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Tilting at Windmills

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September 15, 2007
By: Phillip Longman

ELECTRONIC RECORDS AT THE VA....What's the big deal about the VA's electronic medical record system? Almost uniquely, its original code was written by doctors for doctors, as part of an ad hoc, collaborative process. The story, which I chronicle in my book, Best Care Anywhere, is wonderful. It's one of an underground subculture of geeky doctors and other health care professionals, known as the Hard Hats, that emerged within the VA beginning the late 1970s. Hacking clandestinely on Tandy PCs and DEC mini-computers, they wrote some 18,000 different programs that eventually were integrated to become the VA's world class VistA system.

Because of this history, VA doctors have long had "buy in" to digitalized medicine that is still largely lacking in the rest of the health care system. And while there is no one definition of "open source," the VA's VistA system is essentially that. From this comes all sorts of advantages over proprietary software programs, including free distribution with no licensing fees, rapid detection and elimination of bugs, and the ability of end users to improve the code and adapt it to their own medical practices.

Finally, there's the huge networking effects that are unique to VistA. So your doctor carries a laptop around? Big deal. Electronic medical records have some value over paper files, but not much, if they cannot be widely shared among the many different specialists, labs, pharmacies and other players typically involved in a patient's care, either at one time or over an extended period. Also, the data contained in electronic medical records about which treatments work best is of little use to researchers if they can't aggregate that data across large populations. The potential for electronic medical records to drive the development of safer, more effective "evidence based" medicine is huge, but only if those records are part of a very large, integrated system like the VA's. It took me a long time to get my head around these realities, but once I did it was easy to see what a big deal the VistA system is.

Phillip Longman 12:49 PM Permalink | Trackbacks | Comments (31)

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When my elderly mother was hospitalized at one of Boston's best hospitals, renowned for "patient-centered care," she ended up spending about three times as long there as she should have solely because of repeated mix-ups caused by the failure of one care provider to pass on information to another, or vice versa.

A good friend is a liquor salesman for a big distributor. He goes nowhere without his hand-held computer device, through which he can access the purchase and sales history of each customer he visits, the inventory available for shipment, etc.

Health info is of course vastly more complicated, but good grief, the amount of money wasted by my mother's utterly unnecessarily extended hospital stay -- to say nothing of the effects on her health and wellbeing -- multiplied by however many hundreds of thousands of patients this kind of thing happens with, more than justifies the expense and hassle of implementing the kind of system the VA has.

The hospital this happened in has since gotten a new CEO, who has plunged into an intensive effort to computerize, I believe developing their own system, which I of course applaud but which sounds like is essentially reinventing the wheel.

What will it take to make the VA's system available to the rest of the medical establishment?

Posted by: gyrfalcon on September 15, 2007 at 1:03 PM | PERMALINK

Let me just say a good thing about my HMO, Kaiser. They really get the electronic records thing. Last time I went in about my thyroid, the doctor said "oh, and how is your neck doing?" because she could see the records for my physical therapy on my neck. More to the point, everyone knows all the meds I am taking without me having to remember to tell them, so any contrindications are spotted. There isn't any time wasted in taking medical histories. It's all already there.

Posted by: EmmaAnne on September 15, 2007 at 1:39 PM | PERMALINK

gyrfalcon: I was a resident in 1999-2000 when the VA replaced it's paper system with the new EMR. As an intern, I had requested and been granted "clerk" priveleges by the IT department (to their great amusement) so that I could do my own order entry on the old, monochrome, scrolling menu system. As a result, in my third year I was invited to play on the beta test version before it went live. Before medical school, I was a systems and software engineer involved in computerizing other paper systems. I am a huge fan of EMRs and I thought that the VistA system had been beautifully designed ... for the VA. It wouldn't work in the setting that you describe, nor would it have prevented the problem that you describe.

VistA is much prettier than the more generalized EMRs out there, but it is very, very specific to the way that the VA operates. Although there may have been some docs involved in its development (I know a bunch of people at SAIC who seem to think that they did a lot of the work, too), its relatively easy acceptance was due to the fact that it looked exactly like the paper records that the VA was already using. (Also, the docs didn't have to pay for it out of their own pockets....)

The new EMR was introduced at my VA at the beginning of 2000. The improvement in the VAs systems and outcomes pre-dates it.

Posted by: J Bean on September 15, 2007 at 1:44 PM | PERMALINK

The VistA system is also an kludged-up mess which can never be replaced. The VA has been trying to modernize it for years now, with one failure after another. Between the technical challenges and the VA's bureaucracy, it's likely that VistaA can never be replaced.

It's the perfect example of LUCKY software development, not GOOD software development. It may be a success, but it will never be repeatable.

