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Tag: VA

How Does the VA’s Technology Rate Against Other EMR Vendors?

Health care for veterans has been all over the news.  At the same time, the DoD is moving to procure a replacement EHR system.  So it seems there is no time like the present to review a recent RAND case studies report entitled “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.”

The case studies include a chapter comparing America’s two most broadly deployed EHRs:  The VA’s VistA and Epic.  The tale RAND tells is not one of different EHR technologies, as both VistA and Epic both employ the MUMPS programming language and file-based database. Rather, it is about how different origins, business models and practices have dramatically influenced the respective systems.  As the report itself says, the contrast offers “useful insights into the development, diffusion, and potential future of EHRs.”

VistA

VistA, “the archetype of an enterprise-wide EHR solution,” supports the Veterans Health Administration, “the largest integrated delivery system in the United States.” Initial VistA development was a collaborative, distributed, grass-roots effort where individual VA medical centers built out new clinical functionality on a common platform.

In the mid 90’s, VistA became the instrument of change at the VA.

The pace and scope of EHR adoption increased dramatically under the leadership of Dr. Kenneth W. Kizer, who served as the VA’s Undersecretary for Health from 1994 through 1999.  Dr. Kizer considered installation of a major system upgrade to be a core element in his effort to transform the organization …Continue reading…

The VA Scandal: Implications for Health Reform and a Call for Clinical Research into the Reported Death Rate

VA sealAs your correspondent understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital.  Approximately 1500 vets were assigned to an “off-the-books” waiting list that made the clinics’ official waiting times appear shorter than they really were.

Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command.  If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing.  Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain.  A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General’sinvestigation prejudgment is that none of the deaths can be attributed to delays in care. You can’t make this stuff up.

“Good grief!” says your correspondent.  Numerous articles like thisthis and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

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Six Awkward Concerns in My OpenNotes

I found out this past weekend that the VA will be making clinician progress notes available for patients to view on the MyHealtheVet portal. In other words, the VA is going OpenNotes. (Note: I was a primary care provider in geriatrics clinic at the San Francisco VA from 2006-2010.)

My first reaction was to be impressed by this bold progressive move.

My next reaction was to feel mildly relieved that I’m no longer a PCP there.

Now, it’s not because I’m against transparency in healthcare, or am suspicious of patient engagement, or feel that patients shouldn’t see their health information without the assistance/gatekeeping/interference of a clinician. Far from it.

It’s because in my own VA practice caring for WWII vets, I used to frequently document certain concerns that would’ve been a bit, shall we say, awkward for the patient to see. Reading about these concerns would’ve quite possibly infuriated the patient, or the caregivers, or both.

So whew, I find myself relieved that I don’t have to figure out how to document (or not document?) these concerns.

Instead, I’ll get to see how my friends at the VA handle these issues.

Wondering what they are? Ok, I will tell you but shh … don’t tell my elderly patients that I may be considering these topics as I care for them.

Six awkward concerns in geriatric primary care practice

· Possible dementia. As a geriatrician, I focus on an age group that has a high incidence of dementia. Which means that when someone starts to tell me odd stories (concerns related to poison are a popular theme, as well as reports that someone is stealing things repeatedly), I start wondering about possible dementia. Ditto if he or she starts floundering with the medications, or starts having other difficulties with IADLs.

Why it’s awkward: Patients and families really hate it when I bring up the possibility that there might be dementia. Many find the possibility of a disease such as Alzheimer’s truly terrifying, both because it’s perceived as a terrible disease, and because they worry about having to leave their homes or otherwise losing their independence. Note that if I’m considering the possibility of dementia, I usually let the patient know during the visit.

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Health Care Social Media – How to Engage Online Without Getting into Trouble (Part II)

I have been asked to write up some of the core takeaways from the health care social media presentations I have been giving recently, so I am sharing a version of this narrative on HealthBlawg, in two parts.  You may wish to begin with Part I.

Professional responsibility and malpractice liability

The American Medical Association has promulgated a social media policy; so has the Veterans Administration.  The two represent very different approaches.  The AMA essentially advocates proceeding with caution, and being cognizant of the damage that one’s own social media activities – and one’s colleagues’ – may do to the profession.  The VA, on the other hand, is out in front on this issue – just as it was with electronic health records – encouraging the use of social media tools to disseminate information and engage patients and caregivers in productive dialogue likely to improve overall wellbeing and health care outcomes.

Patient care should not be provided in open social media forums, but appropriate disclaimers on blogs, Facebook pages, YouTube channel pages, and the like, should be sufficient protection for providers seeking to use these tools for sharing of general advice and information.

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Why we need an independent health data utility

This is another in the numerous “death of Google Health” stories that have been appearing since Friday when the Google blog announced the pulling of the plug. I must admit to being more than a little pissed off with Larry Page or whomever it was within Google that made the decision. After all, Google Health was only introduced a tad more than 3 years ago (premiered at HIMSS in Feb 2008; launched officially later that year). And just nine months ago they hired a new product manager and debuted some interesting new features connecting to the new wave of personal sensors.  I know that Wall Street has been telling Google to focus on fewer products and that Page as new CEO has decided to do that but for a company as rich as Google the effort involved in keeping Google Health alive would be trivial. And props here to our friends at Microsoft who are integrating HealthVault into their wider health care business.

The sunsetting of Google Health has meant an outpouring of articles from the factual (Deb Linton at Health 2.0 News), to the historical (John Moore at Chilmark) to the winners/losers assessment (Fred Trotter) to the mega-quotes including mine (Marshall Kirkpatrick at ReadWriteWeb). There’s also been a steady stream of both sad and (sadly) happy people commenting on the Society for Participatory Medicine listserv, and Mr HISTalk was his cynical self–basically saying that tech know-nothings should stay out of our complicated health care business. He’s wrong and now Google is wrong, and here’s why.

With the very notable exception of HealthVault and (hopefully) some new innovation from Dossia, we are now dependent on a number of small companies to maintain the emerging data utility layer. The data utility layer in health is the place that is going to collectively store all the data that is being generated. Apparently Google didn’t have the real patience for two rapid developments.

First, with a combination of the Direct Project and the stipulation in the meaningful use regulations that EHR users share data with other providers and with patients, individuals are going to find that more and more data about themselves is available and easily accessible. Whether or not it’s a Farmville-type hit, the ability to capture all that information in one place is very important. Currently it’s also very time consuming to put together so very few people do it. But I do know of instances where people have laboriously entered lab values into Google Health just to store them. Sooner rather than later that data will be available much more easily in machine readable format, and as those barriers to use fall so the desire to look at that data will increase.

 

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