Prescription for Improvement

As Hurricane Katrina swept across the Gulf Coast region and obliterated vital services for millions of people, 400,000 military veterans living in the region didn't have to worry about losing their medical records or access to care.

by / October 10, 2006
Thanks to the U.S. Department of Veterans Affairs (VA) and its electronic medical records (EMRs) system, all veterans' medical records remained intact.

In disaster situations, current and available medical information is crucial to the safety and health of affected populations. By linking data across all its medical facilities and departments, the VA guarantees both access and high-quality care to veterans when they need it -- no matter their location.

The VA is also experimenting with other ways technology can help improve the delivery of health care, such as alleviating the amount of paperwork by switching to EMRs and completing a system overhaul, each of which will improve the agency's efficiency and effectiveness in terms of providing care.

The VA has embarked on a sweeping effort to use IT throughout its health care system. The federal agency's response during Katrina is but one striking example of what happens when IT is integrated with a mission-critical business need of a government agency.

System Overhaul
The VA, the second largest Cabinet-level department in the United States based on staff size, operates a nationwide system of health care for military veterans via the Veterans Health Administration (VHA), headquartered in Washington, D.C.

With more than 7.5 million participants enrolled, the VHA is the nation's largest integrated health-care provider.

Many health-care systems countrywide suffer from excess paperwork and too little information sharing. The same held true for the VA before the mid-1990s, when paper records were the norm and hospitals did not "talk to each other."

During that time, the VA set out to improve quality of care for veterans, and transform the business processes of an unwieldy and inefficient system.

The agency saw a 25 percent reduction in costs, and dramatic improvements in quality of care and patient satisfaction between 1995 and 2000, according to the VA.

Since World War II, the veterans' health-care system experienced marked growth in its patient population and incorporated additional services when former President Ronald Reagan established it as the Department of Veterans Affairs. In addition to providing medical care for veterans, the VHA subsequently added education, training, research, emergency management and care for homeless veterans to its mission.

By the mid-1990s, the VA's bloat reached critical mass. That was until two people stepped in to transform -- via IT -- the agency's services.

One of them, Dr. Robert Kolodner, the VHA's chief health informatics officer, has served with the VA for 28 years -- 15 years as a psychiatrist, and more recently in the IT field.

"Until the early 1990s, we had a hospital information system that jumped from department to department," Kolodner said. Operational and managerial problems were common, and the VA was forced to transform itself, from the inside out, to remain a viable government agency.

"Major systemic change clearly was needed," said Dr. Ken Kizer, the VA's former undersecretary of health from 1994 to 1999, and the administration's other change agent.

"The first few years of the decade were spent diagnosing what was wrong with the health-care system and consensus-building," Kizer said. "The VHA transformation sought to correct the fragmentation of service delivery by a set of initiatives that aimed to structurally, procedurally coordinate health-care services."

Most IT reforms occurred during Kizer's tenure, and he oversaw the EMR's establishment throughout the VA health-care system in the 1990s. This information sharing technology proved a key element in the VA's IT transformation, and revolutionized the way doctors and nurses cared for their patients.

Tool of Reform
The VA's current front-line clinical system, which Kolodner compared to a set of Legos, is a product of reforms that began in 1995. Kizer's team formed an interdisciplinary clinical group to address the burdens of paperwork, and resulting backlogs and inaccuracies. The VA then began to release experimental software specifically aimed at record keeping for front-line clinicians.

"The Health Summary, which we leveraged from the Indian Health Service, pulled patient information together in a report format," Kizer said. "We were able to make it even more useful by providing both an online or paper version, rather than just a paper version spit out by the computer."

The system was choice-based, where the clinician could select the information needed for each patient and its order. Different reports could be generated for outpatients, inpatients or specialty clinics. "It was very flexible, didn't take new programming and was part of the setup that could be done at the local facility," Kolodner said. "This was the first of the tools designed primarily for the clinician across the disciplines."

The VA later rolled out the EMR system while simultaneously striving to change the workplace culture. "Exceptions taught us that you need to have clinicians who buy into this at the local level and can be the champions," he continued. "We needed to have an ongoing group of people who were there to facilitate the clinicians initially to get over the first uses. And we needed to configure the system and understand the workflow of the individuals, and give software that fit what they needed."

To illustrate this approach, managers worked with each individual specialty during testing and implementation to determine their most common orders. Doctors and nurses didn't have to change the code, Kolodner said, but used what was already in the system, which became more useful to clinicians.

Creating a culture of ownership in the electronic system did not happen instantly, however. "We had our share of doctors who were reluctant to use the system," Kolodner said. "But a large proportion of nurses, social workers, pharmacists and other employees were using the system and happy with it, and word caught on."

Because the VA has hundreds of test sites around the country, the agency has had more opportunities to hone and improve the system. "There is a lot of local innovation and creativity, and we've been fortunate to take advantage of that on the national level," he said. "Some of our most successful applications were developed locally when a doctor or administrator teamed up with an IT person. It's been an evolution at each facility as it catches on."

The EMR rollout was gradual but methodical, Kolodner remembered. "We found that when 40 percent to 50 percent of clinicians were using it, leadership could step in and set a time frame when everyone would need to use it. Once leadership makes that commitment, the new technology can roll out," he continued, "We did round-the-clock support the first few weeks of the rollout for doctors. At that time, we learned that if you have the right combination of leadership, support and configuration, you can be successful. And once we had the tools in place we could do more."

Quality of Care
The VA has an integrated outpatient and inpatient information system called the Veterans Health Information Systems and Technology Architecture (VistA), in which patient records are centralized and accessible regardless of a person's residence or location of his/her hospital, and are viewable in all 1,400 VA facilities.