Posted by: Seng on September 15, 2007 at 2:10 PM | PERMALINK

I have three mostly unrelated questions for Mr. Longman:
1) My sister, who works for a hospital in New Hampshire, consistently has negative things to say about the VA. Is that just the party line pushed by doctors and others in the medical arena who are threatened by any sort of "socialized medicine" ?
2) My sister also claims that a very high (80-90 percent I think she implies) of the cost of medicine is in the last few months of life, when increasingly expensive care is provided to buy very short amounts of time, usually not quality time, because doctors are afraid to encourage families to do anything less than everything possible and families are reluctant to face the truth. So, what percent of healthcare money goes to support very old and/or very ill patients at the very end of their lives ?
3) I worked for a software company in the 90's which sold a ton of their product (a modified version of their DBMS called Model204) to the VA and I wonder if that's part of the Vista system. If memory serves, it was the behind the scenes repository for huge amounts of data for the VA. Do you know if this DBMS is part of the successful EMR system at the VA ? Just curious.
It would be nice to know that code I worked on was part of the success.
Thanks for any light you can shed on the above.

Posted by: Ralph on September 15, 2007 at 2:13 PM | PERMALINK


Hello, some quick rambling thoughts from a health services researcher at the VA. I always figured that a lot of the improvements came with the reforms Kizer put into place in the 1990s, such as the movement to service lines and putting into place performance monitoring systems. He also broke down the bureaucratic nature of the system and divided the VA into 23 vertically integrated service networks the leaders of whom have their renumeration tied to performance monitoring systems. As I understand it a number of the reforms were based on what what was occurring in managed care systems. However, I think because of the nature of private health care systems such reforms actually work better in an integrated system like the VA.
The dream of managed care was that because of capitation (i.e. limited amounted funds to treat each patient) there would be incentives in managed care systems to look after the long term interest of patients. However, in an employment based private system firms and individuals keep changing their insurer reducing the incentives for managed care organizations to care about the long term interests of patients. The VA is capitated in the sense that it is given a budget each year and patients stick around. There is a lot of incentives in the VA to create practices, proceedures, systems, invest in data collection etc. to track patients, to watch for comorbidity, etc.

Best,
Greg

Posted by: Greg G. on September 15, 2007 at 2:20 PM | PERMALINK

I wonder about privacy rights when trying to integrate into the hodge-podge healthcare system we have now. With the VA that's not a problem because anyone in the military doesn't really have privacy.

Posted by: Tilli (Mojave Desert) on September 15, 2007 at 2:25 PM | PERMALINK

As a recipient of VA hospital care I've learned that even new doctors know more about my medical history than I do. Also, curiously, I was diagnosed as PTSD five years before anyone told ME about it.

Posted by: buddy66 on September 15, 2007 at 2:26 PM | PERMALINK

Agree with Greg G.

Tilli's also right. Current privacy laws are written to prevent transmission of data between physicians without explicit consent of patients.

Posted by: J Bean on September 15, 2007 at 2:45 PM | PERMALINK

Phillip what do you think about Dr. Howard's redirection of Vista IT development recently announced at VEHU? It seems that by recentralization they are trying mightily to deny users much input into the IT process.

Posted by: An old fool for posting on September 15, 2007 at 2:54 PM | PERMALINK

We need a $50 transducer that hooks up to the home PC. With a little instruction manual and some software we can diagnos our own sonagrams.

Posted by: Matt on September 15, 2007 at 2:58 PM | PERMALINK

Gee, I wonder about privacy rights too.

The Phillip Longman's posting is just a little too non-privacy rights friendly to have been place on a supposed liberal blog. What the hell is the Washington Monthly doing? Is this a liberal blog or not?

Insurance companies use knowledge of your private health concerns to place riders on you - excluding you from needed treatment - rendering your health insureance policy meaningless - and accentually even some people can even find employment because businesses find you may have pre-existing conditions that cause their insurance rates to go up.

This part where your being told to give up your privicy rights of Doctor-Patient confidentiality is a nothing but a con-game. This confidentiality law is a basic US right - and you're being coerce to give up under on the exact same kind of spin doctoring the Bushies use for their social security privatization bullshit.

Why don't you take a hike Phillip Longman.

Posted by: Me_again on September 15, 2007 at 2:58 PM | PERMALINK

After many years of insurance programs that "let us choose" our doctors, we were pretty much forced into the Kaiser system.

I am shocked at how much better Kaiser is for us than the traditional system. A huge part of the difference is its computerized patient information system. Everyone can quickly tell what the heck is going on and get a fairly fast response to questions they might have for a referring or prescribing doctor. We also think it is great to schedule appointments, see test results, ask questions, and refill prescriptions on the web. It not only must be saving Kaiser a bundle, the system makes us feel that we are getting good, responsive care.

Although the value of the medical records system is clear to us, I have some real doubts that implementing in as part of a national system would play much of a role in controlling costs. I can see an initial, significant savings. I can also see that it will make the system work more efficiently. What I can't see is that the problems it fixes are those causing the rise in costs.

