Resource and Patient Management System (RPMS)

Shepherdstown 28 June 2007If one were looking to acquire and implement a comprehensive "open source" electronic health record (EHR) system, serious consideration should be paid to the Resource and Patient Management System (RPMS) used by the Indian Health Service (IHS). RPMS is an adaptation of the VistA health information system originally developed by the U.S. Department of Veterans Affairs (VA), modified to meet the needs of IHS. RPMS is an integrated health information system ideally suited for implementation in healthcare facilities of varying sizes and complexity. Patients treated at IHS facilities tend to include a diverse mix of all age patients, males and females. While RPMS is deployed at many IHS inpatient facilities, it is more heavily utilized in ambulatory care settings.

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Background

The Indian Health Service (HIS) within the U.S. Department of Health & Human Services (HHS) is charged with administering the principal healthcare program for American Indians and Alaskan Natives and provides comprehensive health services through a system of federal IHS, tribal, and urban-operated facilities and programs. These facilities and programs provide health services to 1.4 million American Indians and Alaskan Natives through 144 service units composed of more than 500 direct healthcare delivery facilities, including 49 hospitals, 190 health centers, 7 school health centers, and 287 health stations, satellite clinics, and Alaskan village clinics.

The IHS and the U.S. Department of Veterans Affairs (VA) have a longstanding tradition of health information and technology sharing spanning the past several decades. In 1984, the IHS began implementation of the VA VistA software, then referred to as DHCP, at sixty of their facilities. They called their version of the VistA system the IHS Resource and Patient Management System (RPMS). Many components of the RPMS health information system are still based on the VistA system. A number of RPMS software modules have also been incorporated into VistA over the years.

U.S. Department of Veterans Affairs (VA) - VistA System -

The Veterans Health Administration (VHA) operates the nation's largest medical system. It provides care to approximately 5 million veterans out of an eligible population of 25 million. VHA currently employs approximately 180,000 healthcare professionals at more than 150 hospitals, 800 outpatient clinics, over 140 nursing homes, 43 domicilaries, 206 readjustment counseling centers, and various other facilities.

The VA began deploying its VistA system in all of its medical facilities starting around 1983. The system was originally known as the Decentralized Hospital Computer Program (DHC) system. The initial "core" system that was deployed consisted of a limited number of clinical and administrative software modules, which included patient registration, inpatient ADT, outpatient clinic scheduling, pharmacy, laboratory, and radiology. Over the years many additional software modules were added, and the DHCP was eventually renamed VistA (Veterans Health Information Systems and Technology Architecture). With the subsequent release of the Computerized Patient Record System (CPRS) for clinicians in 1997 and the deployment of VistA Imaging in the late 1990s and early 2000s, the VistA system emerged as one of the most advanced health information systems in the world. (See http://www1.va.gov/vista_monograph/.)

Resource and Patient Management System (RPMS)

RPMS is a decentralized automated information system of over 60 integrated software applications. Many RPMS applications can function in a standalone environment if necessary or appropriate. The system is designed to operate on micro- and mini-computers located in IHS or tribal healthcare facilities. RPMS software modules fall into three major categories: 1) practice management applications that perform patient registration, scheduling, billing, referrals, and linkage functions; 2) clinical applications that support various healthcare programs within IHS; and 3) infrastructure applications.

Practice Management Applications

The RPMS practice management applications support the business of healthcare provision. Applications in this category are used to collect, store, and report patient demographic information; manage the scheduling, admission, discharge, and transfer of patients in inpatient facilities; create claims and handle both manual and electronic billing and accounts receivables; and electronically manage resource requests and supplies.

Clinical Applications

The RPMS clinical applications directly support the provision of healthcare. Applications in this category generally collect all patient-related information gathered during patient contacts into one comprehensive, centralized data file to support healthcare planning, delivery, management, and research. The Patient Care Component provides for entry of visit data that forms the core dataset used by most of the RPMS applications. Other applications in this category support comprehensive patient care and include Laboratory, Radiology, Inpatient and Outpatient Pharmacy, Allergy Tracking, Immunology, Dental, Women's Health, and integrated case management.

Infrastructure

This category of applications comprises and supports the RPMS environment with management, development, and communication tools. The MailMan application is an electronic messaging system. VA Kernel software provides a portability layer between the underlying operating system and application code and provides a Kernel Toolkit that supplements the Kernel software package with development and quality-assessment tools, capacity management tools, and system management utilities. The VA FileMan is the RPMS database management system (DBMS).

The Division of Information Resources (DIR) distributes electronic notifications of new RPMS applications to headquarters, IHS area offices, and facility site managers. Different facilities use different configurations of RPMS applications, depending upon the types of services they provide.

RPMS

CLINICAL APPLICATIONS
  1. Asthma Register System
  2. Case Management System
  3. Community Health Representative Information System
  4. Contract Health System
  5. Dental Data System
  6. Diabetes Management System
  7. Diagnosis Related Grouper (DRG)
  8. Dietetics
  9. Immunization Module
  10. Laboratory
  11. Behavioral Health System (BHS)
  12. Nursing Patient Acuity Assessment
  13. Patient Care Component (PCC)
  14. PCC+ Customizable Encounter Form
  15. Patient Chart GUI
  16. Pharmacy
  17. Pharmacy Point of Sale (Class II)
  18. Radiology/Nuclear Medicine
  19. Referred Care Information System
  20. Taxonomy
  21. Women's Health

