President George W. Bush has called for widespread implementation of electronic health records (EHRs) by 2014. A recent report claimed that the US government faces an "enormous challenge" in getting EHRs to patients. The Department of Veterans Affairs (VA) has already met and conquered the challenge.
The VA's work in health information technology dates back several decades to when the agency created the Decentralized Hospital Computer Program. The VA built on the foundation of the program to create the Veterans Health Information Systems and Technology Architecture (VistA). VistA is a suite of >100 applications supporting the day-to-day clinical, financial, and administrative functions of the agency's health care system.
In the mid-1990s, the VA developed the Computerized Patient Record System (CPRS) to provide a single, graphical interface for health care providers to review and update a patient's medical record from information captured in VistA. The system also places orders for medications, procedures, and laboratory tests. Currently, 94% of all pharmacy orders throughout the VA are entered electronically by the prescriber.
The Bar Code Medication Administration (BCMA) system and VistA Imaging extend the capabilities of VistA and CPRS. BCMA is a bedside application that validates the administration of medication to ensure that each patient receives the correct medication in the correct dose at the correct time. VistA Imaging stores medical images directly into the patient record as they become available. This real-time imaging provides clinicians with additional information that is essential for diagnosis and treatment.
The VA reported that in December 2005 the VistA systems contained 779 million 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 are added. VistA and CPRS are implemented at the VA's 1400 sites of care.
The agency has served as a role model for many institutions wanting to implement EHRs. "It took lots of people across the country contributing to it," said Robert M. Kolodner, MD, chief health informatics officer for the Veterans Health Administration. "We did it over a period of time when it wasn't widely used. We provided a foundation with a broad basis for widespread implementation."
EHRs are "a national issue, and one of the barriers has been the lack of incentives between the payor and provider," commented Dr. Kolodner. In our case, "the VA was both the payor and the provider. The VA has been successful because we were able to engage the end user to develop the system."
He agreed that many physicians are wary of EHRs because of the cost involved and lack of technical expertise. "[Physicians are] the most resistant. If they can be part of the process, they can help drive it." Dr. Kolodner is confident that the United States can meet the Bush administration's goal of 2014. He said that standardization of data and a way to connect everyone are crucial components.
"I think we certainly can do it," Dr. Kolodner stated. "I hope we put the necessary steps together to do it. I believe it's achievable, but it's not going to be easy. Some of the steps are going to take the proper incentives and aligning them."
EHRs have become a crucial component in treating VA patients with metabolic conditions including diabetes, hypertension, and dyslipidemia. Leonard Pogach, MD, director of the Center for Healthcare Knowledge Management at the VA New Jersey Healthcare System as well as director of diabetes, knows firsthand the benefits of EHRs in treating patients with diabetes. He noted that diabetes is an epidemic in the United States; 24% (1 in 4) of veterans have diabetes; and diabetes is a very number-oriented disease (eg, cholesterol and hypertension readings and performance measures).
Dr. Pogach, who has not seen paper records since 1999, said that EHRs are "often very helpful when the patient is in front of you. Sometimes a picture is worth a thousand words."
Plus, having everything centrally located provides a detailed overview of patient care. For example, the record will show if a patient has not had an eye examination or if cholesterol levels are above a certain value. The records also can run reports to track or monitor drug interactions.
"Time is much better spent when everything is in front of you," Dr. Pogach added. "I personally think, having everything in one place makes for better health.We can spend more time interacting on important things." He pointed out, however, that "EHR is an enabler, but we still need people to do the job."
The health care industry learned another lesson from the VA's EHRs after Hurricane Katrina battered the Gulf Coast last year. The agency's VistA and CPRS proved indispensable. "People treated by the VA didn't lose their medical records," said Dr. Kolodner.
VA Secretary Jim Nicholson noted that, during the hurricane, physicians and nurses were able to treatwithout interruptionpatients who were transferred from VA facilities in New Orleans, La, to VA hospitals in Houston, Tex, because of the system's EHRs. "We were able in every case, after we got them resettled into another hospital, to dial up their medical record," Nicholson said.
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