Veterans Health Information Systems and Technology Architecture (VistA) is a tool used to improve the healthcare of the United States’ war veterans. VistA is used in healthcare facilities across the country and it is easily accessible to healthcare providers everywhere in the world. VistA is “currently one of the most common Electronic Health Records (EHR) systems in the planet” (Ball, 2002). Since its inception around 1985, VistA has undergone various changes to improve its performance. One of such changes is the addition of a graphical user interface (GUI) that is in the form of a CPRS (Computerized Patient Record System). The addition of CPRS was not meant to replace the architecture of VistA but it was meant as an enhancement to VistA. VistA and CPRS are a proprietorship of the VA (Department of Veteran Affairs). However, VistA/CPRS has been used as a prototype for other healthcare informatics programs. To date, VistA remains an effective tool of healthcare provision. Nevertheless, the system can still benefit from a number of improvements. This paper details a process of implementing several improvements on VistA’s/CPRS functionality. The process for planning, implementing, and evaluating the improvements on VistA is clearly outlined in this paper.
Long and Short Range Objectives
The objective of this project is to implement some aspects of CPRS in a non-VA environment. Specifically, CPRS will be employed in Phyllis Home for the Elderly (PHE). PHE has a substantial number of patients who are veterans. Moreover, the home is under the State Administration and not the Federal Government. Therefore, because CPRS is authorized by the VA, which is a federal-based organization, it cannot be employed in a state organization without the necessary permissions (Ball & Collen, 2002). This project is headed by the Head Nurse and Director at PHE. The project’s main objective is to ensure that CPRS is available for use by clients at PHE irrespective of their veteran or non-veteran status.
The short-range objectives of this project are to ensure that the legal barriers that prohibit use of CPRS at PHE are circumvented. Moreover, all the agreements that are necessary to kick start the implementation of the project should be in place before embarking on the long-term objectives. VA oversees VistA/CPRS’ operations across the world. Previously, VA has allowed its flagship program to be used and integrated into other health informatics programs. However, this process takes time and the final decision lies with the VA.
The long-range objectives of this project are to ensure that the time taken to access patient’s health information is reduced. Currently, the process used at PHE is tedious and subject to errors. The number of orders processed by PHE annually is in excess of 200,000. In the long term, the head nurse wants to ensure that CPRS lessens the tediousness of processing these orders in order to save time and resources. Given that these orders have to be written, copied, transcribed, and faxed, CPRS will be able to streamline various operations at PHE. The full incorporation of CPRS into PHE’s operations is expected to take between one and two years after PHE has struck a deal with VA.
Purpose
The purpose of this project is to raise the operation standards at PHE. Upgrading the operations at PHE has been on the agenda for a few years. Integrating CPRS into PHE’s operation is expected to be a step towards the home’s modernization agenda. Moreover, most of the nurses who are joining the home in recent times have already undergone basic informatics training. Therefore, there will be no need for intensive training for most of the PHE’s staff. Another purpose for this project is to ensure that the process of upgrading the operating systems at PHE is cost effective. Using the VA program is cheaper than using alternative proprietary informatics programs (Cherniack, 2011). Initial projections indicate that using other commercial alternatives to CPRS is four times more costly than using CPRS. Implementing the CPRS program will also incur less maintenance costs in the long run.
Assessment of the Environment
Currently, PHE has been assessing some features of the VA’s VistA/CPRS program on behalf of the veterans who are served by the home. Although the home only accesses limited features of the program, the efficiency of these features has encouraged PHE to embark on this project. A mini-survey that was carried out by the PHE indicated that integration of CPRS into PHE’s operations would have an impact factor of five to the home’s operations. The project is being spearheaded by the home’s head nurse and she has the backing of the state’s health department as well as PHE’s Board of Trustees.
Veterans constitute over fifty percent of the population at PHE. In addition, PHE was initially meant to be an institution for taking care of the First and Second World War veterans. However, the home opened its doors to non-veterans after the state took over its management in 1986. The state seeks to take advantage of the VA’s interest in the home when seeking permissions to implement CPRS at PHE. Initial communication with the VA indicates that there is a possibility of obtaining permissions to run some features of CPRS in the home. On the other hand, the internal affairs department at the hospital is encouraged by the fact that most of the staff at PHE supports the integration of the CPRS at home. The administration also supports the integration of a stable federal government initiative as opposed to a commercially motivated initiative.
The harmony within the internal and external environments at PHE is a source of motivation for the project’s managers. In most projects, friction between internal and external projects often leads to delays. These delays are often as a result of differences in opinion between internal and external managements. Successful integration of CPRS in a non-VA environment often depends on VA’s level of interest (D’Avolio, Ferguson & Goryachev, 2009). In PHE’s case, the VA has prior interest in the home. Moreover, the connection between the state and the federal government interests is likely to hasten the integration process. Currently, the head nurse and her project committee are in the process of negotiations with the VA. The time taken by these negotiations depends on the state of internal and external PHE environments.
Workflow Diagram of Current Process
The current patient processing procedure follows the process illustrated below.
