medical Records and
Ancillary Department committees. The various subcommittees report up to the
IT steering committee, which meets monthly for the duration of the project.

OpenVistA1
8
Midland Memorial10
and Medsphere15
also establish a joint project governance
structure with regular project communication and issue resolution meetings.
SYSTEM
ARCHITECTURE
The enterprise architecture chosen by Midland Memorial10
includes a
centralized server cluster with a single OpenVistA1
database residing at Midland
Memorial’s10
main campus facility. Midland Memorial10
selects InterSystems
Cache product for its “M” language and database environment due to its robust
capabilities, proven scalability and rich management tool set, which had been
deployed in large-scale clinical settings. The multi-campus enterprise is the first
acute-care hospital to deploy the OpenVistA1
EHR5
solution on a Red Hat
Linux16
infrastructure. A high-availability cluster, using multi-processor x86
servers and clustering software, is installed and configured by Hewlett-Packard
(HP) 14
. This technology configuration provided Midland Memorial10
with an
affordable, high-performance, and completely redundant solution using a mix of
open source tools, proven application servers, and commodity x86-based
hardware.

OpenVistA1
9
SOFTWARE
SOLUTION
Midland Memorial’s10
best-of-breed software environment presents some
challenges for a fully integrated solution like OpenVistA1
. Medsphere15
is
required to develop several enhancements and interfaces to present a unified
solution within the VistA framework. Midland Memorial10
currently uses
McKesson’s Precision 2000 Health Information System. Precision serves as the
authoritative source of patient demographics, registration, scheduling, master
patient index, and other master files. It is also the primary source of order entry
by the ward clerks for laboratory, cardiopulmonary, dietetics and related consults.
Once patients register, the information is sent to OpenVistA1
by standardized
HL76
messages where it is then “filed” away in the appropriate places within
OpenVistA1
.
From here, at key steps of the clinical-care process, various “events”
trigger the charge capture engine to fire off a charge-related message to the
Precision system. After the clinical course of care has ended, the Precision
system generates a bill and manages the revenue cycle from that point forward.
Medsphere15
developed a unique technology solution to assist with both the filing
and the charge capture component of this interface. The primary OpenVistA1
modules initially to be deployed at Midland Memorial10
included the following:
• FileMan • Radiology and Nuclear Medicine
• Kernel • Computerized Patient Record Sys
• MailMan • Adverse Reaction Tracking
• Patient Information Management • Authorization/Subscription Utility
• Master Patient Index (MPI) • Clinical Reminders
• Inpatient Pharmacy • Consult/Request Tracking
• National Drug File • Health Summary
• Outpatient Pharmacy • Problem List
• Laboratory

OpenVistA1
10
Medsphere15
OpenVistA1
Enhancements Developed for Midland Memorial
The above packages provided the foundation of the OpenVistA1
solution.
From here, Medsphere15
was required to make the following modifications. This
list is not comprehensive, but is representative of the types of changes required to
adapt OpenVistA1
technology in a non-VA setting.
GENERAL:
• Fee Tables in OpenVista1
linked to a foreign system’s Charge Master File
• Common Physician Identifier
• Protocol Event Points for charge capture with HL76
interfaces
• Options to populate User (NEW PERSON) file from a foreign registry
PATIENT REGISTRATION:
• Creation of a common Medical Record Number
• Creation of Account Number file and corresponding field in Visit file
• HL76
interface from authoritative medical manager to OpenVistA1
PHARMACY:
• Charge capture for real-time or batch transmission to foreign billing system
• High Dose Alerts
• Pharmacokinetic Dosing
• Link Lab Results to Inpatient Med Order
LABORATORY:
• Charge capture for real-time or batch transmission to foreign billing system
• HL76
interface for intake of lab orders
• HL76
interface for reporting out of lab orders
• Tracking Specimen Transfers between Facilities
• Faxing of Laboratory Results
• Creating multiple interfaces for Blood Bank
RADIOLOGY:
• HL76
interface for intake of radiology orders
• HL76
interface for reporting out of radiology orders
• HL76
interface for intake of radiology result reports
• Charge Master file automatically populates/ updates Radiology procedure
file
IMAGING:
• Developed document scanning enhancement

OpenVistA1
11
PROJECT
CHALLENGES
• Clinical business transformation and Health IT systems implementation.
• Hardware and Infrastructure Enhancements:
• Upgrade network infrastructure to accommodate user’s needs.
• Upgrade existing hardware for improved reliability and performance.
• Upgrading clinician work spaces to increase access and ergonomics.
• Interface challenges integrating over 15 disparate information systems.
• Mission-critical application training 1,500 users for 24/7organization.
• Project management challenges of moderating expectations, managing
personnel, and developing a repeatable deployment methodology with no
commercial precedent.
• Developing an internal support function aligning to organization and the end
users needs; integrating customer and vendor application support.
The following describes OpenVistA1
’s ability to match Meaningful Use3
Stage 1
• Computerized physician order entry (CPOE);
Orders for lab orders, procedures, diagnostic studies, immunizations and
referrals can be entered electronically and tracked throughout their lifecycle
to a completed or resulted status. Medication prescriptions can be entered
electronically, and OpenVistA1
EHR5
supports e-prescribing to pharmacies.
• Recording patient demographics;
Patient demographics can be recorded using OpenVistA1
EHR’s5
• Maintaining a problem list of diagnoses;
OpenVistA1
EHR5
supports comprehensive problem lists using ICD917
codes
with problems separated into Active and Inactive Problems. Status and
severity can be tracked along with onset, diagnosed and resolved dates.
• Prescribing electronically (e-prescribing);
OpenVistA1
EHR’s5
allows providers to easily perform e-prescribing to
community pharmacies and mail order pharmacies.
• Maintaining an active medication list for patients;
The OpenVistA1
EHR5
maintains complete patient medication lists using
NDC codes and includes active, inactive and temporary prescriptions.

