Translating standards into practice: experience and lessons learned at the Department of Veterans Affairs.

The increased need for interoperable electronic health records in health care organizations underscores the importance of standards. The US Department of Veterans Affairs (VA) has a long history of developing and adopting various types of health care data standards. The authors present in detail their experience in this domain. A formal organization within VA is responsible for helping to develop and implement standards. This group has produced a Standards Life Cycle (SLC) process endorsed by VA key business and information technology (IT) stakeholders. It coordinates the identification, description, and implementation of standards aligned with VA business requirements. In this paper, we review the adoption of four standards in the categories of security and privacy, terminology, health information exchange, and modeling tools; emphasizing the implementation approach used in each. In our experience, adoption is facilitated by internal staff with expertise in standards development and adoption. Use of processes such as an SLC and tools such as an enterprise requirement repository help formally track and ensure that IT development and acquisition incorporate these standards. An organization should adopt standards that are aligned with its business priorities and favor those that are more readily implementable. To assist with this final point, we offer a standard "Likelihood of Adoption Scale," which changes as standards specifications evolve from PDF documents only, to PDF documents with construction and testing tools, to fully functional reference implementations.

A simple strategy for implementing standard reference terminologies in a distributed healthcare delivery system with minimal impact to existing applications.

The Veterans Administration (VA) has adopted an ambitious program to standardize its clinical terminology to comply with industry-wide standards. The VA is using commercially available tools and in-house software to create a high-quality reference terminology system. The terminology will be used by current and future applications with no planned disruption to operational systems. The first large customer of the group is the national VA Health Data Repository (HDR). Unique enterprise identifiers are assigned to each standard term, and a rich network of semantic relationships makes the resulting data not only recognizable, but highly computable and reusable in a variety of applications, including decision support and data sharing with partners such as the Department of Defense (DoD). This paper describes the specific methods and approaches that the VA has employed to develop and implement this innovative program in existing information system. The goal is to share with others our experience with key issues that face our industry as we move toward an electronic health record for every individual.

Timing of initiation of rehabilitation after stroke.

UNLABELLED: Maulden SA, Gassaway J, Horn SD, Smout RJ, DeJong G. Timing of initiation of rehabilitation after stroke. OBJECTIVE: To study associations between days from stroke symptom onset to rehabilitation admission and rehabilitation outcomes, controlling for a variety of confounding variables. DESIGN: Observational cohort study of 200 consecutive post-stroke rehabilitation patients in each of 6 inpatient rehabilitation facilities. SETTING: Six U.S. inpatient rehabilitation hospitals. PARTICIPANTS: Patients (N=969) with moderate or severe strokes who had days from stroke symptom onset to rehabilitation admission recorded in their medical records. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge total FIM, discharge motor FIM, discharge activities of daily living (ADL) FIM, and discharge mobility FIM scores, as well as rehabilitation length of stay (LOS). RESULTS: Fewer days from stroke symptom onset to rehabilitation admission was associated significantly with better functional outcomes: higher total, motor, mobility, and ADL discharge FIM scores, controlling for confounding variables. For severely impaired patients with stroke in case-mix groups (CMGs) 108-114, the relation was strongest, with F statistics greater than 24.1 for each functional outcome. For patients with moderately severe stroke in CMGs 104-107, fewer days from stroke symptom onset to rehabilitation admission was associated significantly with shorter rehabilitation LOS. CONCLUSIONS: Fewer days from stroke symptom onset to rehabilitation admission is associated with better functional outcomes at discharge and shorter LOS.

Information technology, the internet, and the future of neurology.

BACKGROUND: This review addresses the impact of information technology and the Internet on the current and future practice of neurology. Information technology is influencing medical practice in ways that could be both beneficial and harmful. Scenarios are presented to depict some of the ways in which the practice of neurology is being influenced by the growth of technology. REVIEW SUMMARY: First, the advantages and disadvantages of e-mail as a means of doctor-patient communication are presented. Some of the ethical and legal issues arising in this context are discussed.Second, the Internet is changing neurologists' relationships to other professionals in the health care industry. Geographical isolation is less problematic than in the past. Telemedicine, including remote consulting via the Web, has special implications for neurologists in several areas, including stroke management, movement disorders, and epilepsy.Third, the growing availability of large databases, powerful search engines, and online full-text journals is discussed. Skill in navigating and managing these resources will become increasingly important. New computer-assisted decision support systems will continue to be implemented. Applications exist or are being developed for use by clinicians for many specific neurologic disorders.Finally, some of the problematic issues concerning medical use of the Internet are discussed, including availability, portability, security, quality, and outcomes. CONCLUSIONS: Medical information systems, with their attendant advantages and limitations, will become increasingly significant in the practice of neurology. Despite overall improvement in access to information, major barriers still exist to the proper implementation and utilization of truly integrated information systems.