We have extensive experience building custom solutions for large-scale and complex projects that are compliant with Federal and Military standards. From integrating legacy DoD and VA systems to deploying and maintaining commercial health enterprise systems—here’s a look at some of our past projects.
FEDERAL HEALTH – EHR/CDS EXPERIENCE
After pursuing an integrated EHR (iEHR) from 2011-2013, the Department of Veterans Affairs (VA) and Department of Defense (DoD) scrapped the effort in favor of interoperability between two separate systems. Today the VA uses the Veterans Health Information Systems and Technology Architecture (VistA) EHR and DoD is transitioning its Armed Forces Health Longitudinal Technology Application (AHLTA) system into MHS Genesis. Cognitive has done extensive work on VistA, AHLTA, and VA/DoD interoperability initiatives.
VA Office of Information & Analytics – Cloud-based Clinical Decision Support Technology Evaluation Lab
Finding that most CDS was linked with vendor-specific EHR software, the VA sought not only to build their own but to create it so that it formed the basis for international health IT standards.
VA tests all software in test data center environments before deployment to create a “safe harbor” to mitigate risk and optimize benefits of emerging health IT—like CDS—prior to use in Veterans healthcare.
Cognitive designed, developed, and tested an Amazon Web Service (AWS) elastic cloud computing (EC2) Clinical Decision Support Evaluation Lab environment, which enabled VA to test new tools and technologies in an autonomous environment that replicated but is not tied to VA’s environment. A prominent feature was a portal that consolidated and normalized patient data and information in to a readable format with an inbox, alerts, and messages.
Cognitive also supported the development of three service oriented architecture (SOA) service specifications through the HL7 object management group (OMG) standardization processes, which were approved as draft standards for trial use (DSTU). We developed the open-source reference implementation of the three service interface specifications that can be used by VA and third parties to integrate the draft services in any SOA-based system.
Cognitive then integrated the three SOA services reference implementations into the open source electronic health record agent (OSEHRA) VistA / CPRS application hosted within the CDS evaluation lab. Verified and validated CDS user interface (UI) design guidelines by using the guidelines to develop five (5) CDS User Interface (UI) interventions completewith formative and summative usability testing for meaningful use stage II.
This was the first of several contracts Cognitive won with VA’s Knowledge Based Systems group; follow-on work is ongoing.
VA Office of Information & Analytics – Standards-Based Clinical Decision Support Gap Analysis
Cognitive is currently conducting a gap analysis of the current state of clinical reminders as implemented in eHMP using OpenCDS compared to a desired future state defined by VA.
Cognitive has performed object metadata requirements documentation by creating generic metadata models for common widget types, as well as tools to create and edit metadata models for widget types not yet created.
Cognitive has also documented LEGO widget instance definition requirements, specifically by linking instances of widget metadata models to LEGOs to develop tools to create LEGO and FHIR questionnaire resource widgets; ensuring LEGO and FHIR questionnaire resource widgets are able to be stored and are readable, updateable, and versioned with universally unique identifiers; and developed tools that allow users to browse LEGO repository.
VA Office of Information and Analytics – VistA Evolution/VistA Core
In 2013 the VA announced VistA Evolution, an initiative aimed at modernizing the agency’s EHR, specifically to support population analytics and enhanced interoperability. The main components of the modernization effort include the Joint Legacy Viewer, which allows visibility of patient records between the VA and DoD systems, Enterprise Health Management Platform (eHMP) delivery of new graphical user interface (GUI) tools, standardization of VistA instances, and release of an API to expose VistA services via standard web interfaces.
Cognitive helped with the GUI component of the project, specifically migrating functionality of the previous GUI, CPRS, and enhancing the user experience with new screens intended to speed comprehension. Specifically, Cognitive enabled eHMP application to be Clinical Context Object Workgroup (CCOW) compliant for interoperability with other CCOW-enabled applications, including CPRS; supported the definition and management of clinical criteria or quality measures resulting in a particular clinical intervention or recommendation; and supported the definition and management of a rules-based set of clinical interventions and recommendations that result from the presence of clinical criteria or quality measures for any patient.
We collaborated with key VA Informatics stakeholders to define, document and implement application features, which are incorporated into the global eHMP codebase for deployment to integration and testing environments, and later for release to VA facilities nationwide.
Cognitive has completed nearly four dozen feature sets since its involvement with the project, ranging from architecting and building the entire CDS infrastructure to enabling individual domain write-back functions to VistA such as Problem List, Immunizations, Vitals and Allergy records.
DoD Pacific Joint Information Technology Center – EHR/MHS Transition Analysis
Developed a Transition Analysis Plan (TAP) that prototyped two replacement methodologies and software systems to assist in successfully transitioning Composite Health Care System (CHCS) EHR and MHS programs—modernizing and reusing legacy code where possible.
The first methodology encapsulated CHCS constituent functionalities (e.g., CHCS Order Entry and Pharmacy Workflow) in an object wrapper that would then be exposed to the service-oriented architecture (SOA) bus and consumed by the new system components also sitting on the SOA bus.
The second methodology built compatible, replacement constituent functionalities outside of CHCS that are capable of talking to the other new system components via the SOA. Data from the replacement functionality is then inserted back into CHCS so that the other clinical workflows and modules do not break. This approach would take longer for migration of the initial functionality or service; however, the functionality, since generalized, would take less time for subsequent functions. Also, maintenance costs would be significantly reduced because there are fewer unique objects with specialized wrapper requirements.
FEDERAL HEALTH – CLINICAL INFORMATICS EXPERIENCE
DoD – eRPM Deployment to Navy SharePoint Portal
Introduced by the Naval Health Research Center (NHRC) and Naval Medical Research Center, Enterprise Research Project Manager (eRPM) is an information management system designed to assist research and development laboratories and their commands effectively manage portfolios and facilitate individual project workflow. eRPM enables Navy Medicine leadership to monitor budgets, risks, and timelines, and to better align research activities with mission objectives.