OpenVistA1
12
• Implementing drug/allergy checks at the point-of-care;
OpenVistA1
EHR5
supports automatic drug-to-drug and drug-to-allergy
interactions as well as contraindication alerts and duplicates medication
checking.
• Preventive medicine and health education;
OpenVistA1
EHR’s5
health maintenance templates display the status of
preventative care for patients, and feature standard-based alerts based on
guidelines from the AAFP18
and USPSTF19
. At a glance, providers can be
prompted to order overdue exams, tests and procedures.
• Sending patient alerts and reminders;
OpenVistA1
EHR5
supports custom reminder letters that can be generated on
an individual basis. OpenVistA1
EHR5
Report Writer can run custom reports
to identify patients that are due for care and the data can be exported to Excel
for mail merge.
• Sharing patient records among providers;
Multiple-location practices can instantly access and document inpatient
records from any location. This provides patients with the flexibility to make
appointments or receive test or lab results at any location without causing a
paper chase for the practice.
• Providing patients with electronic copies of their medical records;
The OpenVistA1®
Patient Portal is an optional online gateway to the system
that allows patients to review documents online that include medical records,
lab results, etc. OpenVistA1
EHR5
Medical Summary Utility provides
several different methods of extending the patient chart including the export
and import of CCR20
and CCD21
.
• Support for and/or integration with systems for verifying insurance
eligibility and submitting claims electronically; and,
Integrated into OpenVistA1
EPM workflow, OpenVistA1
RTS allows
practices to electronically perform eligibility checking via HIPAA22
-
compliant ANSI7
x12 270/271 Eligibility Inquiry and Response files.
OpenVistA1
EPM can submit claims to any clearinghouse using the ANSI7
x12 data standard or submit directly to multiple payers that accept the ANSI7
x12 data standard.
• Data sharing with immunization registries and public health
agencies.
HL76 immunization export interface can be supported.

OpenVistA1
13
Meaningful Use Stage 1
Health Outcomes
Policy Priority Care Goals Objectives Measures
Improving quality,
safety, efficiency,
and reducing
health disparities
Provide access to
Comprehensive patient
health data for patient's
health care team
Use CPOE CPOE is used for at least
80% of all orders 23
Use evidence-based order
sets and CPOE
Implement drug-drug, drug-
allergy, drug- formulary
checks
The EPl has enabled this
functionality23
Apply clinical decision
support at the point of care
Maintain an up-to-date
problem list of current and
active diagnoses based on
ICD-917-
CM or SNOMED
CT ®
At least 80% of all unique
patients seen by the EP have
at least one entry or an
indication of none recorded
as structured data23
Generate lists of patients
who need care and use
them to reach out to
patients
Generate and transmit
Permissible prescriptions
electronically (eRx)
At least 75% of all
Permissible prescriptions
written by the EP are
Transmitted electronically
using certified EHR5
technology23
Report information for
quality improvement and
public reporting
Maintain active medication
list
patients seen by the EP have
at least one entry (or an
indication of “none” if the
patient is not currently
prescribed any medication)
recorded as structured data23
Maintain active medication
allergy list
patients seen, by the EP, have
at least one entry or
(indication of “none” if the
patient has no medication
allergies) recorded as
structured data23

OpenVistA1
14
Record demographics
o preferred language
o insurance type
o gender
o race
o ethnicity
o date of birth
patients seen by the EP
have demographics
recorded as structured data23
Health Outcomes
Record and chart changes
in vital signs:
o height
o weight
o blood pressure
o Calculate and display:
BMI
o Plot and display growth
charts for children 2-20
years, including BMI.
For at least 80% of all
unique patients age 2 and
over seen by the EP record
blood pressure and BMI;
additionally plot growth
chart for children age 2-2023
Record smoking status for
patients 13 years old or
older
patients 13 years old or
older seen by the EP have
smoking status recorded23
Incorporate clinical lab test
results into EHR as
structured data
At least 50% of all clinical
lab tests ordered whose
results are in a positive/
negative or numerical format
are incorporated in certified
EHR5
technology as
structured data23
Generate lists of patients
by specific conditions to
use for quality
improvement, reduction of
disparities, and outreach
Generate at least one
report listing patients of the
EP with a specific condition23
Report ambulatory quality
measures to CMS9
or the
States
For 2011, provide
aggregate numerator
and denominator through
attestation as discussed in
section II(A)(3) of this

