|
|||||||||||||
|
Home
|
October 30, 2006
It wasn’t too long ago that veterans hospitals were held in low regard. How times have changed. What does today’s Veterans Health Administration (VHA) have in common with the VHA of the early to mid-1990s? If you were to say little or nothing, you’d be almost right. If you were to say little or nothing but go on to single out the VHA’s forward-thinking development and use of HIT, you’d put your finger on one of the most critical aspects of its remarkable rebirth. Indeed, a large part of the VHA’s touted transformation can be credited to its implementation of the Veterans Health Information Systems and Technology Architecture (VistA), an enterprisewide electronic health information system. At the nation’s largest integrated delivery system, “enterprisewide” encompasses more than 1,300 sites of care across the country, including 171 medical centers and hospitals, 876 outpatient clinics, a telehealth program, and various other long-term, community mental health, and home care programs—a very different scope of operations from any other integrated delivery system in the United States. VistA powers the VHA’s program of continuous performance improvement, the center of which is a system of performance measurement coupled with accountability. Together, IT, management, ongoing performance measurement, and improvement operate in a redesigned VHA organizational structure that is patient-centered and whose culture is steeped in collaboration and accountability. All these components work together, enabling the VHA to increasingly outperform even some of the best private healthcare organizations on quality, safety, efficiency, and cost-effectiveness—an accomplishment that is more impressive for occurring while the industry as a whole has struggled to improve quality and efficiency, reduce errors, and contain costs. What’s more, VHA physicians have not only fully embraced VistA, they’re committed to participating in its improvement and continued evolution. Then again, VHA physicians have been involved in the vision, development, and use of IT in the delivery of care from day one more than 25 years ago, making it more a pioneer in the field of health informatics than an early adopter. Its engagement and partnership with physicians and other clinicians from concept through implementation and improvement of its electronic information infrastructure also belongs among the most critical aspects of the VHA’s rebirth and continued success with VistA. “The IT issues are small compared to the issues involving people—particularly the clinical staff—configuration, training, and support,” explains psychiatrist Robert M. Kolodner, MD, the VHA’s chief health informatics officer (CHIO) until he was recently appointed Interim National Coordinator for Health Information Technology, replacing David J. Brailer, MD, PhD. “System users must be part of the effort from the get-go.” An Evolutionary System Produces Revolutionary Results
As the DHCP evolved through the late ’80s and early ’90s, the VHA added more clinical applications, notably what is now known as VistA Imaging in 1992. While incorporating increasing amounts of clinical information, the DHCP was essentially a roll-and-scroll data retrieval system. That changed drastically with the implementation of the VHA’s Windows-based Computerized Patient Records System (CPRS), which sported a well-received graphical user interface. Rolled out over three years, CPRS, for the first time, allowed clinicians to enter documentation electronically into patient records, significantly changing their relationship to the technology. System usage took off from there. Since then, 26 versions of VistA have been released. “We’re always improving the system for clinicians,” says Kolodner. And those improvements are typically clinician-driven and accomplished with their strong participation. According to Kolodner, the VHA’s early vision was to automate the process of care and coordinate the clinical record across disciplines, starting with making pharmacy, lab, and radiology results more accessible to clinicians. “No one really knew at that time how the care processes themselves could change so profoundly,” he recalls. And profoundly changed they have. As new applications and functionality have been added to VistA, it has become a more highly integrated and sophisticated tool that facilitates the VHA’s adoption of a “one-patient, one-record” philosophy and its move to make the practice of evidence-based medicine routine, including the use of IT-powered decision support and other expert systems in the day-to-day delivery of care. The operative word for Kolodner and others at the VHA, however, remains tool. “IT is not a silver bullet—it must be used in combination with other solutions, namely performance measures and accountability,” Kolodner notes. This multipronged approach to putting the patient first and delivering higher quality, safer care in a more efficient, cost-effective manner lay at the heart of the VHA’s plan to reinvent itself in the mid-90s. A New VHA Thus, Kizer’s plan called for a decentralized organizational structure. Specifically, the plan outlined the creation of geographically defined Veterans Integrated Service Networks (VISNs) to which resources would be allocated rather than to individual facilities, as was previously done. Kizer believed this financing model would create incentives for coordination of care and resources among previously