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.