OpenVistA1
15
proposed rule; For 2012,
electronically submit the
measures as discussed in
section II(A)(3) of this
proposed rule23
Health Outcomes
Send reminders to
patients per patient
preference for preventive/
follow up care
Reminder sent to at least
50% of all unique patients
seen by the EP that are
age 50 or over23
Implement 5 clinical
decision support rules
relevant to specialty or
high clinical priority,
including diagnostic test
ordering, along with the
ability to track compliance
with those rules
Implement 5 clinical
decision support rules
relevant to the clinical
quality metrics the EP is
responsible for as
described further in section
II (A) (3). 23
Check insurance eligibility
electronically from public
and private payers
Insurance eligibility checked
electronically for at least
80% of all unique patients
seen by the EP23
Submit claims electronically
to public and private payers.
At least 80% of all claims
filed electronically by the
EP23
Engage patients
and families in
their health care
Provide patients and
families with timely
access to data,
knowledge, and tools to
make informed
decisions and to
manage their health
Provide patients with an
electronic copy of their
health information
(including diagnostic test
results, problem list,
medication lists, allergies),
upon request
At least 80% of all patients
who request an electronic
copy of their health
information are provided it
within 48 hours23
Provide patients with
timely electronic access to
their health information
(including lab results,
problem list, medication
lists, allergies) within 96
hours of the information
being available to the EP
patients seen by the EP
are provided timely
electronic access to their
health information23

OpenVistA1
16
Provide clinical patient
summaries for each office
visit
Clinical summaries are
provided for at least 80% of
all office visits23
Health Outcomes
Improve care
coordination
Exchange meaningful
clinical information
among professional
health care team
Capability to exchange
key clinical information
(for example, problem list,
medication list, allergies,
diagnostic test results),
among providers of care
and patient authorized
entities electronically
Performed at least one test
of certified EHR5
technology's capacity to
Electronically exchange
key clinical information23
Perform medication
reconciliation at
relevant encounters
and each transition of
care
Perform medication
reconciliation for at
least 80% of relevant
encounters and
transitions of care23
Provide summary care
record for each transition
of care and referral
Provide summary of care
record for at least 80% of
transitions of care and
referrals23
Improve population
and public health
Communicate with
public health agencies
Capability to submit
electronic data to
immunization registries
where submissions were
required and accepted
of certified EHR5
submit electronic data to
Immunization registries23
Capability to provide
electronic syndromic
surveillance data to public
health agencies and
actual transmission
according to applicable
law and practice
of certified EHR5
provide electronic
syndromic surveillance
data to public health
agencies (unless the public
health agencies to which an
EP submits do not have
capacity to receive info
electronically) 23

OpenVistA1
17
Ensure adequate
privacy and
security protections
for personal health
information
Ensure privacy and security
protections for confidential
information through
operating policies,
procedures, technologies
and law compliance.
Provide transparency of
data sharing to patient.
Protect electronic health
information created or
maintained by certified
EHR5
technology through
appropriate technical
implementation.
Conduct or review a
security risk analysis per 45
CFR 164.308 (a)(1) and
implement security updates
as necessary23
References
1. OpenVistA http://sourceforge.net/projects/openvista/
2. Accountable Care Organizations https://www.cms.gov/ACO/
3. Meaningful Use http://healthit.hhs.gov/portal/server.pt?open=512&objID=1325&mode=2
4. Certification Commission for Health Information Technology http://www.cchit.org/
5. Electronic Health Records http://www.himss.org/ASP/topics_ehr.asp
6. Health Level Seven http://www.hl7.org/
7. American National Standards Institute http://www.ansi.org/
8. American Recovery and Reinvestment Act http://www.recovery.gov/About/Pages/The_Act.aspx
9. Centers for Medicare and Medicaid Services http://www.cms.gov
10. Midland Memorial Hospital http://www.midland-memorial.com/
11. Healthcare Effectiveness Data and Information Set (HEDIS)
http://www.ncqa.org/tabid/187/default.aspx
12. Big Springs VA Medical Center www.bigspring.va.gov/
13. Computerized Patient Record System cprs
www.va.gov/vdl/documents/clinical/...patient...(cprs)/cprssetup.pdf
14. Hewlett Packard http:// www.hp.com
15. Medsphere Systems http://www.medsphere.com
16. Red Hat Linux http://www.redhat.com
17. The International Classification of Diseases http://icd9cm.chrisendres.com/
18. American Academy of Family Physicians (AAFP) http://www.aafp.org/online/en/home.html
19. U.S. Preventive Services Task Force (USPSTF) http://www.ahrq.gov/clinic/uspstfix.htm
20. Continuity of Care Record (CCR) www.nchica.org/Past/06/presentations/Kibbe.pdf
21. Continuity of Care Document www.hitsp.org/ConstructSet_Details.aspx?&PrefixAlpha=4...32
22. The Health Insurance Portability and Accountability Act 0f 1996 http://www.hhs.gov/ocr/privacy/
23. Meaningful Use Standards https://www.cms.gov/.../Downloads/MU_Stage1_ReqSummary.pdf

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