VA gets fit with tech

The general perception from the outside is that the massive Department of Veterans Affairs health care system is outdated. The VA's bureaucratic system is largely seen as a last resort for veterans who are too poor to afford care in better-equipped and better-staffed private hospitals, which are perceived as providing better care.

The size of the system is undisputed: The VA operates 163 hospitals and 850 clinics nationwide that treat about 4 million veterans a year.

But perceptions may not match reality, particularly in terms of the technologies the VA health care system uses, said Scott Wallace, a former lawyer and venture capitalist who is now chief executive officer of the National Alliance

for Health Information Technology.

Six years ago, Wallace's father, a veteran, had a series of adverse drug reactions at a private hospital under the care of more than 20 doctors. A doctor friend advised Wallace to take his father out of the private hospital and put him in a VA hospital.

Wallace said he found the quality of care his father received from the VA superior to that of the private hospital, in part because of the quality of the department's information systems.

At the private hospital, the teams of doctors who cared for his father had no common communications platform, Wallace said. By contrast, at the VA hospital, clinicians could easily tap his father's health record via the VA's Veterans Health Information Systems and Technology Architecture (VISTA).

At the VA, "everyone had the information at the time they needed it" to provide the best care for his father, Wallace said.

This experience at the VA turned out to be a transformative event for Wallace, who in 2003 gave up his venture capital business to become an advocate for the national development and deployment of the kind of electronic health care systems that have routinely been used at the VA for more than 20 years.

The kind of adverse drug reaction Wallace's father experienced in a private hospital could not happen in a VA hospital thanks to VISTA, said Kay Craddock, a nurse and the clinical applications coordinator at the VA Medical Center in Washington, D.C.

Craddock said the VA's Bar Code Medication Administration (BCMA) system, part of VISTA, has "safety checks built in, which will stop the administration of the wrong drug to the wrong patient." Each VA patient has a bar-coded identification bracelet, Craddock said, as does every medication dispensed in a VA hospital.

Robert Kolodner, the VA's acting chief health informatics officer, said VISTA has other built-in safety valves that help avoid adverse drug reactions.

At the VA, doctors generally do not write orders for medications, Kolodner said. Instead, they enter them directly into a Computerized Patient Record System (CPRS).

That enables the VA to order about 93 percent of all medications electronically. Annually, this amounts to roughly 200 million electronic prescriptions dispensed to the VA's patient base of more than 4 million people.

The VA now fills 75 percent of its outpatient prescriptions through the Consolidated Mail Out-patient Pharmacy System, which automates that process. Kolodner said each of the seven systems can dispense and mail 20,000 to 40,000 prescriptions in an eight-hour workday.

BCMA and CPRS are among the newest additions to VISTA, Kolodner said, which the VA deployed in 1985 as the Decentralized Hospital Computer Program. The VA has now started deploying its newest system, VISTA Imaging, which will digitize all imaging, such as X-rays and EKGs, and add them to electronic patient records. About 200 million images have been digitized already.

Kolodner views VISTA as a gold standard for electronic health care systems and believes its utility and value derive from its development philosophy. VISTA has succeeded, Kolodner said, because "it has been shaped by physicians. They have been involved [in development] every step of the way."

As a result, VA clinicians have embraced VISTA as a useful clinical tool instead of a burden. Ross Fletcher, chief of cardiology at the VA Medical Center in Washington, D.C., said because VISTA allows him, for example, to visually chart a patient's vital signs on a CPRS screen, it has enabled him to make better diagnoses more efficiently.

But despite VISTA's success, Kolodner said VA officials have started drastically revamping the department's electronic health care system under a project known as HealtheVet, which will rectify one of the major problems that dates back to VISTA's beginnings: the decentralized nature of the system.

As Fletcher explained, he can easily access patient medical records only if they have sought medical attention in the VA's Washington, D.C., region. But if a patient comes into the Washington hospital from California, Fletcher said the decentralized nature of VISTA keeps him from accessing those records.

Kolodner said HealtheVet will include a central patient record repository accessible by clinicians in any medical facility and linked to the Defense Department's Composite Health Care System so patient information can be readily exchanged between the two systems.

He said the massive project will take at least five years, with a changeover expected in 2009. The consolidated and centralized health information infrastructure will usher in a new era for the VA.