Grass-roots strategy turns VistA into world-class health care program

But that reality has changed dramatically over the past decade and, in fact, the Veterans Health Administration has in many ways overtaken private health care in quality. A 2004 Rand Corp. study found that VHA patients on average received 67 percent of the care recommended by national standards, while other patients in the national sample received just 51 percent of the recommended care. The University of Michigan’s 2005 American Customer Satisfaction Index showed for the sixth year in a row that veterans were happier with their health care than others. VA scored 83 out of 100, while non-VA public and private institutions received a 71.

Most recently, the Veterans Affairs Department received major recognition of its health care turnaround in the form of an Innovations in American Government Award and a $100,000 grant for its electronic health records system. The award is sponsored by the Ash Institute for Democratic Governance and Innovation at Harvard University’s Kennedy School of Government, and is administered with the Council for Excellence in Government. The criteria were novelty, effectiveness, significance and replicability or transferability.

“It was very clear [that the program] was a home run,” said Patricia McGinnis, president and chief executive officer of the Council for Excellence in Government. “The software was actually developed in the VA, and that speaks to the novelty. The effectiveness goes to the heart of the leadership, building ownership and building a novel approach. In terms of significance, very seldom do you have results as clear as these in terms of what’s been accomplished and the ability to apply it to other areas.”

Stephen Goldsmith, director of the Innovations in American Government Award and a professor of government at the Kennedy School, said that while the agency is transforming health care, “secondly, and maybe more importantly, it allows the VA to measure health outcomes in a way not done before. Their huge database allows them to make prudent decisions. It has great applicability to Medicaid and Medicare, and has plenty of fascinating technology applications that would serve as a model for the private sector.”

The heart of the program is the Veterans Health Information Services and Technology Architecture, or VistA, a continuously evolving electronic medical record project that serves VA’s 7.6 million enrollees throughout its more than 1,400 medical centers, community-based clinics, nursing homes, residential treatment programs and veterans’ centers.

Its components include a computerized patient records system; a document-scanning application; a bar code system that electronically validates and documents patient medications; and My HealtheVet, a personal health record accessible to patients, family members and clinicians through a secure Web application.

VA officials and in-house programmers have been developing an electronic health record system for years. But as technology has matured, the system has become more comprehensive and sophisticated.

Dr. Robert Kolodner, chief health informatics officer at VHA, said the data is not only becoming easier to move around, it’s improving in quality. Even as a work in progress, VistA has let VA become acknowledged as a health care leader in the U.S. and globally.

Destination VistA. The VA program “is a model for modern health management,” said Stephen Shortell, dean of the School of Public Health at the University of California at Berkeley. “It is where the rest of the U.S health system needs to go in terms of widespread use of electronic information technology.”

VA credits VistA with helping it achieve a number of goals, including lower costs, better care, fewer errors, fewer hospitalizations, and promotion of preventive care. Patients’ waiting times have declined, and access to care has increased because of online availability of health information.

And while the cost of private health care providers has escalated 40 percent, VA is actually reducing costs through the VistA program, officials say. For example, pneumonia hospitalizations have been cut in half because of improved vaccination rates among veterans with emphysema, reducing costs by $40 million per year.

Indeed, over the past 10 years, while the number of veterans receiving treatment has more than doubled—from 2.5 million to 5.3 million—VA has treated them with 10,000 fewer personnel and kept costs per person steady during that time.

Overall, VA’s cost of maintaining its system is $87 per patient annually—less than the cost of one lab test.

Because VistA consistently provides physicians, nurses, pharmacists and others with virtually immediate access to patient data—it has a 99 percent uptime rate—decisions can be made based on a holistic understanding of the patient’s medical history.

According to VA officials, the use of electronic health records has largely eliminated errors stemming from lost or incomplete medical records.

Preventive care is also facilitated through the system. Clinical reminders, for example, alert clinicians when a test is required.

But technology, no matter how good, cannot alone transform an organization and how it delivers health care. VA’s leaders realized that there was an urgency to transforming VA health care, so they used a frontline implementation strategy and a performance management system to ensure that the program met goals.

“If the VA kept going the way it had 10 years ago, it might well be out of business,” said Dr. Jonathan Perlin, senior vice president for Nashville, Tenn.-based Hospital Corporation of America and, until earlier this year, undersecretary for health at VA. “Our noble mission was that the focus should be health promotion and disease prevention. It should be more efficient, less expensive and better for patients. Our goal was safe, effective, efficient and compassionate care. We cultivated that model.”

VA’s executives knew that such a culture-changing initiative would affect thousands of health care workers and require an approach that would engage the users.

Perlin and Kolodner agreed the key factor in VA’s success was that, from the beginning, the program was led, fostered and supported by the frontline clinicians.

“What’s so critically important is the clinical community buy-in and ownership,” Perlin said. “We went to extreme care to make sure that everyone was involved—administrators, doctors, pharmacists, nurses.”

Once a technology was developed, individuals came on board to be first users of the system, Kolodner said.

“They’d provide feedback,” he said. “A certain amount of configuring the system needed to be done so it fit a particular workflow used at a given site. These first users became our champions and could market the system to their colleagues about why it was good. It wasn’t the administrators or IT people who did this.”

Dr. Robert Lynch, director of the South Central VA Healthcare Network, described the program as a “grass-roots effort” in a presentation to the Harvard committee that evaluated it for the Innovations in American Government competition.

From the Bottom Up. “There was no master plan laid out years ago to do this,” he said. “It was an interactive approach developed from the bottom up. The technology pieces were centralized, but in terms of creating the foundation, our clinicians drove this process.”

VHA also established VHA eHealth University, an annual training conference that educates users on the system and is an effective technology evaluation environment. VA officials effected some structural changes in the organization as well. For example, they made a decision to let funding follow patients instead of hospitals so care would be delivered where it was most appropriate, Perlin said.

The program’s performance measures hold VA accountable to veterans, taxpayers, the Office of Management and Budget, and to itself. The electronic health record provides the support system for meeting these measures and a data system for meeting performance measures, Perlin said.

The program “is innovative because of its unique linkage with systematic, rigorous performance measurement,” Perlin told the evaluation committee.

The program’s six performance measures are quality, access, customer satisfaction, restoration of functions, community health and cost-effectiveness.

This grass-roots, performance-based strategy has led experts in the health care industry to marvel and try to emulate what VA has done.

“I think the VA is a wonderful example of what a large health care system can do in utilizing electronic health records,” said Marie Schall, a director at the Institute for HealthCare Improvement in Cambridge, Mass., a nonprofit organization that seeks to improve health care worldwide. “We’re working with organizations now to help them maximize the functionality of electronic health records.”

Other federal heath agencies are adapting VistaA for their own purposes. For example, the Health and Human Services Department’s Centers for Medicare and Medicaid Services is collaborating with VHA to make the benefits of electronic health records available to private physician offices and clinics.

In addition, the VistA Software Alliance is facilitating the widespread adoption of VistA, which has been implemented in the United States, such as Hawaii and Oklahoma, and and abroad in places such as Egypt, Samoa and Mexico.

Schall and others believe that VHA’s approach to building the program cuts across all organizations.

“One of the keys to success is making sure that the frontline using and touching the technology has input into the development and that they feel it will help them as well as the system,” Schall said. “There are examples of systems that have had a lot of money invested in them but aren’t used because they don’t meet front-line needs. A way to avoid that is to engage those who use it. This is a wonderful example.”