FINANCIAL AND ADMINISTRATIVE APPLICATIONS

  1. Accounts Receivable
  2. Administrative Resource Management System (ARMS)
  3. Contract Information Systems (CIS)
  4. Emergency Room System
  5. Equipment Data Entry
  6. GPRA+ Clinical Indicator Reporting System
  7. Medical Administration System (MAS)
  8. Patient Information Management System (PIMS)
  9. Patient Registration
  10. Quality Assessment and Improvement Management
  11. Quality Improvement Linkages
  12. Release of Information System (ROI)
  13. Staff Credentials
  14. Supply Accounting Management System (SAMS)
  15. Third Party Billing
  16. Uniform Data System (UDS) Reporting System

INFRASTRUCTURE APPLICATIONS

  1. Area Data Consolidation Export System
  2. Automated Information Systems (AIS) Security
  3. IHS V Files 200 Conversion System
  4. Generic Interface System
  5. VA MailMan
  6. VA Kernel
  7. VA Kernel Toolkit
  8. VA FileMan

See http://www.ihs.gov/Cio/RPMS/Downloads/AppDesc.pdf

Technical Environment

  • The RPMS suite runs on mid-range to personal computer hardware platforms. Typical configurations range from two RS 6000 computers for large facilities to one Intel-based Windows NT computer for small facilities.
  • RPMS applications operate individually and as an integrated suite. Using the HL7 protocol, RPMS applications can be interfaced with a variety of commercial off-the-shelf software products.
  • RPMS information can be exchanged over a local area network (LAN) within a single facility, a wide area network (WAN) with other facilities, and the Internet with other providers and medical researchers.

RPMS: An Example of an EHR Screen Developed for Use Within IHS

Functional Capabilities - VistA vs. RPMS

While generally based on the same infrastructure (e.g. Kernel, Fileman) with most of the same core software modules and files (e.g. pharmacy, laboratory, radiology), over time some differences between the two systems have emerged. For example, IHS has chosen to develop its own componentized version of the VA's Computerized Patient Record System (CPRS) GUI front end using the VueCentric proprietary software utility tool set. RPMS also includes enhancements that better fit its more diverse mix of patients that tend to be treated in ambulatory care settings. These include the Child Health, Women's Health, Obstetrics, iCare, Patient Accounts Management, Reference Lab Interface, and a clinically-focused query tool (Q-MAN). The VA in turn has enhanced several other VistA modules to better serve its clientele of aging veterans in a setting that is weighted a little more to an inpatient setting.

Other Plans and Activities

The Clinical Reporting System (CRS) is an RPMS software application designed for national reporting as well as local and Area monitoring of clinical performance measures. CRS produces on demand from local RPMS databases a printed or electronic report for any or all of over 300+ clinical performance measures, representing 55 clinical topics. CRS is intended to eliminate the need for manual chart audits for evaluating and reporting clinical measures that depend on RPMS data. Each year, an updated version of CRS software is released to reflect changes in and additions to clinical performance measure definitions.

In order to facilitate a process that allows IHS and tribal sites to continue to use the RPMS Immunization Package as well as benefit from state immunization registries, IHS has been working on an immunization data exchange project. The objective was to develop an automated, two-way exchange of immunization information (batch files or real time) between the RPMS and state immunization registries, using the HL7 standards set out by CDC in the "Implementation Guide for Immunization Data Transactions" using Version 2.1 of the HL7 Standard Protocol. Data exchange was piloted in Wisconsin and Arizona, with plans to include South Dakota, Utah, Minnesota and Washington. The system is now being deployed.

The IHS plans to continue to improve RPMS over time, adding enhancements to the electronic health record, a clinical imaging module, and other software modules that focus on population health. In addition, the IHS and the Veterans Health Administration plan to continue their longstanding practice of collaborating on various software development projects related to health information exchange, health informatics standards, personal health records, VistA-Office EHR (VOE), and other initiatives.

iCare is a new component of the Resource Patient Management System (RPMS). It provides a graphical user interface (GUI) for a fully integrated case management system that pulls together all the information available about a patient into one view. Key features of iCare include:

  • iCare displays patient "flags" related to care management, including abnormal labs, hospitalizations, ER visits and unanticipated ER returns.
  • iCare utilizes logic written for other clinical applications to "tag" individuals with pre-defined diagnoses and conditions; this "tagging" occurs on a daily routine, ensuring early notification of patient with new chronic care diagnoses.
  • iCare generates nationally-defined general prevention and disease/condition specific healthcare reminders that are integrated to display most stringent criteria applicable to the patient's chronic condition(s).
  • iCare provides users with the ability to create multiple, predefined and easy-to-define patient panels that are customizable.
  • iCare provides clinical users with a fully integrated tool to manage any patient within the context of his/her entire health, physical and environmental conditions, not just within the isolation of one disease state, e.g., diabetes.
  • iCare will incorporate additional information regarding both the patient's household and community in the future.

Finally, RPMS software is in the public domain, making it a cost-effective choice in software applications for others to consider using. IHS recently signed a memorandum of understanding to share the RPMS software with the National Aeronautics and Space Administration (NASA). Other healthcare organizations in the public and private sector are also implementing RPMS to meet their health IT needs, e.g. Community Health Network of West Virginia (CHNWV) - see http://www.chnwv.org/medsphere.html

Key Reference Web Sites

Authors

Peter J. Groen is on the faculty of the Computer & Information Science Department at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation - see www.shepherd.edu/surc. He is also one of the authors of a book entitled "Medical Informatics 2020", published in January 2007 by Jones & Bartlett. See http://www.jbpub.com/catalog/0763739251

Terry Cullen MD, MS, is a board certified family physician that has worked for IHS since 1984. She has been the CIO for IHS since 2006.


Peter Groen and Terry Cullen

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