VistA, the electronic patient record of the Veterans Health Administration (VHA) have been credited with transforming the VHA into one of the safest and highest quality health care systems in the world. I was keen to find out what their frontline doctors thought of this system.

Recently, I had the privilege of visiting a VA facility with 200 inpatient beds, an emergency department, a large outpatients department and several long term care facilities (ie. nursing homes). Every site uses VistA. I spoke to 4 attending physicians (consultant equivalents) and the chief medical officer (Medical Director). They were incredibly gracious with their time and were not short of opinions!

‘VistA makes it easier for us to do the best we can at chronic disease management and preventative care. For example, when a patient is diagnosed with diabetes, automatic alerts are generated to remind us to perform routine disease monitoring such as eye checks and neurovascular assessment of the feet. All of this information is captured in a structured way so that we can continuously monitor our performance. Sure, it more time, but we are confident that our patients get the care they deserve. This is less common in the private sector, as longer consultations and preventative medicine does not generate any monetary compensation.’

Throughout my visit, different clinicians were very keen on demonstrating to me the ability of VistA to access records on any patients wherever the patient was based. This was what made it possible for the VA to ensure continuity of care for their patients during the city wide evacuation when Hurricane Katrina devastated New Orleans in 2005. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1854987/]. Back when Tony Blair was making the case for Connecting for Health, he said that if he ended up in Accident and Emergency in Bradford, he wants the doctors there to have access to his GP records in Guildford.

‘You are impressed with BCMA, surely not!’ This was the response from one of the more senior physicians when I mentioned that I was very impressed by their bar coded medicines administration (BCMA) system that ensured that the right patient, get the right medications at the right time. He continued, ‘We had this for years. This is nothing to be impressed about. After all, supermarkets have been doing for this decades.’ Slightly taken a back, I was embarrassed to admit that in NHS organisations, even those with electronic prescribing and medicines administration systems, do not come close to this level of sophistication.

More than an hour into our discussions, I was starting to feel guilty that I was eating into their clinical time given that I arrived unannounced! A bit like racing car drivers critiquing the performance of their cars, the doctors here have clearly formed a working relationship with VistA and was keen to share their views with me. Like any symbiotic relationship, they were equally critical in what they perceive as the slow progress for improvements in the system (details in a separate post). ‘At the VA we have become experts in utilising electronic patient records to improve the quality of care out patients receive’. I aspire to the day that I’m able to say the same of myself and my colleagues here in the UK.

Just before I left, I met with the chief medical officer. Clearly proud of the VistA system, he explained how it allows him to ensure that his organisation maintains and drives up the quality of patient care.’ I know how well each of my doctors are doing. For example, in diabetes, I can find out the average HbA1Cs for different groups of patients. If one of my doctors are under performing, I can show him/her the evidence and agree a plan of action.’ He continued, ‘Do you know why the private sector did not just pick up on VistA? It is free after all.’ I shrugged. ‘Traditionally, the design of their IT systems were driven by billing and reimbursement requirements, VistA is not particularly good at that.’

As I was leaving the facility, my guide pointed out to me how the hospital has changed over the last 10 years; less inpatient beds, larger outpatients department and expanded community services. It then occurred to me, VistA has not only shaped the way their doctors work, it has shaped the whole organisation and enabled care delivery systems that could not have existed otherwise.

I wondered to myself, what if Connecting for Health delivered the vision it set out way back in 2002. How would the NHS look like today? It is sobering to note that the VA already had this level of IT functionality at the turn of the millennium.

How much longer can the NHS afford to wait?

About the author
Dr Wai Keong Wong is a Haematologist in Training in London. Wai Keong is fellow on the NHS Medical Director Leadership and Management Scheme. He hopes to acquire skills that would allow him to drive up quality by aligning systems and processes which will remove barriers to safe, effective and personal healthcare – something he believes all patients deserve. He believes passionately that a fully integrated clinicians driven electronic patient record based on open standards is central to achieving this vision. He recently had the opportunity to visit a VA hospital whilst he was in the United States.

Saturday 24th December, Christmas Eve, 2011.

This is a story of two hypothetical John Smiths; one who lives in the US, and another in the UK. They both fall ill on Christmas Eve 2011.

Scenario 1: New York, USA | Veterans Health Admistration (VA)

John Smith is a 77 yr old navy veteran visiting his son Steve’s family in New York having travelled all the way from San Francisco, a 2500 mile journey. This is a particularly poignant Christmas as John suffered a major heart attack earlier in the year.

This morning, Steve found his father sweaty and disorientated. John was taken to the Emergency Department of the local VA Hospital. John was diagnosed with an infected ulcer in the right leg. The infection has spread to his blood stream. They looked up his electronic health record on the VA’s VistA system and instantly they had access to his whole medical record in San Francisco. They found out that in addition his recent heart attack, John also suffered from diet-controlled diabetes, kidney disease and high blood pressure. Indeed, John’s diabetic control has been poor; he has not collected his last 2 prescriptions and has been an inconsistent attender at outpatient clinics. His blood pressure has been difficult to control and his last recorded blood pressure (BP) was 165/85 mmHg.

