Easy Enterprise: The Vision

-by Terry L. Wiechmann

Background

Since the Gulf War, subsequent administrations have made the integration of DOD and VA resources a priority. To accelerate this effort, “… President George W. Bush established the Presidents Task Force to Improve Health Care Delivery for Our Nation’s Veterans (PTF) by Executive Order 13214 on May 28, 2001. The PTF was directed to identify ways the Department of Veterans Affairs (VA) and Department of Defense (DOD) could coordinate their activities and resources to meet the Presidents goal of improving health care delivery for America’s veterans.”¹

The Information Management/Information Technology (IM/IT) workgroup is one of seven PTF workgroups. Their responsibilities include reviewing current IM/IT resources and making recommendations as to how to effect sharing of these resources. Under intense scrutiny are the clinical information and ancillary systems. The PTF Interim Report says this about them.

“The distinctly different VA and DOD electronic medical record systems were developed four years apart and are based on different technology and architectures that cannot readily share data. Since there is no interoperable IM/IT system or process for transferring patient records, treatment for dually eligible beneficiaries is not easily coordinated. In the event of war or national emergency, VA is the back-up heath care delivery system for the DOD. If a large number of casualties are incurred, the ability to know the location of military personnel and their state of health becomes a matter of national security; however, there are no interoperable data systems or processes to allow this information to transfer across the two Departments…”²

The Vision

What is the Vision?

The vision of healthcare today is the elusive longitudinal patient record. Within a patient’s lifetime, he or she makes numerous visits to healthcare facilities, leaving encounter information stored in isolated computers or on paper. Combined, these encounters form the patient’s full record; giving clinicians valuable historical information needed for the on going care of the patient. However, in most cases, this is impossible because the information is not accessible.

Realizing the Vision

ESI Technology Corporation (ESI) and the Naval Medical Center San Diego (NMCSD) have created a prototype system that demonstrates how remote, disparate data can be collected and viewed as if it were stored on one computer system.  This system is known as Easy Enterprise. It leverages software built for the VA under the GCPR program as well as bi-directional data wrappers technology built for the Navy. It demonstrates how clinical data can be extracted from the DOD’s CHCS and the VA’s VistA systems and viewed from a Common Web Provider Portal. The following scenario represents a typical provider interaction with the Easy Enterprise system.

At the beginning of the day a CHCS provider would sign on to the Easy Enterprise system. The following illustrates the sign on screen.

System Sign On

Once signed on to the system, if the provider has scheduled appointments, they will be displayed. The web page is displayed below. For this example, the provider does not have appointments.

Provider’s Appointment List

At any point, the provider can select his or her patient list by simply clicking on the My Patients button. The example below displays the provider’s patient list.

Provider’s Patient List

At this point the provider will select the patient. This brings up a page the lists the patients Inpatient and Outpatient diagnoses. These diagnoses are those stored on the local CHCS system.

Patients Inpatient and Outpatient Diagnosis

However, if the provider wishes to pull the patient’s information from one or more external sites, the Find Sites link under the MPI section would be clicked on. This brings up a page shown below that lets the provider choose the sites where the patient has had previous encounters.

Selecting Sites

Selecting the desired sites and clicking on the Select button will redisplay the Diagnosis Summary page shown below, with diagnosis from all sites selected.

Patients Inpatient and Outpatient Diagnosis for all Selected Sites

From this point on, all links traversed will retrieve data from the sites selected. For example, if the provider wants to view the patient’s Hematology and Chemistry results, clicking on the Heme/Chemistry link will prompt the system to retrieve the patient’s results from all selected sites and display it with a clear indication of where it came from.

Patients Lab Summary for all Selected Sites

Infrastructure Overview

The Prototype System

The diagram below illustrates the technical infrastructure of the Easy Enterprise prototype system. The prototype is only used to demonstrate how data can be extracted from disparate systems.

Easy Enterprise Prototype System Infrastructure

The communications core of the system is based on the open CORBA standard³. The CORBA communications standard, in conjunction with the Internet, provide the communications backbone for the Easy Enterprise system. It can provide access to all CHCS and VistA systems around the world.

Inherent in the CORBA standard are common and domain specific standard services. CORBA Standard Common Services are services that are available to every site that is participating in the Easy Enterprise system. The Domain Specific Standard Services implement services that are specific to the DOD or VA.  The Person Identification Services (PIDS) provides access to a Master Patient Index (MPI). The MPI contains location information for each patient. It is responsible for keeping track of the patient’s encounters.  Note: The MPI for the Easy Enterprise prototype contains only the information needed to access a few patient test records.

Access the CHCS and VistA Databases is provided through the EsiObjects Object Interface. EsiObjects™ is an object-oriented environment that provides CORBA access to the CHCS and VistA data objects.

The Common Web Provider Portal provides access to the patient’s medical record via a common Web Browser interface. The interface has the same look and feel as the Easy CHCS Provider Portal.

The Pilot System

To evolve the Easy Enterprise system to a pilot system that can be deployed to VA and DOD test sites, several system enhancements must be implemented. They are:

• Data Mapping and Naming
• Master Patient Index
• Common Provider Portal User Interface

Data Mapping and Naming

One design goal of Easy Enterprise is to provide a common display of data independent of the data source.  Data elements need to be grouped and named correctly according to standards if they exist. Data elements with associated dimensions should be normalized to a common dimension.

The diagram below is identical to the diagram in the last section with one exception. In an effort to present the provider with one standard naming convention, the Lexicon Services should be integrated. Lexicon Services provide access to naming standards needed to reconcile the differences in names (laboratory test, radiology procedures, etc.) between participating systems.

Easy Enterprise Prototype System Infrastructure

The Master Patient Index

A real Master Patient Index will be required for the participating systems as well as enhancing the Provider Portal to provide sign-on from either a CHCS or VistA host system. This can be implemented as a stand-alone DOD MPI that would collaborate with the VA’s MPI or, one unified MPI could be implemented starting with the VA’s existing MPI.

Common User Interface

The Common Web Provider Portal must be enhanced to integrate the data in a more seamless fashion.

With these additions, the technical components would be ready for a pilot deployment to test sites.

Conclusion

The problem is clearly stated within the President’s Task Force Interim Report: “If a large number of casualties are incurred, the ability to know the location of military personnel and their state of health becomes a matter of national security; however, there are no interoperable data systems or processes to allow this information to transfer across the two Departments…”

The Easy Enterprise system clearly demonstrates interoperability between the DOD’s CHCS and VA’s VistA systems. The infrastructure exists to integrate other disparate data sources, moving towards the elusive longitudinal patient record.

Evolving this system to a test pilot status and eventually to national deployment will accomplish the goal of knowing the location of military personnel and their state of health. It’s a matter of national security!

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