Work on VistA began in 2001 and is expected to be complete by 2012. At the end of fiscal 2005, the VA had spent $514 million on VistA, according to the General Accountability Office.

The system has had an impact on health care's biggest issue: error rates. Automatic alerts built into the system remind doctors and nurses when a patient needs a particular procedure, test or follow-up visit. "We are trained to administer certain types of care to certain patients, but in busy clinics, the computers always remind us and raise the standards of care we want to practice," Kolodner said.

In busy hospitals, EMRs can reduce human error and prompt health-care professionals to double-check their work and patients' specific conditions and needs.

Since work on VistA began, the system has saved 6,000 lives by improving vaccination rates, according to the VA, which also stated that the system has reduced hospital stays for certain illnesses, cutting costs by $40 million per year. In addition, VistA costs the VA approximately $87 per patient per year to maintain.

There are still opportunities to refine and experiment with EMRs in individual locations. For example, one VistA tool creates templates that are envisioned as boilerplate text for creating progress notes. A local hospital took them and created elaborate interactions with clinicians, capturing other information and using logic to make sure clinicians were properly administering the right medication to the right patients.

The VHA is currently revamping its enrollment information system to automate health-care eligibility, enrollment and case management, and more effectively maintain VHA eligibility policies and procedures for veterans and their families, said VHA spokesman M. Jay Eigenbrode. For instance, the agency's Health Eligibility Center uses ILOG JRules -- a business rule management system -- to streamline the enrollment process with a "central bank" of rules and a platform for cross-agency collaboration, Eigenbrode said.

JRules allows VA health-care administrative staff and clinical providers to access the latest eligibility and benefit level information on all patients, in real time, as it's being updated in the system. "[With the system], policymakers and business analysts can access and modify the rules more quickly, react to change easier, and ultimately improve the speed and quality of the decision-making eligibility processes," he said.

Northrop Grumman built the first Bidirectional Health Information Exchange (BHIE) for EMR for the VA -- and the Department of Defense (DoD). BHIE provides immediate and updated information on outpatient prescriptions, drug and food allergies, laboratory results, radiology text results, and demographic data on shared patients from the VA's Computerized Patient Record System.

The EMR system, although electronic and Internet-based, also works efficiently for senior veterans, who can authorize the creation of their personal health record and perhaps give their children permission to look at the records. Seniors then discuss their medical needs over the phone and avoid going on the computer.

In Other News ...
The VA also leads in bar-code scanning technology, which is used on patients at the bedside. Ken Kleinberg, senior director of marketing and health-care solutions for Symbol Technologies, works with the VA on enterprise mobility, wireless technologies and bar-code scanning.

The VA's deployment of mobile technology, he said, is catching on in the health-care sector. In the past, nurses and doctors entered data into a desktop or laptop computer at a separate nursing station; now they scan a wristband to give medication or track the patient. The VA has also adopted PDA mobile computers with added capabilities, such as collecting specimens and any other bedside data.

"The new excitement at [the] VA is the use of mobile computers," said Kleinberg. "Many organizations started out with desktop applications and pushed the cart around with full-sized keyboards and screens, but those were very unwieldy, and were left in the hallways. You had to worry about cleaning them, and they are expensive."

Nurses now carry mobile devices that enable them to administer medication throughout their shifts, and newer ones have VoIP capability. Over time, Kleinberg expects the laser bar-code scanner to keep pace and move to newer units as they are developed.

Health-Care Transformation
EMRs have been shown to decrease the error rate for medication administration, remove needless laboratory tests, cut costs and improve overall delivery of medical care. "Out in the community, presenting at conferences and helping people understand it, the VA has done more to promote these technologies than any other organization I know of," Kleinberg said.

Also, as CEO of Medsphere, an IT provider for health-care organizations, Kizer has taken specifics about the VA's system to the commercial sector and is working to promote its use.

Other federal and state agencies are looking at how an EMR system like VistA can be applied in their jurisdictions. In 2005, the U.S. Department of Health and Human Services established the Certification Commission for Healthcare Information to certify health-care IT products and help speed adoption of EMRs. "[The] VA is effectively the world's leading user of information technology in hospitals," Kleinberg said. "[The] DoD is looking to VistA software as a benchmark for how to do it right and cost-effectively. The VA is viewed as the leader by governments as well as the private sector."

And the change in recordkeeping for VA medical professionals has been transformative. "Just having doctors able to e-mail each other, share notes and find computer records of appointments is key," said disabled veteran and government contractor Bruce Fenton. "Investment in IT systems has already helped the VA a great deal, and will continue to help them deal with the stresses on the system. The VA has a unique mission among federal agencies because its primary work is to care for all these veterans -- a mission of large scope and scale."

Other reasons that have made it easier for the VA to adopt health IT, according to Kleinberg, are that a large population of patients give it economies of scale; and the physicians are employed by the VA, not by a typical hospital, giving the agency greater control over the system's users. This reduces political and cultural barriers to accepting new technologies and the changes that come with it.

Kolodner chalks up a lot of the VA's success to numerous factors, but one in particular stands out, he said. "Leadership has played an active role at all levels, with ongoing testing in the laboratory and test sites, feedback and making sure software really is useful. What we are achieving now is much better than 10 years ago and on many more levels because it's tailored and provided only when patients need it.

"The VA is a laboratory for the nation," Kolodner continued. "True, we have some alignment of incentives and no barriers of state laws, but we can demonstrate there isn't a technical barrier to better care -- the level and quality we all deserve. So with the VA being that laboratory, we do what we can so the rest of the nation can use it too."