The instant availability of the EHR system is a key benefit of practicing in a VA hospital, says Dr. Saint. “It involves not only being able to get up-to-date, relevant patient information at our VA but also the information obtained if the patient has been seen at other VAs.”
“One of the reasons why [the VA’s EHR] is so good is that it is fully integrated,” says Dr. Kizer. “Everything was made to fit together to begin with—in contrast to essentially all commercial products, which have been melded together from pieces that come from a variety of origins. Being fully integrated certainly increases the speed and efficiency of operations. The second reason why VistA is so good is that it was developed by clinicians for clinicians … .”
A key feature operating as part of the EHR is the focus on computer-based provider order entry (CPOE). CPOE can help physicians make correct clinical decisions, says Dr. Saint. He cites the example of a pilot test he and co-workers conducted at the Seattle VA: After 72 hours of urinary catheterization in a patient, an alert reminded physicians to remove the catheter. From that simple type of quality improvement experiment, the data revealed that those patients for whom the reminder had been used had a significantly reduced rate of infection compared with those for whom it had not.
One particularly good, but perhaps underutilized, aspect of the computerized system is the use of care protocols or models that can be used across the VA, says Peter Kaboli, MD, MS, hospitalist at the Iowa City VA Hospital, an affiliate of the University of Iowa. “And we could probably … have more available electronically [that] could be modified for the local care environment,” he says, adding that insulin protocols come to mind first.
Another key EHR feature is an extensive adverse event reporting system, including registering near misses. About 96% of prescriptions and physician orders are entered with the system; in private sector hospitals, the rough estimate is 8%. There is also a bar-coding system for verification of medications and identification of patients. The VA “has done a great job of changing the culture to foster systems-based care and to address errors and adverse patient outcomes straightforward[ly] and deal with them up front.”
Another distinguishing feature of the VA, says Dr. Saint, is its heavy investment in quality improvement and health services research (HSR). The VA has large repositories of administrative and clinical data for performing research with hospitalized patients. Dr. Saint also points out that a lot of the academic centers benefit from having a VA as an affiliate. “The house staff, medical students, and physicians often will be at the VA [and can] see the state-of-the-art electronic medical records and CPOE system and inquire, ‘Why can’t we have that at the university hospital?’ ”
Discharge: Seamless Transition
Dr. Kaboli can point to another advantage for hospital medicine in the VA: a concerted interest in developing hospitalists. Two-thirds of VA medical centers (VAMCs) use hospitalists, and two-thirds of inpatients are cared for by hospitalists. In total, approximately 400 hospitalists are employed by the VA, making it the largest single employer of hospitalists in the United States. Within two years, 75% of VAMCs will use hospitalists.2