Best Care Anywhere

by Phillip Longman

  Some Hardhats started calling themselves members of the “underground railroad” and even had business cards printed up with a drawing of a steam engine. But soon, this railroad was underground no longer. Swayed by Custis’s report of what he’d seen and fed up with the recurring problems with the VA’s formal computer division, the new Reagan administration’s top appointee to the VA, Robert P. Nimmo, and his deputy, Chuck Hagel (the future U.S. senator from Nebraska), signed off on the Hardhats’ initiatives and pulled the plug on the high priests.

  Key allies in Congress, such as Rep. G.V. (Sonny) Montgomery, concurred. A conference report that would later take on historical irony noted that “any further delay in proceeding with the decentralized … system is not justified and will only result in VA’s medical computer system falling further behind the private health-care industry.”11 Hundreds of high priests got riffed—government parlance for “laid off.” And within a short while, recalls Hardhat Richard Davis, “many highly labor-intensive and error-prone systems of daily operations within the VA medical centers were dismantled.” The Hardhats had won.

  Fortunately, all the different programs that became VistA were written in an easy-to-use, common language that lent itself to integration and file sharing. This meant that they could all be fit together, in literally less than a week, into a central module. Eventually that module grew to include more programs so that, for example, all the different forms of care a patient received, in all different parts of a hospital, as well as in clinics, could be combined into a single electronic health record.12 The benefits in coordination, patient safety, and adherence to evidence-based medicine have been so extensive that by 2007, the VA realized an estimated $3.7 billion in cumulative savings net of the costs the Hardhats incurred in developing VistA.13

  Catching the Age Wave Early

  Maybe this still does not seem like such a big deal. Even today, the potential of electronic health records to improve the practice of medicine is only beginning to become apparent to the public, or even to many private-sector health-care providers. But individual doctors practicing within the VA were already in many ways living in the world of the future. As early as the 1970s, the population they served, which was dominated by veterans of World War II, was aging rapidly, much as the U.S. population as a whole is now beginning to experience a rapid increase in the number of elders.

  This meant that VA doctors in the 1970s, like doctors everywhere today, were seeing increasing numbers of patients beset with complicated, chronic conditions such as diabetes. These conditions, which were often accompanied by numerous comorbidities such as high blood pressure and cardiovascular disease, required constant monitoring and coordinated care involving dozens of people—specialists, nurses, radiologists, lab workers, physical therapists, counselors. The nature of these chronic diseases also demanded that patients become vitally involved in their own care, such as in measuring their own blood sugar levels, and that a system be in place for keeping track of such measurements.

  The comparative frailty of the population served by the VA also made patients exceptionally vulnerable to medical errors, such as different doctors prescribing dangerous combinations of drugs. The advancing age of the veterans population also put a premium on record keeping that could quickly pinpoint who, for example, was due for a flu shot or a prescription refill. Since patients approaching the end of life often consume high volumes of expensive treatment, VA doctors and administrators also had an exceptional need for data about which of these treatments worked better than others and, indeed, about which didn’t work at all.

  For all these reasons and more, the environment in which VA doctors were practicing medicine in the 1970s and ’80s made the value of electronic health records and other information technology easier to see than in many private health-care settings. Tellingly, Kenneth Dickie found his inspiration for developing electronic medical records while trying to contend with his caseload of VA nursing home patients in the 1970s.

  A final and all-important consideration was that the VA as an institution maintained a near lifetime relationship with its patients. This meant there was a pressing institutional need to coordinate record keeping among the many different VA hospitals and clinics a veteran might use over his or her lifetime. And, crucially, it meant that any improvement to the quality of care the VA could achieve through its investment in information systems would rebound to its own long-term advantage. Managing diabetic care properly, for example, meant fewer expenditures for costly amputations down the road and would even help save on nursing home costs, for which the VA was potentially liable.

  By contrast, in private-sector health-care settings, where patients typically move on to another plan every few years, investment in preventing long-term complications more often than not brings no return to the institution. Thus, from a very early date, both VA doctors and administrators were far more likely than their private-sector counterparts to see the value of investing in information technology that could improve the practice of medicine.

  As Timson recalls,

  By the mid-’80s everybody wanted everything. We finally kind of broke out of our illegitimate status as garage operations in different parts of the country and proved that we could put the pieces together. And then by the middle of the ’80s we were building complete hospital information systems, using, of course, hardware that was laughably limited compared to the PC that’s on your desk today.14

  Private-sector vendors repeatedly pressured Congress to make VA doctors and technicians stop writing software. But VA doctors argued persuasively that there was no product available on the market that could compete with their own, user-made system.15

  Since then, the growth in computer power and the emergence of the Internet, far from making VistA obsolete, has allowed it to grow still more capabilities. The original software is still in place in most facilities, but it is continually updated electronically with patches that fix bugs or add new features. Today these include electronic medical records containing X-rays, pathology slides, video views, scanned documents, cardiology exam results, wound photos, dental images, and endoscopies. The code that makes all this possible isn’t elegant by today’s standards, but it is stable and time-tested, and it works just the way someone trying to practice state-of-the-art medicine would want it to work.

