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 survivor 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 drug 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

Wired for Science

VistA is also useful in identifying medical procedures that don’t work, as well as particular doctors or surgeons who are not getting good results. For example, VA researchers have been able to use VistA’s database of medical records to create the first national, risk-adjusted analysis of how patients fare after undergoing different types of surgery in different veterans hospitals. The study showed good news for the system as a whole. Between 1994 and 1998, mortality rates for major surgery fell by 9 percent, while morbidity rates, or the rate of complications after surgery, fell by 30 percent. But the study also quickly showed where outcomes were best and worst, thereby pointing to which surgical teams could stand as exemplars and which needed improvement.5

VistA’s records can also provide important insights into the environmental factors behind disease and reveal important and otherwise overlooked correlations. For example, in October 2005, Dr. Fletcher, with a few keystrokes, checked to see how many patients in DCVAMC had blood pressure readings exceeding 140/90. The answer that came back was 45 percent. When he checked again in January 2006, he found that 50 percent had readings exceeding 140/90. Perplexed, he had VistA retrieve all blood pressure readings going back to 1998 and made an important discovery: blood pressures increase every winter and drop every summer. This insight has important implications for how blood pressure readings are interpreted and for prescribing appropriate medications. It has only come to light because of VistA.

VistA also makes it possible to track down new disease vectors with great speed and effectiveness. For example, when a veterans hospital in Kansas City noticed an outbreak of a rare form of pneumonia among its patients, its computer system quickly spotted the problem: all the patients had been treated with what turned out to be the same bad batch of nasal spray. VistA today plays a key role in the VA’s avian flu surveillance program and allows for real-time data links with the Centers for Disease Control and Prevention—features that are likely to be invaluable in the event of bioterrorist attacks as well.

VistA has also proved invaluable during natural disasters. When Hurricanes Katrina and Rita devastated New Orleans and the Gulf Coast in 2005, just about the only people whose health-care records weren’t gone with the wind or buried in mud were veterans registered with the VA, and it made a big difference. Floodwater swamped the VA hospital in New Orleans and destroyed its hospital in Gulfport, Mississippi. In all, an estimated 100,000 veterans in the area were forced to evacuate. But thanks to VistA’s backup files, all patient records were preserved and within 100 hours became continuously available through a special Web site accessible to VA medical personnel around the country. “So if the patient walked into any VA and said, ‘I’m an evacuee from New Orleans,’” explains Terry Algood, chief of pharmacy at the Jackson Veterans Affairs Medical Center in Mississippi, “then that meant I could call into the Katrina Web site, look at the prescriptions, and then transfer those prescriptions into their database right there and take care of the patient on the spot.”6

The VA estimates the total direct cost of installing VistA came to about $300 million in wiring and $450 million in computers. Its upkeep costs $485 million per annum, or about $90 per patient—quite a bargain!7

But it is not just information technology spawned by the Hardhats that transformed the VA into what is now the nation’s best-performing health-care system. It also took shrewd and charismatic leadership from above to reengineer its culture and rationalize its processes. The story of the man who led that effort is one of the few truly successful examples of the Clinton era’s many attempts to reinvent government. In essence, he succeeded by allowing the institution to take advantage of three of its unique features: its large-scale and deeply integrated information systems, its long-term relationship with its patients, and its comparative freedom from market-driven forces that have impeded the quest for quality health care in the private sector.