for Health Care Providers
Chapter 1 - Background and Perspective
1.1 The Department of Veterans Affairs, Veterans Health Administration
The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) is a federally funded, comprehensive health care system serving eligible, enrolled US veterans. Organizationally, the VHA is divided into 21 geographic regions called Veteran Integrated Service Networks or VISNs, each of which encompasses a number of local healthcare systems. These local systems include over 1,100 facilities consisting of medical centers, community based outpatient clinics (CBOCs), domiciliaries, extended care facilities, hospices, and specialty centers for mental health, blind rehabilitation, spinal cord injury, polytrauma and traumatic brain injury. In federal fiscal year 2008, there were 7.8 million enrollees with 5.6 million (72%) receiving care at VHA facilities. Nationwide, inpatient care involved 641,000 discharges (70% of which were for acute care) totaling 4.3 million bed days of care. Average daily census in nursing homes was 33,782 Veterans. Over 67 million outpatient visits were provided by the VHA in fiscal year 2008, 13.7 million of which were at community-based outpatient clinics. Additional information on the general Veteran population can be found at http://www1.va.gov/vetdata/.
1.2 Overview of Program Office and Quality Initiatives
The Office of Public Health and Environmental Hazards (OPHEH) improves Veterans' health through prevention, outreach, treatment and surveillance. OPHEH focuses on specific populations of Veterans including women Veterans, Veterans with HIV/AIDS, Veterans with hepatitis C, and Veterans exposed to hazardous materials during military service. OPHEH also manages VHA's medical response to emergencies and protects the safety and health of VHA employees.
Public Health Strategic Healthcare Group
The Public Health Strategic Health Care Group (PHSHG) is a component of the Office of Public Health and Environmental Hazards. PHSHG's mission is to improve the health of Veterans through the development of sound policies and programs related to several major public health concerns including: HIV infection, hepatitis C infection, seasonal influenza, smoking and tobacco use, and emerging infections of public health significance--including healthcare associated infections. PHSHG strives to ensure the highest quality, comprehensive care is provided to Veterans and to have that care recognized as the standard by which all healthcare in the United States is measured. PHSHG efforts include patient care activities, clinician education, patient education, prevention activities, policy development, and research directed at continuous improvement of medical and preventive services delivered to Veterans.
Center for Quality Management in Public Health
The PHSHG oversees the HIV/AIDS programs through its National Clinical Public Health Program Office. The Center for Quality Management in Public Health (CQMPH), a component of the PHSHG, is based at the VA Palo Alto Health Care System campus and oversees the Clinical Case Registry (CCR) for HIV. The CQMPH mission is to catalyze continual innovation and improvement in VHA clinical care via the use of quality management techniques and the strategic use of clinical information systems. CQMPH fosters innovation and improvement in patient care using the VHA system as a "working laboratory." This work is possible because of the unique VHA electronic medical record (EMR). Taking advantage of clinical data from the VHA's EMR, CQMPH develops centralized patient registries and structures, and enhances registry data to provide clinicians useful information about their populations of Veterans with HIV. CQMPH staff members provide support to VHA clinicians and administrative staff to enhance their ability to use the CCR. CQMPH also provides other electronic tools such as Clinical Reminders. All these efforts are designed to enhance the quality of care delivered to Veterans.
1.3 Electronic Medical Records, the Clinical Case Registry and CCR Reports
VHA has a state of the art EMR covering all aspects of healthcare delivery and documentation. Electronic tools use healthcare data to provide clinicians with patient-centric reminders and guidance related to care delivery including safety functions such as drug-drug interaction and allergy checks, reminders to provide vaccinations, laboratory tests and screenings, and alerts regarding abnormal results or procedures. The VHA EMR also includes population management tools, such as the CCR. The CCR software, deployed throughout VHA, provides a registry at every VHA facility to support local care delivery and a national clinical database. Staff members at VHA facilities serve as local registry coordinators, reviewing the medical records of Veterans with laboratory results and/or diagnosis codes reflecting potential infection with HIV and confirming their addition to the local CCR if the condition is actually present. Addition to a local registry triggers addition to the national CCR, which is created through extraction of specific clinical data from the local EMR. Extracted data elements include allergies, demographics, diagnoses, discharges, laboratory tests, prescriptions, procedures, and radiology.
Using data from all VHA facilities, periodic summary reports are created on the population of Veterans with HIV/AIDS receiving care through VHA. Each report uses the latest available data, providing information at the national, VISN, and local healthcare system to VHA clinicians, administrators, and researchers. With each extract, CCR data is refreshed with new data for Veterans already in the CCR, as well as current and historical data for Veterans newly added to the CCR. Because CCR data collection is dynamic, reports from different time periods may not be directly comparable; nonetheless, comparison of information from various summary reports is generally useful for monitoring trends. The ultimate goal of these reports is to provide information to guide clinical and administrative activities directed to assuring safe, effective and efficient care for Veterans with HIV/AIDS.
In addition to the periodic summary reports, local staff has access to population management reporting tools in their local CCR software. While such local reports are based only on data in the local registry (as opposed to the national CCR) they permit the user to examine a variety of process and outcome related questions.
Examples of valuable ways the CCR is used in practice include:
- Measurement of patient volume to inform decisions about how care is delivered, allocation of staff and other resources.
- Describing patient demographic characteristics and co-morbidities to assess types of services likely to be required, such as treatment for age-related issues or chronic conditions.
- Assessment of adherence to national guideline recommendations, such as receipt of appropriate prophylactic medications, and monitoring CD4+ lymphocyte count and HIV viral load levels.
- Identification of trends over time, such as trends in the uptake or monitoring of a specific medication or other treatment
- Measurement of treatment outcomes and effectiveness of current practices, protocols or guidelines
- Performing ongoing comparison across VISNs or healthcare systems of like size to identify rates of variation that may indicate quality issues or opportunities for improvement
Feedback reporting is a fundamental strategy that PHSHG employs to achieve its mission to assure the highest quality, comprehensive care to Veterans. This State of Care Report joins PHSHG's efforts in clinical surveillance, patient care activities, clinician education, patient education, prevention activities, and research directed at continuous improvement of medical and preventive services delivered to Veterans living with HIV. The report is intended to provide information that will be of interest and use to providers and administrators of care as they plan and deliver services to Veterans with HIV/AIDS. Outside VHA, this information can be used to support quality assessment and improvement efforts and highlight best practices within VHA.