The document discusses the implementation of the VISTA health information technology system in Jordan, highlighting the country's healthcare challenges and the potential benefits of VISTA. It details Jordan's strategic leapfrogging approach to health IT, emphasizing its capacity for cost savings and improved clinical outcomes. The achievements include establishing a self-reliant nonprofit, successful adaptation of the system, and plans for a national rollout of VISTA across various healthcare facilities.

1. Implementing VistA Internationally:
Myth-Busting Lessons From Jordan
Nuffield Trust, London
July 5, 2012
Joseph Dal Molin
President, e-cology corporation
Chairman, WorldVistA
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2. Agenda
 Background and Context
 Why VistA
 Jordan's Leapfrog Approach
 Achievements
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3. Background and Context
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4. 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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5. 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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6. Why VistA?
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7. 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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8. 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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9. VA Top Clinical Performance
VA VA COMMERCIAL MEDICARE MEDICAID
INDICATOR 2009 2008 2008 2008 2008
Breast Cancer Screening 87% 87% 70% 68% 51%
Cervical Cancer Screening 92% 92% 80% n/a 66%
Colorectal Cancer Screening 80% 79% 59% 53% n/a
LDL 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%
Diabets: BP < 140/90 80% 78% 66% 60% 57%
Smoking Cessation Counseling 96% 89% 77% n/a 69%
Smoking: Medications Offered 90% 84% 54% n/a 41%
Smoling: Referral/Strategies 96% 92% 50% n/a 41%
Immunizations: Influenza 83% 84% n/a 71% n/a
Immunizations: Pneumococcal 95% 94% n/a 67% n/a
Source: VHA, 2009
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10. Model for Radical Transformation:
Transition to More Effective Care Settings
Source: Perlin et al., 2004, American Journal of Managed Care
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11. 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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12. 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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13. Jordan's Leapfrog Approach
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14. Leapfrog over this
Photo credit: www.ericmackonline.com
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15. .....to this
Photo credit: Wikipedia 15
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16. ...and iterate to this
Photo credit: Marianna Day Massey, Zuma Press
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17. 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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18. 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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19. Technology Strategy
 FollowVA 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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20. Benefits of Phased Implementation Approach
 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
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21. Asessment = Road Trip
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22. Assessing the Health Ecosystem
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23. 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
savings
Imaging
 Cost of PACS software savings
 Cost of film savings
 Telemedicine support – savings through remote consultation
Laboratory
 Avoid duplication of tests
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24. 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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25. 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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26. 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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27. Achievements
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28. 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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29. 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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30. Achievement: Patient Number One
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31. Thank You!
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32. 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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33. 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)
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