competing facilities.2 At the same time, he knew a decentralized organization would need a mechanism of some kind to ensure a consistent level of quality across the system. His solution looked to performance and its transparency. The organizational restructuring was to be bolstered by performance accountability. This was perhaps the most radical pillar in Kizer’s plan. The level of accountability envisioned was to be ensured vis-à-vis a negotiated performance contract with each VISN director. Collaboratively designed contracts would include measurable objectives focused on outcomes in six areas known as value domains: technical quality of care, access to services, patient functional status, patient satisfaction, community health, and cost-effectiveness. To support this level of accountability, the VHA implemented a program of performance management, which includes the identification of performance measures in each value domain. Clinical performance measures emphasize the provision of evidence-based healthcare services in preventive health, disease treatment, and palliative care as expressed in evidence-based clinical guidelines or other recommendations. In the remaining domains, experts use comparable data and information to identify and support areas for improvement.2 Kizer harbored no illusions about the degree of culture change his restructuring plan would necessitate, anticipating that it would be neither easy nor painless to accomplish. At the same time, he knew the culture had to change if the VHA was to remain viable and that collaboration between clinical and administrative staff and accountability through performance measurement and management would be central to creating the kinds of new attitudes and behaviors that could make the vision a reality.1 The lynchpin in the plan was an electronic information infrastructure that could provide the tools necessary to support the delivery of efficient, patient-centered care and capture the data needed for effective performance management. VistA rose to the challenge as the right set of tools for the right job, and with it, the new VHA. VistA: Assisting Practice, Performance
Improvement With a few exceptions, CPRS enables the VHA to maintain a paperless health record for each of its 5.3 million patients. Its highly interactive nature enables interdisciplinary teams to create, record, archive, and access electronic information covering all aspects of patient care and treatment. CPRS comprises an integrated and comprehensive suite of clinical applications that work together to provide a longitudinal record of a patient’s health history. Its functionality automates many processes of care, such as order entry and management and results reporting on lab and other ancillary tests. Images of all kinds, including x-rays, pathology slides, cardiology motion views, and pictures acquired during endoscopies, eye exams, and surgeries are brought into a patient’s health record via VistA Imaging. Scanned documents, such as handwritten records, diagrams, or medical records or reports from outside the VHA system, are brought online through VistA Imaging as well, further supporting record completeness and the “one patient, one record” ideal. A combination of free-text and template-driven documentation options make documentation and record completion a more timely and less painful process. And VistA reporting capabilities enable as close to real-time assessment of performance around documentation as possible. “We can assess [record completion] delinquencies almost instantly—as well as where they’re occurring—and take action,” says VHA Chief of Staff Ross Fletcher, MD. “We brought down our delinquency rate from 50% to 10% in three months. A clinician only has to add about one quarter of the needed verbiage; three quarters of the information needed for the note is right there in the chart itself. This has been a huge incentive for clinicians to document at the point of care.” With a more complete record, clinicians provide care with greater efficiency and, as Kolodner puts it, compassion because situations such as delays in treatment due to missing information are avoided. When a patient record is selected, a comprehensive cover sheet displays essential and timely patient information, such as active problems, allergies, current medications (including prescription, over-the-counter, food supplements, and herbals), recent lab results, vital signs, hospitalizations, and outpatient clinic history, further facilitating efficient and compassionate care. This has certainly been the case for Robert Eaton, a former Marine who saw three tours of duty in Vietnam where he received several non–combat-related head injuries which left him with nerve damage that affects his neck and shoulders. In addition to those injuries, there are a few others that are also considered service-related, such as exposure to Agent Orange. “I was impressed at first. I was really impressed,” Eaton, who returned to the VHA in 1999, says of his care. He is now on 100% service-connected disability and included in the Agent Orange registry. “Back in the ’70s, I did have some contact with the VA and I got the feeling that they couldn’t be bothered with us being Vietnam veterans. But I know many changes were imposed by the Clinton administration that really tightened up that organization and made it much more efficient. I was quite surprised when I went back to the VA for health services; they basically accepted me