  To be sure, political appointees at the VA, often under the influence of proprietary software vendors and threatened by VistA’s decentralized Hardhat culture, have not always constructively supported the software’s continuing modernization. Especially during the late years of the Bush Administration, the VA’s political appointees began outsourcing health IT projects to private vendors, and shutting off innovation in the field. But the VA has more recently taken the important decision to keep VistA in open-source code, which means that the original vision of VistA as a program “written by doctors and for doctors,” still lives on. “The beauty of VistA,” says former Hardhat Greg Kreis, “is certain parts of it were not engineered in the early days in the classic top-down kind of design; it was more of a bottom-up design. What it may have lost in its engineering, it gained in its relevance.”

  FOUR

  VistA in Action

  One can see the legacy of the Hardhats’ triumph by visiting the Washington DC Veterans Affairs Medical Center (DCVAMC). It’s an imposing structure located three miles north of the Capitol building. When it was built in 1972, it was in the heart of Washington’s ghetto, and as one nurse told me, she used to lock her car doors and drive as fast as she could down Irving Street when she went home at night.

  Today, the surrounding area is gentrifying rapidly, and the medical center, too, is not what it once was. Certain sights, to be sure, remind you of how alive the past still is here. Standing outside of the hospital’s main entrance, I was moved by the sight of two elderly gentlemen, both standing at near attention and sporting neatly pressed Veterans of Foreign Wars dress caps with MIA/POW insignias. One recounted that he was a surviv
or of the Bataan Death March.

  But, even with history everywhere, this hospital is also among the most advanced, modern health-care facilities in the world—a place that hosts an average of four visiting delegations a week from around the world. The spacious lobby resembles that of a normal suburban hospital, containing a food court, ATM, and gift shop. But once you are on the wards, you notice something very different: doctors and nurses wheeling bed tables down the corridors with wireless laptops, or just recently, iPads, attached. How does this change the practice of medicine? Opening up his laptop, Dr. Ross Fletcher, an avuncular, white-haired cardiologist who helped pioneer the hospital’s adoption of information technology, begins a demonstration.

  With a keystroke, Dr. Fletcher pulls up the medical records on one of his current patients—an eighty-seven-year-old veteran living in Montgomery County, Maryland. Normally, sharing such records with an outsider would, of course, be highly unethical and illegal, but the patient, Dr. Fletcher explains, has given him permission.

  Soon it becomes obvious why this patient feels that it is important to get the word out about the VA’s information technology. Up pops a chart showing a daily record of his fluctuating weight over a several-month period. The data for this chart, Dr. Fletcher explains, flow automatically from a special scale the patient uses in his home that sends a wireless signal to a modem.

  Why is the chart important? Because it played a key role, Fletcher explains, in helping him to make a difficult diagnosis. While recovering from Lyme disease and a hip fracture, the patient began periodically complaining of shortness of breath. Chest X-rays were ambiguous and confusing. They showed something amiss in one lung but not the other, suggesting possible lung cancer. But Dr. Fletcher says he avoided having to pursue that possibility when he noticed a pattern in the graph generated from the patient’s scale at home.

  It showed that the patient had gained weight around the time he experienced shortness of breath. This pattern, along with the record of the hip fracture, allowed Dr. Fletcher to form a hypothesis that turned out to be correct. A buildup of fluid in the lung was causing the weight gain. It occurred only in one lung because the patient was consistently sleeping on one side as a way of coping with the pain from his hip fracture. The fluid in the lung indicated the patient was in immediate need of treatment for congestive heart failure, and, fortunately, he received it in time.

  Laptop Medicine

  VistA is also an invaluable tool in managing chronic diseases such as cancer. “In the field of oncology,” explains Dr. Steven Krasnow, the hospital’s chief oncologist, “following blood counts of patients over time is very important. And the ability to essentially click one box and show a graph of the patient’s individual blood count has been invaluable in maintaining patient safety and providing guidance to the clinician.”1

  VistA also plays a key role in preventing medical errors. Kay J. Craddock, who spent most of her career with the VA as a nurse and who today coordinates the use of the information systems at the DCVAMC, explains how. In the old days, pharmacists did their best to decipher doctors’ handwritten prescription orders, while nurses, she says, did their best to keep track of which patients should receive which medicines by shuffling three-by-five cards.

  Today, by contrast, doctors enter their orders into their laptops, and the computer system immediately checks any order against the patient’s records. If the doctors working with a patient have prescribed an inappropriate combination of medicines or overlooked the patient’s previous allergic reaction to a drug, the computer sends up a red flag and prevents the doctor from continuing until the concern is acknowledged. Later, when hospital pharmacists fill those prescriptions, the computer system generates a bar code that goes on the bottle or intravenous bag. This bar code registers what the medicine is, whom it is for, when it should be administered, in what dose, and by whom.

