Saturday, March 3, 2007 | In recent months, national media have highlighted the challenges facing injured veterans returning home from fighting in the conflicts in Iraq and Afghanistan. A series by The Washington Post, in particular, has focused attention on the neglect at one of the nation’s top facilities for veterans health care.

However, in recent years, the Department of Veterans Affairs has proven a pioneer on one front of innovation in the delivery of health care: the use of electronic medical records. The federal government operates 157 medical hospitals for former soldiers, in addition more than 1,000 smaller clinics and care centers — and all of them rely on digital records for recording the treatment and medical histories of veterans.

In San Diego, the system maintained by the VA Hospital in La Jolla has even attracted international attention, with doctors from around the globe making visits to study its implementation.

Health care experts say a wider use of electronic medical records could dramatically reduce hospital errors, currently the biggest preventable cause of death in American hospitals. President Bush has also made the drive toward the digitizing of records a key priority of his health care policy.

But as Dr. Robert Smith, the director of critical care services at La Jolla’s VA Hospital, explained recently, a national system of electronic medical records can also create privacy concerns for patients.

Can you tell me a little bit about the VA’s electronic record system?

Certainly. The VA has been a pioneer in the development and implementation of electronic record systems really going back to the late ’80s, when a great deal of information, laboratory data, medication data, radiology data was being placed into mainframes. Then, in the mid-’90s, the VA made a decision that, in order to really achieve the kind of quality of care that it wanted to for the delivery of good health care to veterans, it really needed to have in place a system to measure quality and to display information to providers, and really decided to develop and implement an electronic medical system.

How many records does it have?

Well, first off, you have to recognize that all veterans have their records documented electronically. So it’s not a question of whether a half of them, or whatever. One hundred percent of the care provided at the VA is documented electronically. And I think we are talking on the order of 3.5 to 4 million people. …

In terms of pure cost, how much on investment did it take? Is it a savings overall?

Well, I’ll answer that in two or three ways. Trying to calculate the return on investment and the overall cost of electronic medical records is a little bit difficult. The reason for that difficulty is that some parts of the infrastructure that you need for electronic medical records may be there anyway. So if I have a hospital and I’m having to put in place a network in the building in order to have offices connected, that’s a big chunk of the cost of electronic medical records, so how much of the cost can be attributed to the system?

Overall, the cost for delivery of electronic medical systems at the VA has been estimated to be around $40 or $50 per patient per year, which, overall, I think is pretty modest in terms of cost. And then the return on investment is huge. It’s been estimated in the private sectors that something like 15 to 25 percent of lab tests are reordered because the physician can’t locate the test. And the cost of just pulling a paper record from the file room, delivering it to the office, and then filing it again — if you look at personnel costs, storage costs and so forth — is maybe $10 a visit.

So when you start adding those things together, and balancing them against the cost of electronic medical record systems, depending on how you do the analysis, I think you can even show that electronic medial systems not only pay for themselves, but they return a huge dollar on the investment that you make.

Is it unusual that the VA has been leading in this sphere, instead of say a private insurer?

Well, I think it’s unusual in some ways. In fact, it’s not just the VA, but the federal health care system has generally led private sector here. The VA has been a major leader in this because the VA has really the largest enrolled health care population. In many ways, it’s the largest health care provider in the world, in terms of an integrated system.

And do the patients themselves actually have access to their records? Have you heard any feedback from them?

Right now, today, the patients don’t have direct access to all aspects of the electronic medical records. Patients own their medical records in any system, so they can certainly get copies of the information, but the VA is actually building a portal that’s called My HealtheVet for patients. It has been implemented, but right now it’s only in a more educational mode.

But the intent is that it will allow patients to view their electronic medical records online, and to see their lab results and health care reminders online, and to communicate with their health care providers in a controlled fashion.

One of the big issues with access to care online, or access to records online, how do you do it in a secure way, so that only the right person sees them? Some of those security issues are some of the things the VA is working on.

I know that one of the biggest problems — one of the biggest killers — in U.S. hospitals is simple, human errors. How has electronic record system changed that?

Sure, there is no question that electronic health records can be a huge tool in improving patient safety. Perhaps the best example I know is the use of automation in the delivery of medication.

One of the things the VA has also pioneered is the use of a system that uses barcoding to double check the delivery of medications at the bedside. So, using barcode scanners, the same thing you see at the supermarket or the same thing a rental car company might use to check your car as you drive in, the VA, at the bedside, has its nurses use a computer system. We have a completely electronic medication list. And the nurses scan the patients’ wrists and then scan the individual medications, and then if it’s not the right medication, at the right time, for the right patient, at the right dose, given the right way, the system basically flashes a red light and says, “Don’t go ahead.”

We’ve shown that we can reduce medication errors by more than 70 percent using this system, and it’s a huge change, and it’s just the tip of the iceberg in terms of reducing error and improving quality. … It’s a huge advantage in terms of preventing errors, through simple things, like having patients’ records documented.