with open arms.” Since then, Eaton has been a part of the VHA’s transformation, witnessing its evolution from its hybrid record days to its fully electronic current state, not to mention its growing use of technology for administrative functions such as scheduling, appointment reminders, and registration. For him, technology has changed his experience of care and treatment, whether related to quicker turnaround times on the lab work he needs to monitor his liver function or the speedier availability of consultation reports that affect his disability status and thus his sense of financial well-being. Even simple things, such as being called when an earlier appointment becomes available—“virtually unheard of outside the VA,” says Eaton—or waiting less than 15 or 20 minutes for a scheduled appointment has left him with a much different experience of VHA health services. “It gives you a good feeling, really, that you do matter to that system even though they’re only going by the last four digits,” he says. “You get that feeling that you’re being tended to, that you’re involved in a health service organization—a health service provider—instead of a health business provider.” Eaton’s experience is not an outlier at the VHA, where working with more complete patient medical information has become a way of life for its clinicians. “Clinicians aren’t working with incomplete information any more,” stresses Kolodner. While accessing that information certainly gives caregivers a leg up, the VHA has found ways to exploit the technology to make that information work even more effectively to assist clinicians in the provision of care. For example, “patient-specific clinical reminders are built into a patient’s information,” says Kolodner. “In this way, VistA becomes an assistant that reminds a clinician of what to do.” These patient-specific clinical reminders are grounded in evidence-based clinical guidelines and help caregivers provide higher-quality preventive care and chronic care management. They also help ensure that timely clinical interventions are initiated. The clinical reminder system is part of additional CPRS functionality that works in conjunction with patient information to support clinical decision making and promote patient safety. Other similar functionality includes the following: • a notification system immediately alerts clinicians about clinically significant events, such as critical lab values; • a patient posting system prominently displays that information is available in the patient’s record regarding crisis notes, warnings, adverse reaction, or advance directives; and • a real-time order checking system alerts clinicians as they enter a new order that a possible problem could exist if the order is processed. Other functionality in CPRS directly supports performance improvement. For example, standardized data elements can be aggregated to assess performance on clinical measures at all levels of the VHA organization, from individual caregiver teams to clinics, facilities, VISNs, and the overall system. These same data elements serve as the basis for implementing clinical reminders used to support immediate feedback and improvement for care providers. Fletcher refers to this functionality as predictive performance. “We can look at aggregate data and find all patients with elevated blood pressure then implement reminders in their patient records to assist physicians in the treatment they provide to these patients specifically around blood pressure,” he explains. “We can then look at the percentage of those returned to normal after the reminders were established. We can see which clinics are doing well, which physicians are doing well at any given point in time.” This functionality is especially meaningful to Fletcher as chief of staff. “VistA helps me see how we’re doing and how we can make specific, targeted improvements,” he says. Ultimately, the VHA plans to increasingly use these data as the basis for online health assessment and education for patients and caregivers, who they hope will use the information for more effective management of their health needs. Closing the Gap The IOM’s recommendations in that report emphasized, among other things, redesigning the processes and structure of care delivery, making care patient-centered, integrating evidence-based practices in care delivery, using proactive risk-reduction strategies to improve the safety of care, implementing IT such as EHRs and clinical decision support applications, and measuring performance and outcomes to aid improvement and accountability. By the time “Crossing the Quality Chasm” was released, the VHA’s transformation was well underway. The success of its efforts have not only made it a leader internationally in healthcare improvement and innovation, but they have also gone a long way toward providing evidence in support of the IOM recommendations for closing the quality gap in the U.S. healthcare system. — Aggie Stewart is a freelance writer and editor, specializing in HIM and HIT. She also serves as consulting editor of Health Information Management Manual, 2nd edition. References 2. Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care. Am J Manage Care. 2004;10(part 2):828-836. 3. Institute of Medicine. “Crossing the Quality Chasm: A New Health System for the 21st Century.” Washington, D.C.: The National Academies Press, 2001.
|
3801 Schuylkill Rd • Spring City, PA 19475 Publishers of For the Record All rights reserved. |