Uncategorized

TECH: The VA and Health IT A Model that Works By Maggie Mahar

VetsDid it ever occur to you that your dog might have better health records than you do? While veterinarians routinely keep computerized records of their four-footed patients’ medications and vaccinations, human health care still relies heavily on pen, paper, phone and those little yellow Post-it notes that all too often come fluttering out of a patient’s file.

While most U.S. industries make superb use of information technology to collect, manage and distribute information, when it comes to healthcare, we lag far behind.  In 2000, 90 percent of physicians in Sweden, 88 percent in the Netherlands, 62 percent in Denmark, 58 percent in the UK, 56 percent in Finland and 48 percent in Germany were using electronic medical records. Six years later, roughly 80 percent of U.S. physicians are still shuffling through manila folders.

Meanwhile only 15 to 20 percent of U.S. hospitals use electronic records–although nearly everyone agrees that computerized medicine is the key to sparing patients the risks and expense of missing records, redundant tests and medication errors.

In “Money-Driven Medicine: The Real Reason Health Care Costs So Much (HarperCollins, May 2006),  I describe, in detail, how healthcare IT could lift quality and, over the long run, help contain costs. Just one example:  if physicians used computers to order medication, we could eliminate two million “adverse drug events” that range from allergic reactions to death.

Concerned about privacy, some patients might opt out. Certainly, legislation will be needed to assure that records will be safe from prying eyes.

But experience shows that where IT is available, most patients like knowing that if they wind up unconscious in an ER, a doctor can open his laptop and find a complete and detailed medical history that includes a list of what drugs they’re taking, pre-exiting conditions, test results, x-rays, prior hospitalizations, notes from various specialists who have examined them.

Dr. David Brailer, the man President Bush appointed as his Health IT czar in 2004, was supposed to usher in an IT revolution in the U.S. But last month Brailer left Washington. Explaining that Brailer was departing for family reasons, the administration  stressed that, despite his brief tenure, he had made “significant progress” toward the president’s goal of giving most Americans electronic records by 2015.

The facts suggest otherwise. Despite much rhetoric, funding Health IT is not among the administration’s priorities.  In 2005 a panel that included Brailer estimated that developing electronic medical records that gather a patient’s history, X-rays, lab results and prescriptions into a single database would require $165 billion in start-up capital –plus $48 billion in annual operating costs.

For fiscal 2007, the White House budget allocated a paltry $169 million to healthcare IT.  By contrast, the UK is spending $11 billion to wire a much smaller system.

The administration hopes the private sector will foot the bill. But hospitals are strapped for cash, and pediatricians earning an average of $150,000 a year are reluctant to spend $44,000 per physician to wire a group practice. Even for a cardiologist earning $500,000, the business case for IT is slim: the financial rewards for avoiding duplicate tests will go to the insurer, not to the doctor. 

Nevertheless, Washington insists that the private sector foot the bill—which brings us to the second hurdle: persuading competing players in a market-driven system to agree on complementary standards. Hospitals and doctors  need electronic records that can talk to each other.

In an interview published in Health Affairs last fall, Brailer acknowledged that “divergent stakeholders’ interests” create “a significant barrier to agreement. . . . It’s the same problem as VHS versus Betamax [videotape], although I think there’s more at stake with health care than with videotapes,” he remarked.

Yet, since Brailer shares the administration’s faith in market-based solutions he  remained committed to trying to coax rival hospitals, doctors, health plans and IT vendors to reach a consensus–even while admitting the real danger that we will wind up with a wired maze of health care providers who still cannot communicate with each other. (Remember when competing U.S. wireless telephone carriers refused to agree on protocols, and we all paid roaming fees?)

As J.D. Kleinke, executive director of Omnidex Institute, a nonprofit health care research and information  technology development organization,   pointed out in a 2005 Health Affairs article titled “Dot-Gov:Market Failure and the Creation of a National Health Information Technology System”:

“The market has refused to coalesce around health care IT standards on its own. The time has come for rational, orderly design, one that will allow us to get on with the real work of improving the health care system with an IT infrastructure that other industries take for granted.”