Posted by: Mark on September 15, 2007 at 3:10 PM | PERMALINK

Certainly the technology can improve a lot of things. But it seems to me that a big key to cost savings is eliminating the notion of insurance. The second part is eliminating the "for profit" entities.

By definition, having insurers and providers creates an adversarial system, which instead of acting to reduce costs, sends them soaring. Much of this phenomenon comes from the competition between the for profit provider and the for profit insurer, each vying for the piece of the pie to which each feels entitled. More automation of this madness might make happen more quickly, or it might cause it to metasticize.

Comparing the operation of my dentist to other providers is night and day. THe dentist office is fully automated, including almost real time access to xrays via the terminal at the dentist chair. They also can actually give prices for most procedures. Sure there is insurance nonsense involved, but the stakes are generally a lot lower in dental insurance.

So sure, by all means standardize medical system records and make them portable and available, and secure. In my view, the other issues are paramount.

Posted by: RickG on September 15, 2007 at 3:53 PM | PERMALINK

Mr. Longman, you need to study Estonia's health care system. They use "smart cards" with embedded chips that contain all of your health information and medical history. You swipe it once when you check in at the clinic and all information is uploaded to the doctor's terminal and you don't need to fill out one form or do another damn thing. Seamless and efficient.

How pathetic that a former Soviet satellite is leaving us in the dust, technologically speaking.

Posted by: The Conservative Deflator on September 15, 2007 at 4:09 PM | PERMALINK

I joined the VA system about four years ago after falling into a health care crack at the end of my active business career. It was a last resort for me, and I entered in thinking that I was going to get bottom-of-barrel care. Today I have absolutely no complaints.

I see my GP twice per year at a local clinic, and if I have any sort of illness I go straight to the VA hospital. If I need emergency service by ambulance, the VA will pay the hospital I'm taken to.

Prescription service is great, and unlike private providers, the VA has the ability to negotiate lower prices from suppliers. I get it in the mail two days after it's ordered.

Not being a career or disabled vet, I have some copay, but it's not even close to the costs of private insurance.

Posted by: Tom Chapman on September 15, 2007 at 4:14 PM | PERMALINK

Regarding privacy issues, while none of us would probably want our medical histories published in the newspaper, most of the really serious privacy concerns are related to insurance companies using our histories to deny us coverage. This wouldn't be a concern with a decent single payer plan (just as it isn't a concern within the VA or within Kaiser). If you are already covered there is no incentive to use your health against you.

Posted by: Emma Anne on September 15, 2007 at 4:18 PM | PERMALINK

As a Kaiser doc I see some disadvantage of the EMR system we use. It's slower to write notes and we seem to spend more time facing the computer screen than the patient. I don't see us saving money for a long time and in fact the huge investment in the EMR has made it necessary to raise rates locally, to the point where there's no advantage for us vs. the local BC/BS fee for service plan.

The advantage is realized in quality of care. We are so far ahead of the competition (excluding the VA where I don't have personal contacts, and can't say) in managing chronic disease, in large part due to our EMR and related systems. Even other local specialists have admitted as such to me. Here's an example. At Kaiser we're developing systems, some of which have been successfully implemented, in which a specialist uses the EMR to review the care by primary care docs of individual patients at risk to make sure that patients with chronic disease meet current standards of care. Primary care docs have to keep up with all the changing rules and standards in each and every specialty so they are grateful for the help. In fee for service, you can get a great doctor or a doc who's struggling (or not attempting to keep up with current standards of care) and in fact, you cannot truly know how good your doctor is unless you yourself are a physician. At Kaiser, you're pretty much guaranteed your primary care doc meets a certain level of care, at least in terms of chronic disease management.

Posted by: Brian MD on September 15, 2007 at 4:49 PM | PERMALINK

Mark, who has joined Kaiser, says:

Although the value of the medical records system is clear to us, I have some real doubts that implementing in as part of a national system would play much of a role in controlling costs. I can see an initial, significant savings. I can also see that it will make the system work more efficiently. What I can't see is that the problems it fixes are those causing the rise in costs.

Kaiser, like the VA, uses more than a medical records system to reduce costs. It is part of a system that allocates resources to save money and prevents future costly illnesses.

For example, when I have minor problems, I call the Advice Nurse for free. She can pull up my records on her screen and she knows what my basic health is like. Most times, I can buy an over-the-counter remedy and solve my problem. Once, however, I was told to go to Urgent Care (not Emergency.) I drove myself there and was treated by a Nurse Practitioner; but, a doctor would have been available, if needed. This whole process was cheaper for Kaiser—and for me.

To prevent costly illnesses like cancer, I am always sent reminders to schedule mammograms and pap tests. If I don’t respond immediately, I get phone calls. I also get an e-newsletter with health and diet tips and schedules for free flu shots.

