VA Is a Pioneer in EHRs

President George W. Bush hascalled for widespread implementationof electronic health records(EHRs) by 2014. A recent reportclaimed that the US government facesan "enormous challenge" in getting EHRsto patients. The Department of VeteransAffairs (VA) has already met and conqueredthe challenge.

The VA's work in health informationtechnology dates back several decadesto when the agency created theDecentralized Hospital Computer Program.The VA built on the foundation ofthe program to create the VeteransHealth Information Systems and TechnologyArchitecture (VistA). VistA is asuite of >100 applications supporting theday-to-day clinical, financial, and administrativefunctions of the agency's healthcare system.

In the mid-1990s, the VA developedthe Computerized Patient RecordSystem (CPRS) to provide a single, graphicalinterface for health care providers toreview and update a patient's medicalrecord from information captured inVistA. The system also places orders formedications, procedures, and laboratorytests. Currently, 94% of all pharmacyorders throughout the VA are enteredelectronically by the prescriber.

The Bar Code Medication Administration(BCMA) system and VistAImaging extend the capabilities of VistAand CPRS. BCMA is a bedside applicationthat validates the administration ofmedication to ensure that each patientreceives the correct medication in thecorrect dose at the correct time. VistAImaging stores medical images directlyinto the patient record as they becomeavailable. This real-time imaging providesclinicians with additional informationthat is essential for diagnosisand treatment.

The VA reported that in December2005 the VistA systems contained 779million progress notes, discharge summaries,and reports; 1.54 billion orders;and 425 million images. Every day>577,000 new clinical documents,906,000 orders, and 608,000 images areadded. VistA and CPRS are implementedat the VA's 1400 sites of care.

The agency has served as a rolemodel for many institutions wanting toimplement EHRs. "It took lots of peopleacross the country contributing to it,"said Robert M. Kolodner, MD, chiefhealth informatics officer for theVeterans Health Administration. "Wedid it over a period of time when itwasn't widely used. We provided afoundation with a broad basis for widespreadimplementation."

EHRs are "a national issue, and one ofthe barriers has been the lack of incentivesbetween the payor and provider," commented Dr. Kolodner. In our case,"the VA was both the payor and theprovider. The VA has been successfulbecause we were able to engage the enduser to develop the system."

He agreed that many physicians arewary of EHRs because of the costinvolved and lack of technical expertise."[Physicians are] the most resistant. Ifthey can be part of the process, theycan help drive it." Dr. Kolodner is confidentthat the United States can meetthe Bush administration's goal of 2014.He said that standardization of data anda way to connect everyone are crucialcomponents.

"I think we certainly can do it," Dr.Kolodner stated. "I hope we put the necessarysteps together to do it. I believeit's achievable, but it's not going to beeasy. Some of the steps are going to takethe proper incentives and aligning them."

EHRs have become a crucial componentin treating VA patients with metabolicconditions including diabetes,hypertension, and dyslipidemia. LeonardPogach, MD, director of the Center forHealthcare Knowledge Management atthe VA New Jersey Healthcare Systemas well as director of diabetes, knowsfirsthand the benefits of EHRs in treatingpatients with diabetes. He notedthat diabetes is an epidemic in theUnited States; 24% (1 in 4) of veteranshave diabetes; and diabetes is a verynumber-oriented disease (eg, cholesteroland hypertension readings andperformance measures).

Dr. Pogach, who has not seen paperrecords since 1999, said that EHRs are"often very helpful when the patient is infront of you. Sometimes a picture isworth a thousand words."

Plus, having everything centrally locatedprovides a detailed overview ofpatient care. For example, the record willshow if a patient has not had an eyeexamination or if cholesterol levels areabove a certain value. The records alsocan run reports to track or monitor druginteractions.

"Time is much better spent wheneverything is in front of you," Dr.Pogach added. "I personally think, havingeverything in one place makes forbetter health.We can spend more timeinteracting on important things." Hepointed out, however, that "EHR is anenabler, but we still need people to dothe job."

The health care industry learnedanother lesson from the VA's EHRs afterHurricane Katrina battered the Gulf Coastlast year. The agency's VistA and CPRSproved indispensable. "People treated bythe VA didn't lose their medical records," said Dr. Kolodner.

VA Secretary Jim Nicholson noted that,during the hurricane, physicians andnurses were able to treat—without interruption—patients who were transferredfrom VA facilities in New Orleans, La, toVA hospitals in Houston, Tex, because ofthe system's EHRs. "We were able inevery case, after we got them resettledinto another hospital, to dial up theirmedical record," Nicholson said.