In April, an article in Modern Healthcare seconded Kleinke’s concern, noting that:

” One of the problems with the administration’s market-based approach is that the market isn’t entirely sold on the idea of a single set of standards for certification of IT systems. The main vendor organization announced its own road map for a national IT system and then grumbled about the government’s pass-fail system for electronic medical records certification, saying letter grades for degrees of success ought to be handed out.”

What is ironic is that the administration’s insistence that the best solutions always spring from market competition ignores one of the most efficient corners of American healthcare: the government’s own fully-wired Veterans’ healthcare system –a system that Fortune magazine recently called “the most cost- effective health system in the land.”  (May 15, 2006)

The VA’s IT revolution began in 1994, when a new leader, Dr, Kenneth Kizer, ordered a gut-renovation.  When I visited a Veteran’s hospital in Vermont last spring, I was impressed by the results.

When a physician prescribes a new medicine, he calls up the patient’s chart on his laptop and taps in the order; the computer then checks the drug against others the patient is taking, and warns if there might be an adverse reaction.

IT helps co-ordinate care. At many hospitals, if five specialists are called in to consult on a patient, they may not consult with each other. At the VA, they are each making notes on the same electronic chart, creating what is, in effect, an ongoing dialogue.

When Hurricane Katrina forced the relocation from New Orleans to Houston of hundreds of Veterans Affairs hospital patients, electronic medical records enabled doctors and nurses to treat the sick and injured “without skipping a beat” according to the Washington Post .

The VA also uses its database of how thousands of patients have responded to various treatments to make the head-to-head comparisons of risks and benefits that drug-makers loathe. Relying on that data, the VA , like the Mayo Clinic and Kaisier Pemanentne (which also has an impressive IT system),  curtailed its use of Vioxx two years before  Merck took the drug off the market.

How could the VA afford IT?  The answer is simple: VA hospitals aren’t competing with anyone. When allocating resources, Kizer was making medical decisions, not marketing decisions. By contrast, in the fiercely competitive private sector, even not-for-profit hospitals must ask themselves: Which is more likely to bring in well-insured customers, a new heart pavilion with a waterfall, or IT that won’t pay off for years? Thus, many communities have more heart centers than they need—all overflowing with paper.

The VA has not achieved medical Utopia. Lapses at individual hospitals still set television cameras whirring, and those stories can overshadow the larger tale of systemic reform.

But the VA’s triumphs in “Creating a Culture of Quality” have grabbed headlines in medical journals where studies show the VA matching private-sector health care both in term so quality and costs. (See The New England Journal of Medicine ("Effect of the Transformation of the Veterans Affarirs Health Care System on the Quality of Care, May 29, 2003)The Annals of Internal Medicine ("Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study," August 17, 2004) and the American Journal of Managed Care ("The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care," 2004,10; part2). Mainstream media have also recognized the VA’s achievements (see Washington Monthly ("The Best Care Anywhere," January/February 2005) The Washington Post ("Revamped Veterans Health Care Now a Model," August 22, 2005).

The VA has been doing more with less. By 2005 the number of patients the VA was treating had doubled in ten years. Meanwhile a more efficient system had cut costs by half.

Washington’s reaction to the VA’s success?  Starve the beast.

As Bloomberg News has  pointed out , (August 18, 2005) as the Veterans system improved, it has  attracted more and more veterans who wanted care. “Greater-than-expected demand for services from soldiers returning from Iraq and Afghanistan" also added to demand  But, Congress have refused to fund the VA system "to keep pace with health care inflation and rising enrollments."

In 2005, Bloomberg reported out that "in the seven years after the Veterans Healthcare Reform Act was enacted in 1996, enrollment grew 141 percent to 7 million while funding increased 60 percent.  The VA’s healthcare system may be more efficient than the  private sector–but it can’t be that much more efficient. It needs funding.