I run a lot of the quality reports for the facility, and I can show that, of the patients who are receiving medications, literally 100 percent have their allergies documented. It sounds trivial, but the system automatically double checks if the physician tries to order medication to which the patient is allergic. Perhaps the patient can’t tell him that right at this time; perhaps he had an accident, perhaps he is unconscious for some reason.

Why have electronic records not really caught on in the United States to the same extent as Western Europe?

I don’t want to overestimate how much they have caught on in Western Europe. But one of the things you asked about before, why has the VA been leader in this, because it has a system of managed care. And many of the systems in Europe similarly have a system of government organized, managed care, if you will. And it’s those larger systems that can realize the return on investments and the advantages of a seamless electronic medical record system.

In the United States, care has been much more fragmented, between hospitals and individual physician groups, and care delivery, both in terms of who is paying what, who is delivering what, and where things might be done. So there hasn’t been as much of a push to share the information widely. But I think that’s changing. The Centers for Medicare & Medicaid Services, in the Department of Health and Human Services, actually has a number of groups that have been put together to try to define the standards for electronic medical record systems and to provide incentives, if you will, for the sharing of information.

In fact, in San Diego, the San Diego County Medical Society has really been out in front in trying to develop standards and create a framework for the exchange of information between health care providers. Even the simple things, like information on the prescription that patients are taking … sharing that between physicians could go a long way to beginning an exchange of electronic medical records.

Critics of electronic records point to concerns over privacy. To what extent do these concerns have merit?

Oh, I think they have a great deal of merit, in the sense that there is reason to be concerned any time you start putting sensitive information into a forum where it might be readily sent out or copied inadvertently. Those are concerns, and patients have a right to want to have their sensitive information maintained in a confidential way.

Those are the things that have to be looked at very carefully, and we have spent an awful lot of time and efforts at the VA trying to make sure that the records are protected behind the right kind of firewall, that they are only available to people with a need to know. Having said that, there is more risk, if you will, that’s involved in electronic medical record systems. And if the VA has put together a system of medical records that can be shared with physicians across the country, it has also put in more vulnerabilities. And it’s a concern.

But saying that it’s a concern doesn’t make it insurmountable. The standards for providing appropriate security to records, the standards for making sure that communications can be encrypted and only shared with the right people at the right time, I think, can be developed and put in place. And the advantages of the electronic record systems are so immense that I don’t think privacy concerns should be used as a reason not to pursue them.

If you look at health care industry, although it’s one of the largest in the United States, it’s been one of the slowest to look at the usage of new automation technology and so forth. Again, it’s shocking: You go to the grocery store and someone can see more automation in the automation of commodities on the shelves than you see in the physician’s office of things that are of vital importance to you as an individual. So the reason, in part, is the complicity of health care delivery — it’s a very, very complex structure that’s hard to get your hands around — and because of the concerns about privacy.

In recent months, the VA has been involved in some controversy on this front as well. Last year, a laptop with information on 27 million patients was stolen, and in February, an Alabama hospital lost records for another 1.8 million people. What have you done to make sure that doesn’t happen here?

Oh, yes, and that was a very painful time for the VA, and those concerns remain one of the really primary issues that the VA leadership is grappling with. From what I just said, that privacy is a concern, is highlighted in that particular episode. That episode had to do with an individual who was trying to do analysis — at least I believe they were trying to do analysis — of some efforts that had to do really with VA benefits more than VA health care, but nevertheless had a file that Social Security numbers of a large number of veterans and veteran dependants. And that individual shouldn’t have had that information, at least in the format that he had it.

Now since that time, the VA has taken a lot of steps to the effect of basically encrypting all of the laptop devices and hard drives that are out there, and has moved very rapidly to try to plug those leaks, but sometimes you are in a position where human error can cause problems. This is really one where we really need to build technical systems that can prevent human errors to prevent the release of information that shouldn’t be released. …

One last question, what sort of other innovations are in the works?

Well, you know, health care records are a constantly evolving field. And having been in the position of leadership, the VA is really trying to move ahead and to continue to develop their electronic medical record systems to provide more flexibility and functionality for the providers and more accessibility for the patients. …

For example, the VA right now has developed a system that allows patients to document their consents for procedures online, using the same electronic signatures they might use in commercial settings. …

So we’re learning, over time, how to have the best encounter with the patient. But one of the concerns that are still there, and one that we worry about a lot, is that we want to be dealing with patients, not computers. So how do we use a computer in an office visit in a way that promotes good quality health care and doesn’t interfere with the interaction between the provider and the patients. Those are things we are continually learning and trying to find the tools. I think some of these might actually allow the patients to interact with some of these electronic systems even before they see a doctor. So you can imagine a system with a tablet PC, or a kiosk, where the patient may actually answer some questions on the computer perhaps by clicking a few buttons with the mouse, or using a stylus, that might help indicate what the patient’s concerns are. …

It is fascinating, and it is interesting, and it’s really one of the exciting things that is happening in medical care right now.

— Interview by VLADIMIR KOGAN

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