From 2012 to 2013 there was effort to institutionalize eRPM by converting it from Microsoft Access to an SQL application hosted on BUMED SharePoint for easier user access, greater data security, and creation of a central repository for the system information and product library.
As part of Leidos’ contract with NHRC to advise the Navy medicine enterprise on integration and execution of the eRPM business management software onto Navy networks, Cognitive verified eRPM met the business, functional, and technical requirements specified in original procurement documents; performed a gap analysis of the original eRPM system architecture and the desired architecture; and deployed eRPM to the Navy’s Enterprise Services Operation Center SharePoint portal.
VA Central Business Office, Office of Purchased Care – Patient Centered Community Care (PC3)
To address an appointment backlog for VA care Congress passed the Veterans Access, Choice, and Accountability Act of 2014, which established the Choice Program. Under the Choice Program, the VA is required to authorize care outside of the VA if the veteran is unable to get an appointment at a VA facility within 30 days or lives more than 40 miles away from the nearest VA medical facility. Health Net and TriWest were selected to handle non-VA care for the Choice Program under the Patient Centered Community Care (PC3) contract, which already supported purchased specialty care but was expanded to include the Choice Program.
For the PC3 contract, Cognitive successfully implemented a cloud-based and hosted environment in 90 days, and maintained the environment with an uptime of 100% for the first year at a security level of FISMA-Moderate, using the Amazon GovCloud. Cognitive supports Health Net under this contract by maintaining a Web-based provider search tool, the Health Net Integrated Management System, which it also built. We configured, customized, integrated, and tested the primary information systems, which manage all referral, authorization, consult, claims processing and medical documentation for the program.
In year two, Cognitive successfully scaled the systems environment (cloud infrastructure, networking, and software) to support the Choice Program. And, in only 30 days, we also successfully scaled to support an additional 1,500 call center representatives who handle questions and make appointments for eligible Veterans.
As of 2016, there are more than 3,000 concurrent users in the environment daily.
VA Office of Information & Analytics – Standards Terminology Services (STS)
Provided subject matter expertise to support ongoing maintenance, administration and the transition of STS systems and associated code sets related to multiple VA health care domains.
VA Industry Innovation (VAi2) Office – Agile iHealth
Contributed to the iHealth data architecture and its implementation, managing an internal development team responsible for clinical data extraction from VistA using OVID, an RPC resource-messaging interface, including clinical schedules as standard iCAL objects. Supported iPhone/iPad development for a patient’s clinical summary viewer and lab/medication graphing. Cognitive also provided support for an ongoing pilot at VA Medical Center in Washington, D.C., to demonstrate iHealth.
National Science Foundation – Small Business Innovative Research (SBIR) Grant
This R&D project was to develop a prototype framework and validate the concept for an Adaptive Hybrid Intelligent System with an autonomous medical device. Using Cognitive’s own real-time rules engine, a closed-loop ventilator system was developed and paired with a patient simulator to address real-world clinical challenges. Cognitive successfully demonstrated that an Adaptive Management Framework has the real-time ability to both alter existing models and switch models when necessary to mitigate the issues of concept drift and concept generation, which often arise in real-world situations. This system supports new clinical decision support technologies needed to process and reason over complex patient data to assist clinicians in making appropriate decisions.
FEDERAL HEALTH – STANDARDS EXPERIENCE
HHS Office of the National Coordinator – Health eDecisions Standards Support
Cognitive assisted the Office of the National Coordinator (ONC) in preparing several draft standards for balloting Health eDecisions through HL7 standards committees. We contributed to the harmonization of the vMR and NQF/QDM quality metric data models, the development of the HeD expression syntax, and the national demonstrations of HeD use cases #1 and #2. Our experience in delivering real-time, actionable CDS using DoD and VA information systems provided valuable and pragmatic insights into runtime requirements.
Perinatal Quality Collaborative of North Carolina (PQCNC)
Because it handles the most vulnerable patients in the hospital, the Neonatal Intensive Care Unit (NICU) faces special challenges. The Perinatal Quality Collaborative of North Carolina is a community of organizations, agencies, and individuals working to improve birth care in the US through common-sense approaches. Originally started in North Carolina, the program now consists of over 200 NICUs across many states and healthcare delivery systems in the US.
Among their many quality improvement projects are the Associated Blood Stream Infections (CABSI) and Human Breast Milk in Nursery initiatives. CABSI is more prevalent in the NICU because premature babies have immature immune systems. Meanwhile encouraging exclusive breast milk in the NICU helps establish a practice that traditionally suffers when mothers and babies are separated for intensive care.
Cognitive supported quality improvement for these initiatives by developing mobile apps based on the Cognitive Decision Support Framework (CDSF) to capture real-time data and deploy clinical decision support rules. CDSF enables quality improvement data to be collected using mobile devices—in this case iPads at each pod—and analyzed in real-time upon data submission.
CDSF determines who should be notified, how they should be notified and when escalation to an alternative recipient is necessary. This reduces manual and paper-based data entry, increases data accuracy and allows the clinical care staff to intervene at the point of care based on analysis of the data in real-time.
The project had a positive reception from the nurses and reported a reduction in time to complete paperwork. The platform served as a focal point for content delivery (drug reference, patient handouts, etc.).
Total Child Health – Child Health and Development Interactive System (CHADIS) Centricity Interface Implementation
Established an interface between Child Health and Development Interactive System (CHADIS) and GE’s Electronic Medical Record (EMR) Centricity product. Using Mirth Connect, an open source healthcare integration engine, this enabled the migration of online data to the Centricity EMR product.