Since 2005, the VA has gotten some additional funds– but not enough. Too often, Vets face long waits for care. And as of 2003, the VA no longer offers healthcare to all vets. Only those who earn less than $25,000 a year, and/or those whose condition is related to their medical service qualify,  leaving roughly 1.7 million Vets uninsured. Many served in Vietnam, the Gulf War, Afghanistan or Iraq. Most are employed, but in many cases, either their employer doesn’t offer health insurance or they can’t afford it. (With annual  premiums averaging  $4000 for an individual, and well over $10,000 for a family, it’s easy to see how a Vet earning $25,000—before taxes—has a hard time paying for health insurance.,.)

Perhaps Washington needs to re-think its agenda.  Fund the one part of our health care system that works, and look to the VA as a model to ensure that medical priorities— rather than the market’s priorities—dictate how to bring U.S. healthcare into the 21st century.

How can other healthcare providers follow the VA model?

Ken Kizer might have a solution. The man who transformed the VA is now CEO of Medsphere Systems, a company that is adapting the VA’s software (VisTa) for other doctors and hospitals.  The software itself is free— anyone can download it online. But you still need to install VisTa, adapt it, and learn how to use it. Medsphere offers those services plus 24-hour support to customers like Midland Memorial Hospital in Texas.  Because Midland didn’t have to pay licensing fees for the software, it says it is spending only $7.1 million– less than half the total cost of commercial software.

The key is that, in contrast to the proprietary software that many companies sell, the VA software is “open source” which means that it’s available at no or minimal cost, and allows different IT systems to operate compatibly.  Because anyone can download it, the software is not controlled by Medsphere or any single company. Instead, a community of users can work to improve the code simultaneously, sharing ideas, and speeding development.

Cynics suggest that corporate lobbyists who hope to turn a neat profit on proprietary software will block open source Health IT.  And money is still an obstacle: hospitals and doctors will need subsidies.

But if Congress has the will, the VA has shown the way.

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as:

16
Leave a Reply

16 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
13 Comment authors
Naveed Ahmed KhanDr. Marcinko saysDaveprakashRay Recent comment authors
newest oldest most voted
Naveed Ahmed Khan
Guest
Naveed Ahmed Khan

i visit your site n i got more information then other visited last month
was good enough then last what i had gone throught

online degree

Dr. Marcinko says
Guest

Hmmmmmm! As a doctor – now health economist – who did some training in the VA System, my overall impression was not a favorable one. Ditto for any related internship or residency training. So, you might wish to take a look at this new link and decide for yourself. http://healthcarefinancials.wordpress.com/2007/11/23/a-real-american-hero-2/#comments And, although this credentialing issue was well known to most of us, the public might be very surprised. But, it is not a new problem! Of course, the idea that docs are technophobic is probably a correct one. That’s one reason I edited a series of three dictionaries – my… Read more »

Dave
Guest

I see where the HHS has “announced a five-year demonstration project that will encourage small to medium-sized physician practices to adopt electronic health records (EHRs)”.
Personally, I don’t see the need for such a system involving the everyday patient. I am a transplant recipient. If any sector of the public would benefit from such a program, it would be folks like myself. BUT, it must remain optional. I for one would not participate in such a program due to security of my personal info.
http://www.disabilityhelpsite.com

prakash
Guest

web-based systems, where the computer is owned by the service provider are often linked to billing services. Web based systems offers cost effectiveness and are suited for smaller practices where the cost of having a dedicated system turns to put off these practices from the costlier versions, but then these come at a price as accessability tend to limit the number of patients that can be seen during a day.

Ray
Guest

The way that E H R is going to make an impact on a broad basis is by making it affordable, simple and secure for the small practices. These physicians would love to move to E H R but it is too costly for them, and too complicated or leaves them exposed as far as security. My company looked at this and has made some strides in help the smaller practices. http://www.medlinkus.com

none
Guest
none

Will you please truncate this post and do “read more”? It’s way too long for the gateway.

none
Guest
none

Will you please truncate this post and do “read more”? It’s way too long for the gateway.