Labels
W– Write C– Copy F– Fax D– Data Entry P– Print M– Mail O– Courier R– Proof Read T –Transcribe H– Hand Carry
Definition of process-The physician is only involved in the W process while the nurses perform the C, F, O, T, and R processes. The pharmacy department performs functions D, P, M, and H. The complexity of this informatics process is evident from the figure above. The nurses at PHE have to conduct numerous activities that occur between the time the physician’s order is issued and the patient-treatment records are administered. The nurses bear the most of the information-processing burden. Last year alone, PHE handled over 200,000 orders that involved the illustrated processes. This process meant a lot of faxing, copying, and writing operations for the nurses. This project seeks to integrate all these processes into the CPRS program. Therefore, the information processing will move directly from the physician order process to the treatment administration process without bouncing back and forth between the pharmacy and nursing departments. The CPRS program will be situated between the physician and the nurse. The physician can make orders directly to the CPRS interface where the nurses can receive these order sheets. The CPRS program will also enable nurses to process requisitions, medical administration records, order labels, prescriptions, and treatment administration records directly.
Options for Improvement
The first option of implementing the CPRS program at PHE is through a comprehensive agreement with the VA headquarters at Washington DC. These negotiations are expected to take between one and three years. This approach will take a long time but if it is achieved it will be more efficient and less costly. The other option is to approach the VA with the intention of buying some features of the CPRS. This option takes a lesser period but it is more expensive.
Identification of Preferred Options
The aim of this project is to form a partnership with the VA. Therefore, the option of negotiating for a deal with the VA remains the best option. VA’s interest in PHE remains the main motivation behind this project. The option to implement only a few purchased features of CPRS will be expensive and less effective. Furthermore, the cost of this option will be very high in the end. There is also the issue of the veterans who are contained in the PHE. Implementing another informatics program will lead to conflicts within the program’s operations. Most of the clients at PHE are already being served by the VistA/CPRS. Given that this program aims to harmonize operations, the option to operate CPRS under a partnership with the VA remains the best one. The VA has already entered into agreements with other healthcare providers (Brown, Lincoln & Kolodner, 2008). Therefore, implementation of CPRS features by way of purchase would only lead to more purchases hence increasing the budget of the project.
Implementation Plan
After the necessary permissions to use the CPRS have been obtained, the next step will be the actual implementation of the project. The first step is to ensure that the PHE’s IT department is up to the standards that are specified by the VA’s IT-Security department. This includes an upgrade of PHE’s entire computer network. The new computer network will be compliant with VA’s network security specifications. Another crucial upgrade will involve the installation of high-speed data cables to facilitate the increased network-data traffic. After these standards have been achieved, the next step will be gaining access to the CPRS servers. This process can only occur under supervision of VA. The servers that will be running the CPRS program will be stored and supervised by the VA. The cost of storing and maintaining these servers will be covered by PHE. The new CPRS program will initially be used for the assisted living facilities with a 250-bed capacity. Nevertheless, there are hitches that are expected from the VA’s CPRS program. The first adjustment to the program involves adjusting it to fit it into a non-federal facility.
The pharmacy and laboratory functions of the CPRS operate under prior agreements with LabCorp. LabCorp can access the CPRS at any time or location under the agreement with VA’s Federal Authority (Smith & Joseph, 2006). Moreover, this agreement allows CPRS’ users to order and report about lab tests. PHE’s lab tests are carried out within the state while LabCorp operates in North Carolina. To avoid miscommunication concerning lab tests, PHE’s programmers will have to readjust this part of the CPRS interface. This additional programming will be performed under the stewardship of VA-appointed programmers. The same strategy will be used to replace the VA-appointed pharmacist. The last step of the implementation plan involves extensive staff training. This training will also be very important to the project’s evaluation. Some aspects of the CPRS will only be employed after the initial implementations of the program have been completed. For instance, the VistA/CPRS imaging functionality will not be implemented for the first six months. This functionality will eventually enable CPRS to incorporate x-ray images into the patients’ charts.
Evaluation Strategies
A complete evaluation of this project will only be complete after a period of one year. The first step of the evaluation process involves testing the staff’s familiarity with the improved CPRS program. The home will keep a log of how the staff interacts with the new CPRS interface in an effort to gauge the staff’s comprehension of the program. The next step in the evaluation process will involve keeping track of the changed aspects of the CPRS program. The new pharmacy and laboratory programs will consist of untested software architecture. The success of this project depends on the successful integration of this new software.
References
Ball, M. J., & Collen, M. (2002). Aspects of the computer-based patient record. New York, NY: Springer.
Brown, S. H., Lincoln, M., & Kolodner, R. M. (2008). VistA—US Department of Veterans Affairs national-scale HIS. International journal of medical informatics, 69(2), 135-156.
Cherniack, E. P. (2011). Complementary medicine use is not associated with non-adherence to conventional medication in the elderly: a retrospective study. Complementary therapies in clinical practice, 17(4), 206-208.
D’Avolio, L., Ferguson, R., & Goryachev, S. (2009). Implementation of the Department of Veterans Affairs’ first point-of-care clinical trial. Journal of the American Medical Informatics Association, 19(1), 170-176.
Smith, M. W., & Joseph, G. J. (2006). Pharmacy data in the VA health care system. Medical care research and review, 60(3), 92-123.