John was not looking great. He look dehydrated and he was confused. His BP was 110/60 mmHg, pulse 110 bpm, Temp 38.5 C and his blood sugar was very high. He needed antibiotics right away. Steve said that he thinks that his father might have a penicillin allergy but cannot be sure. Thankfully, his doctors were able to confirm on the VistA system that this was untrue as he has been prescribed a course of penicillin earlier in the year for a mild chest infection and responded well to it.

To make a decision on which antibiotic to use, John’s doctor consulted their local antibiotic guidelines. After that, they looked back at John’s microbiological history on the Vista computer system. To their surprise, they found that a highly resistant strain of bacteria was found in John’s bloodstream earlier in the year when John had a similar infection. On the very same report, alternative antibiotics that can kill this bacteria was listed. The microbiologist on-call was consulted over the phone. Sitting at her home computer and using VistA, she recommended an alternative course of penicillin-related antibiotics tailored to John’s current illness.

These were commenced intravenously. John was transferred to the high dependency unit as even-though his blood pressure was ‘normal’, this was significantly lower than his usually high blood pressure. Over the next 24 hours, John slowly but surely improved. The blood test results from the day before confirmed the presence of the highly resistant strain of bacteria.

John did end up spending Christmas in the hospital but his family all visited. He was discharged on boxing day back to his son’s house. The intravenous course of antibiotics was continued at home by the community nurses. His doctors remotely monitored his treatment from the hospital using the Vista computer system. They also made minor adjustments to his diabetic medications.

Meanwhile in San Francisco, Dr Johnston, John’s primary care doctor has already been in contact with his colleagues in New York having been alerted by the VistA system that John has been admitted to hospital 2600 miles away. What John’s family did not realise was that John has also made a prior decision that in the event of his heart or breathing stopping, he did not want to be resuscitated. This was clearly documented on the VistA system with John’s signature electronically recorded. Thankfully, this document never needed to be consulted on this occasion.

Scenario 2: London, England, United Kingdom | NHS – National Health Service

John lives in the Newcastle, situated in north of England but is visiting his son’s family in London in the south. When Steve noticed his father was unwell, an ambulance was called and he was promptly admitted into of one of London’s most prestigious teaching hospitals.

Once again, a diagnosis of an infection in an ulcer spreading to the blood stream was promptly made.

As Steve thinks that his father is allergic to penicillin, a second choice antibiotic was used as recommended by the local antibiotic guidelines. Even though John’s blood pressure was much lower than his usual, the doctors did not have this information at hand; a blood pressure of 110/60 is the normal range for the general population. John received care on the standard medical ward.

Anti-diabetic treatment also commenced. The doctors did not know what medication John was usually on and his general practitioner (primary care practitioner) would not be open until 4 days later given the long Christmas weekend.

Over the next 24 hours, John deteriorated. His blood pressure continued to drop and he stopped passing urine. Appropriately, he was transferred to the high dependency unit. His blood results confirmed that he has an infection in his blood. Based on preliminary investigations, the antibiotics he is on should be effective. It was just too early to expect a response.

John continues to deteriorate. His is now in complete kidney failure. Fluid starts to accumulate in his lungs, depriving oxygen from vital organs such as his brain. He is transferred to intensive care unit (ICU) where his is put on a dialysis machine to take over the role of his kidneys and a breathing machine to oxygenate his blood. Blood results then revealed the highly resistant strain bacterial. His antibiotics was promptly changed. It is now 48 hours after his admission to hospital.

John suffers a cardiac arrest and after 10 mins of CPR and 3 cracked ribs later, the doctors successfully resuscitate him. Unfortunately his organs has taken another severe insult. The decreased blood supply to his brain has caused a stroke.

Over time, John starts to make a slow but steady improvement as the antibiotics start working. He spends a total of 10 days in intensive care. He lost 30% of his body weight and a lot of his muscle mass. He is in constant pain from his rib fractures. After discharge from ICU he was to spend another 30 days in hospital.

He finally felt to have recovered enough to be discharged back home to Newcastle in a wheelchair, carers 3 times a day, 20% lighter and a broken man psychologically. Dr Johnston, his GP, had no idea that John has been in hospital for the past 40 days until he was phoned up as part of the discharge process. When Dr Johnston visited John at home, he could hardly recognise him.

So, what are the differences and similarities between the two scenarios?

Similarities
Both scenarios took place in publicly funded heath systems in first world countries.
Both employ salaried and highly trained healthcare professionals doing the best they can for their patients.
Both encourage the use of locally agreed protocols and patient safety initiatives.

The difference?
Vista – the VA’s fully integrated Electronic Patient Record.
and
A patient with his health and dignity intact.

Find out more: http://nhsvista.net/

About the author

Dr Wai Keong Wong is a Haematologist in Training in London. Wai Keong is fellow on the NHS Medical Director Leadership and Management Scheme. He hopes to acquire skills that would allow him to drive up quality by aligning systems and processes which will remove barriers to safe, effective and personal healthcare – something he believes all patients deserve. He believes passionately that a fully integrated clinicians driven electronic patient record based on open standards is central to achieving this vision. He recently had the opportunity to visit a VA hospital whilst he was in the United States.