Brian Klepper
Guest
Brian Klepper

Excellent piece!
Actually, Maggie, I believe that eClinical Works, which recently won a competition with AllScripts and GE in the Boston area by getting 170 of 180 votes by participating practices, charges $10K for the first physician and $5K for additional physicians within a practce.
Most of your points are very well taken. However, this is not to say that all practice manage software is equal. I think we need to hear from some practice managers who have reviewed or worked with a range of systems to provide feedback on their utility and ease-of-use.
Brian Klepper

Steve Beller, Ph.D
Guest

The VA CPRS, along with a host of other EMRs, are important tools for collecting and reporting patient data, and for offering a little bit of decision support. Anything that helps improve care quality, after all, has value.
But we ought not be complacent with even the best HIT available today because there is still a huge HIT gap to be bridged, and clinical decision support is still in its infancy (see A Roadmap for National Action on Clinical Decision Support).

Tom Leith
Guest
Tom Leith

Not “risk avoidance software” — just “risk avoidance” as a business result. That this risk avoidance may be gained during a software implementation project doesn’t matter. Mainly it is the improved business processes that software systems force upon organizations that produce the results: not the software itself. They could get most of the benefits without buying software at all. I am not convinced at all that the big players get a payoff any sooner because of their size per se. They may get it sooner because they attract more talented managers. So I think it is a matter of vision… Read more »

Maggie Mahar
Guest
Maggie Mahar

Tom — I agree that open-source vendors should try to sell risk-avoiance software. But as to why Kaiser permanente, the Mayo Clinc, and 20% of phyisians and hopstials can afford software–they’re not “special”–they just have deeper pockets than most healthcare providers. Kaiser Permpanente, like the VA, enjoys ecoomies of scale– becaue of their enromous size, they can reap the savings from heatlhcare IT far sooner than a stand-alone hopital or a practice of 6 physicians. Very large group practices in affluent areas also are in a much better position to afford healthcare IT. And the Mayo Clinc, like a a… Read more »

Tom Leith
Guest
Tom Leith

> Cynics suggest that corporate lobbyists who > hope to turn a neat profit on proprietary > software will block open source Health IT. They may try to spread FUD (Fear, Uncertainty, and Doubt) among health system CIOs. Hospital CIOs do not care (usually) about the details of their IT. They want to avoid risk. If the Open Source vendors come to realize this and sell “risk avoidance” they might be able to push reasonably interoperable EMR and patient accounting systems into hospitals. But this won’t address all the ancillaries. Vista is in some respects a little old-fashioned, but you… Read more »

Maggie Mahar
Guest
Maggie Mahar

Thanks very much–and you’re completely right. Kizer didn’t invest the VA software–nor did he hire someone who invented it. Like the Web itself, it was invented by people who did not believe that ideas are “proprietary” and for sale. They thought of ideas as something that we share. This is how the greatest minds (Einstein, et. al.) have thought of their ideas. That said, what Kizer did was a “revolution” only in that he brought this software into one the largest healthcare systems in the country. As you suggest, very few people at the highest levels of our government would… Read more »

Fred Trotter
Guest

First, bravo for an article showing how VistA has positively impacted the VA healthcare system. I learned some things that I did not know about the current political issues with the VA. However you have some things wrong. In fact not merely wrong but backwards. For instance “The VA’s IT revolution began in 1994, when a new leader, Dr, Kenneth Kizer, ordered a gut-renovation.” Wrong. Not just a little wrong. Completely wrong. Kizer was a a very smart administrator, who finally took advantage of VistA, he took a risk in doing so and deserves credit for it. But you are… Read more »

Anonymous
Guest
Anonymous

Congress is set to vote on HR 4157 next week: the Health Information Technology Promotion Act of 2005. This act seeks to codify the Office of the National Coordinator of Health Information Technology and amend the Social Security Act to promote health informatrion exchange. This is to result in the NHIN that will contain computerized electronic medical records of Americans. There are many counterpoints to the idea that health IT is the complete saviour of health care. First, the VA system can not even keep the medical records and information of its members private and secure: it recently had a… Read more »