  Meanwhile, all patients and nurses have ID bracelets with bar codes. Before administering any drug, nurses must first scan the patient’s ID bracelet, then their own, and then the bar code on the medicine. If the nurse has the wrong patient, the wrong medicine, the wrong dose, or the wrong time, the computer will provide a warning. The computer will also create a report if a nurse is late in administering a dose. “And saying you were just too busy is not an excuse,” says Craddock.

  Craddock cracks a smile when she recalls how nurses first reacted to the system. “One nurse tried to get the computer to accept her giving an IV, and when it wouldn’t let her, she said, ‘You see, I told you this thing is never going to work.’ Then she looked down at the bag.” She had confused it with another, and the computer had saved her from a career-ending mistake—not to mention possible lethal harm to the patient. Today, says Craddock, some nurses still insist on getting paper printouts of their orders, but almost all applaud the computer system and its protocols. “It keeps them from having to run back and forth to the nursing station to get the information they need, and by keeping them from making mistakes, it helps them to protect their license.” The VA has now virtually eliminated dispensing errors, while in the rest of the U.S. health-care system, dispensing errors kill some 7,000 hospital patients a year, according to the Institute of Medicine.

  Speak to the young interns and residents at DCVAMC and you soon realize that the computer system is also a great aid for efficiency. At the university hospitals where they had trained, the medical residents were constantly running around trying to retrieve records—first upstairs to get X-rays from the radiology department, for example, or downstairs to pick up lab results. By contrast, when making their rounds at DCVAMC, they just flip open their laptops when they enter a patient’s room. In an instant, they pull up all the patient’s latest data and a complete medical record going back as far as the mid-1980s, including records of any care performed in any other VA hospital or clinic.

  Along with the obvious benefits this brings in making diagnoses, it means that residents don’t face impossibly long hours dealing with paperwork. “It lets these twenty-somethings go home in time to do the things twenty-somethings like to do,” says Craddock. One neurologist practicing at both Georgetown University Hospital and DCVAMC reports he can see as many patients in a few hours at the veterans hospital as he can all day at Georgetown. I couldn’t help but wonder if Robin and I might have experienced fewer mix-ups and better access to her doctors at Georgetown’s hospital if they had had access to a program like VistA.

  Today, a new feature called My HealtheVet allows individuals enrolled in the VA to access their own complete medical records from a home computer or give permission for others to do so. “Think what this means,” says Dr. Robert M. Kolodner, a leading Hardhat who helped develop the program. “Say you’re living on the West Coast, and you call up your aging dad back East. You ask him to tell you what his doctor said during his last visit, and he mumbles something about taking a blue pill and a white one. Starting this summer, you’ll be able to monitor his medical record, and know exactly what pills he is supposed to be taking.” Through the My HealtheVet Web site, which is integrated with VistA, vets are also able to refill prescriptions and keep track of personal health information, such as blood pressure levels, blood sugar readings, and lab results. They will also soon have the ability to get appointment reminders online and communicate with their doctors by secure email.

  VistA also reminds doctors about patients who need to make appointments and what medications they need. For example, it keeps track of which vets are due for a flu shot, a breast-cancer screen, or other follow-up care—a task that is virtually impossible to accomplish using paper records. Today, the VA estimates that VistA has saved 6,000 lives by improving rates of pneumonia vaccination among veterans with emphysema, cutting pneumonia hospitalizations in half, and thereby reducing costs by $40 million per year. At the same time, because VistA was written by VA personnel themselves, the VA pays no royalties for its use.

  Another benefit of electronic records became apparent in 2004 when d
rug maker Merck announced a recall of its popular arthritis medication Vioxx. The VA had already become deeply suspicious of Vioxx three years before, based on patient outcomes data, and restricted its use. After the recall, it was able to identify which of its patients were still on the drug, literally within minutes, and to switch them to less dangerous substitutes within days.2

  That same year, in the midst of a nationwide shortage of flu vaccine, the system also allowed the VA to identify, almost instantly, which veterans were in greatest need of receiving a flu shot and to make sure they got one. One aging relative of mine—a man who has had cancer and been in and out of nursing homes—wryly reported that he beat out 5,000 other veterans in the New London, Connecticut, area in getting a flu shot. He was happy that his local veterans hospital told him he qualified but somewhat alarmed by what this implied about his health. During the 2004–2005 flu season, 75 percent of all VA patients age sixty-five and over received a flu shot, as opposed to only 63 percent of Americans in that age group who were not enrolled in the VA.3

  The VistA system also helps to put a lot more science into the practice of medicine. Its electronic medical records collectively form a powerful database that enables researchers to look back and see what drugs and procedures work better than others, without having to assemble and rifle through tons of paper records. For example, using VistA to examine 12,000 medical records, VA researchers were able to see how diabetics were treated by different doctors, hospitals, and clinics, and with what outcomes. This allowed for development of treatment protocols based on hard data, rather than, as is often the case, on factors such as where a doctor went to medical school or highly variable, local traditions of care.4