Joining Kaiser is like being adopted by a nagging mother. Some people might resent this, but I like it. As a result, I am in good health--and Kaiser has saved money.

Posted by: emmarose on September 15, 2007 at 4:53 PM | PERMALINK

As a physician with friends who work for both Kaiser and the VA, I think that both have good records and that Ralph's sister is an ideologue. I have worked for several teaching hospitals that had disastrous change-overs to commercial electronic systems, sold by idiots who glibly said "We know exactly what you need, leave it to us" often abetted by pressure from wealthy people on the board of trustees to adopt this or that company's system because they had business ties to the company.

Kaiser seems to have a doctor and nurse morale problem, which the VA has less of. Kaiser, at least in Southern California, has been asking more and more of its doctors and nurses so that they can compete price-wise with HMOs that provide much inferior quality of care. More and more of their people are bailing out. Remember that society asks a lot of doctors and nurses; if they feel shat upon, they can move. People don’t even think about the advantages of being able to go to a Kaiser or VA Hospital in another city or state and have them instantly pull up your full medical record- they think only in terms of short term costs.

Commercialization of health care plus the huge debt loads that most physicians have when they enter practice guarantee that US medicine will be excessively shaped by drug companies and below the quality of that in many other countries; that's what I've seen. I agree that a system like the Estonian one would be a big step forward. It would however cost billions in the change-over and would be abused by our corrupt insurance companies.

Posted by: old croaker on September 15, 2007 at 5:43 PM | PERMALINK

Almost uniquely, its original code was written by doctors for doctors, as part of an ad hoc, collaborative process.

This is scary, but I see from comments above that it may not be the complete story.

Posted by: RSA on September 15, 2007 at 6:38 PM | PERMALINK

It took me a long time to get my head around these realities, but once I did it was easy to see what a big deal the VistA system is.

Does it run linux?
Imagine a Beowulf Cluster of these!!

Posted by: absent observer on September 15, 2007 at 9:13 PM | PERMALINK

The database is based on "M" a descendant of MUMPS. Not sure if the Model 204A product is a variant VA used at some point. There's a lot online about the history of Vista. Googling "hardhat" and Vista should get anyone interested started in the right direction. OpenVista runs on Linux and has an interesting story and potential all by itself. I think we're going to see a lot more of this software in the future.

Posted by: dennisS on September 15, 2007 at 10:06 PM | PERMALINK

I have worked for several teaching hospitals that had disastrous change-overs to commercial electronic systems, sold by idiots who glibly said "We know exactly what you need, leave it to us" often abetted by pressure from wealthy people on the board of trustees to adopt this or that company's system because they had business ties to the company.

This is my great fear with regard to widespread adoption. Vendors will come in, promising a turnkey system, they will have a massive project, and it won't really fit the needs of the institution. The evolutionary software model that the VA used will produce, over time, a much more usable and comfortable result.

The critical thing is that any system must be developed in a tight loop with users, and it must be expected by all parties that it will be changed on a regular basis as the parties refine their idea of what works best.

This is the model that produces the best software. Always.

Posted by: Doctor Jay on September 15, 2007 at 11:53 PM | PERMALINK

I wonder if Phillip will ever answer any of our questions. Are we just asking questions of an advertisement for his book??

Posted by: Doc at the Radar Station on September 16, 2007 at 12:56 AM | PERMALINK

Another very positive vote for Kaiser. No more hauling x-rays around or waiting for test results! It's all in the computer system and instantly available to all within the system. Plus I can see my lab test results on line and order refills. If I order online or by email, I get a 90 day supply for the price of a 60 day refill. That means I'm getting a 90 day supply of Vytorin 80/10 for $20.00. That also show the power of negotiating prices with drug companies!
And I can get same-day appointments,altho not always with my primary,but with they computer system,they can review every test and visit instantly.

Posted by: Palolo lolo on September 16, 2007 at 5:12 AM | PERMALINK

Actually, yes there is one definition of "open source."

Software is open source if it is released under one of the licenses approved by the Open Source Initiative. A list of licenses can be found at http://www.opensource.org/licenses/category .

Those licenses are chosen by the Open Source Initiative according to The Open Source Definition, which dates to 1999 or so: http://www.opensource.org/docs/definition.php

There's been no argument about this in the open source community since, I would guess, late 1999.

Posted by: Jamie McCarthy on September 16, 2007 at 8:01 AM | PERMALINK

Having quite a few years in healthcare information technology, I have to raise one quibble:

You "digitize" medical records by converting them to machine-readable form.

You "digitalize" a patient with congestive heart disease by dosing him or her with digitalis.

Posted by: Faber on September 16, 2007 at 6:35 PM | PERMALINK

Since we have this system established, does this give credence to the idea that we should extend the VA system to about everyone to make a national health care system?

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