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The Future of Health Informatics

Peter L. Levin
Senior Advisor to the Secretary & Chief Technology Officer U.S. Department of Veterans Affairs @pllevin

November 2012

is open, deep, and blue

Its been exactly two years

And today I can announce that for the first time ever Veterans will be able to go to the VA website, click a simple Blue button, and download or print your personal health records so you have that when you need them and can share that with your doctors outside of the VA. Thats happening this fall [2010].
- President Barack Obama

A framework of health record modernization at VA

JANUS, the jointly developed user interface, now in four locations (one with DoD)

Clinical Applications and Services

The core of the iEHR program; OSEHRA as the custodial repository and front-line certification agent

The core of the VLER program, with Blue Button emerging as a very good way to structure, view, download, and transmit data; now part of ONCs meaningful use requirements


Lets focus on the data

Today clinicians have many patients and patients have many clinicians

Almost all medical information is exchanged with paper

Photo taken by Peter Levin at a VBA regional office

Which is dangerous and drives up costs

1.5 million adverse reactions or Rx errors 200,000 deaths per year from medical errors

I went through eight years of training to become a surgeon, and yet I still see mistakes every week. So we worked with Boeing to learn [how to make] a two-minute checklist for operating rooms. And when we implemented it in eight hospitals, ranging from rural Tanzania to Seattle and London, the average reduction in deaths was 46%. - Atul Gawande 8

Blue Button is a good way to (at least) get data to the patient, now
1.25 million users VA DoD CMS

In March OPM required all federal carriers to Blue Button-enable their PHRs

In the near future, it will be the way that we view, download, and transmit data

#ABBI for your primary care physician specialty care provider in-home caregiver pharmacist

PHRs that are tagged, labeled and coded will be even more clinically useful

Blue Button downloads self-entered and clinically valid medical record data
Blue Button file is easily readable and shareable Downloads in text and PDF: read, store, print on any computer no special software Patients can share with anyone they trust to improve or maintain their health

My HealtheVet page and sample Blue Button output


Why an ASCII file?

Its machine readable Its human readable Supports electronic data exchange (not ideal, but good) We could create it very quickly

Sample Blue Button immunization record output released in October 2012


The future of personal health data

proteomic description (~2 million) 106 genetic blueprint (~22,000)

individual data elements

lumped parameters (~220) 102



day after tomorrow


Scope of data
Size of one proteomic snapshot for a single patient: Amount of (non-image) data contained in the entire AHLTA electronic health record at DoD for 9.7 million patients today: Storage space required for a single proteomic snapshot data for those 9.7 million AHLTA patients:

0.04 terabytes 113 terabytes 390 thousand terabytes

If every patient who had an office visit last year had a single proteomic snapshot taken, it would equal:
Amount of data passed over the internet globally in 2010: If everyone in the United States had a proteomic snapshot taken every day for one year, it would equal:

10 million terabytes
250 million terabytes 4600 million terabytes

Veterans are about half of all users


There are plenty of commercial EHRs, but they dont communicate well
Interoperability has been historically neglected Were making progress on standardization
but progress is really slow

Blue Button starts with an ordinary ascii file

this has proven to be surprisingly well adopted

VAs platform was already in the public domain

now weve closed the loop with OSEHRA


VAs recent health IT innovations

VistA, AHLTA, and the Joint Common Platform OSEHRA Blue Button

New Electronic Health Record (EHR) New Implementation Roadmap New Personal Health Record (PHR)


Why open source?


Problem Statement
Federal software acquisition is notoriously slow and error prone

Encyclopedic requirements Choose once/choose wisely procurement Near-zero visibility into development Epic program slips and cost overruns


Solution Statement
Theres a much better way to do this

Incremental requirements Interoperable apps (like a smart phone) Regular customer-facing deliverables Negotiate features, not time


Use model for open source


In July 2012 we installed the first vendorcontributed OSEHRA component

Dr James Kahn, VA Medical Center Palo Alto


October 2012 JANUS pilot performance metrics

More than 600 clinical users
James Lovell Federal Health Care Center (Chicago) Tripler medical center (Honolulu)

Over 20,000 patient records retrieved Economic benefits

First OSEHRA installation cost approximately $100,000
Recently completed a second one for approximately $50,000

Takes about an hour to learn Cost savings scale to $10-$50k per clinical user, per year

86% of users agreed that JANUS saves time and resources, leads to better care

Whats on, and whats next


What is our vision for Blue Button?

To extend the simple, efficient data format in a way that enables industry-wide data exchange. Blue Button is becoming a broadly deployed, easily adopted (inter?)national PHR.


To be fully successful, we have to

Keep data current We need Blue Button apps that always have latest update of patient records We need Blue Button apps that make it easier to patients to see whats going on

Enrich the patient experience


Blue Button for America

Our purpose is to give patients better access to
and use of their Personal Health Information based on Blue Button. Improved readability and organization Increased data portability Easier mobile development Patient-Mediated Information Exchange

For example, better presentation makes the data even more meaningful

Created by Thomas Goetz, used by permission


Selected Blue Button partners

over 400 commitments on the ONC website

Coming soon: the complete medical record

VA Blue Button Additions (targeted for December 2012)
VA Demographics VA Problem List VA Admissions and Discharges (including Discharge Summaries) VA Notes (progress notes) VA Laboratory Results: (adds Microbiology) VA Vitals and Readings VA Pathology Reports: (Surgical Pathology, Cytology, Electron Microscopy) VA Radiology Reports VA Electrocardiogram (EKG) Reports Self Entered Food and Activity Journals VA Continuity of Care Document (VA CCD)

How to get engaged.

Follow Blue Button: nitiative Twitter: @ProjectBlueBtn

Follow development:

The future of health informatics is open, deep, and blue

Open: we're moving from a world of proprietary, closed, and monolithic systems to a better one based on open architectures, standards and modular components Deep: distinguishes the kind of data we have from "big"; the progression to 2 million proteins and what that means in terms of infrastructure, outcome, and scale Blue Button: is it becoming the national platform for personal health records, and is on the vanguard of the worldwide open data initiative