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From our prior discussions, you're familiar with some of the background information that you see on slide 2. For the purposes of this discussion, it is important to note that we are a large training facility for medical residents and nursing and other allied health professionals throughout the United States. This means that these individuals are exposed not only to the veterans but to our electronic health record.
On slide 3, you see a screen capture of the face sheet of our electronic health record, the basis of which is known as VistA, the veterans health information systems and technology architecture. The computerized patient record system actually sits on top of this system called VistA, which we've had for almost three decades. The interface with the clinician and the electronic health record is about a decade old. This is available throughout the country. If a veteran is seen in New York and goes on vacation in Florida, the clinicians there can access the information, including images from around the country.
On slide 4, we have pictorial representations of the use of the electronic health record in place. In the upper right-hand corner is a cardiologist using the imaging component. Imaging encompasses not only radiology images but also cardiology images and waveforms. It could be a video of an entire procedure, for example.
On slide 5, we go into a little bit of what I referred to earlier as this availability of data no matter where the veteran presents. We have different applications that are used for this. The thing you might be interested in is that the component of VA that does the benefits determination for compensation also has access to our electronic health record. For example, when diabetes related to Agent Orange exposure in Vietnam is determined to be what we call automatically adjudicated if the veteran has diabetes and was exposed to Agent Orange, for those veterans that we treat directly, we can use the electronic health record to actually find that without bringing the veteran back in.
So there are uses for direct clinical care, for quality oversight, and for benefits determinations.
Slide 6 talks a little bit about that evolution I referred to and the fact that for almost three decades our practitioners have been able to look up lab results, radiology results, and pharmacy information in electronic format. Over time, really, what we've built on top of that is the clinicians actually ordering their own medications and seeing their own drug-drug alerts and other clinical decisions support that's presented to them.
Slide 7 shows some comparative statistics of the volume that we're talking about within our electronic health record system. It's just a point of reference. Because of the nature of how we provide care, which is much like a closed system such as yours, it means that we do reap the benefits of providers not reordering a lab test because the results were not available. Or it means referring a patient to a consulting physician and making sure that information is available without repeating radiology tests or laboratory tests just due to the unavailability of records and results. This talks about that economic benefit a little bit.
I want to touch briefly on our sharing with the Department of Defense. We have done this incrementally over time. It began with just the ability to view Department of Defense information. The most recent evolution is actually invoking clinical decision support on information from the Department of Defense in our system and the VA system and, in turn, the Department of Defense invoking clinical decision support. So it means that drug-drug and drug allergy interactions are performed not just on the information within the local database, but actually across the two organizations.
The “Quality Evidence” slide just talks about how our electronic health record has really been noted throughout the country, both in the private sector and in the public sectors, for the impact it has had in the area of economic savings, as I just discussed, but also in the area of quality and that ability to remind physicians of interventions for chronic disease patients or preventative medicine interventions such as influenza vaccinations or pneumococcal vaccinations.
The next slide, slide 11, provides a link to a demonstration site of our electronic health record.
I was also asked to cover the personal health record, which is a newer project for VA. The vision was that patients would be in control of their information, including information they record in this online database, but also that it would serve as a trusted source of health information. We collaborated with the Department of Defense to contract for a commercial health information module, and we actually augmented that with veteran-specific diseases, injuries, and mental health conditions. It has really evolved over time.
I'll talk about that a little bit. It was to improve access to services. It's also the way we provide for the veteran to communicate if they have external-to-VA physicians or want to look for assistance for a family member in the progress of their treatment. So we list some of those benefits here: improved communication and enhanced satisfaction with resources.
For example, in 2008 we added the ability for parts of the medical record to be available online to the veteran through this personal health record portal, so that they wouldn't have to come to the hospital to obtain a copy of their lab results or radiology results. This year, in 2009, we're adding the ability for veterans to communicate with their clinicians through a secure portal on My HealtheVet to ask questions or to clarify treatment requirements.
On slide 16 we've added some of the statistics about this. As we've added new functionality, it has encouraged more veterans to participate. For example, when we added the ability to refill prescriptions online, there was a large surge in the number of veterans who signed up online to participate in My HealtheVet. We anticipate a similar surge will come this year when we add the ability for provider-patient communications.
The next slide talks a little more about that. The veterans can also use this site to record military histories or personal histories, or as a diary to record their blood pressure, temperature, weight, anything that they may be tracking personally or that their provider has asked them to track.
The other things that we use both of these tools for are patient education and patient involvement. It's a big impact to the patient when you can show that a new medication or a change in lifestyle—weight loss or stopping smoking—reflects in their lab results or their spirometry results. To make that correlation between changes in behaviour in a positive or negative way has been another use of the electronic health record and the personal health record.
On My HealtheVet we also collaborate with research to make sure that veterans are aware of research opportunities specific to their disease or specific to veterans. This is another functionality that we use.
We talked earlier about the ability of veterans to refill prescriptions online through My HealtheVet, and we've depicted that here with the My HealtheVet pharmacy options. As I indicated earlier, this was certainly a highly requested feature. All of the features that we've added to the personal health record are determined by veteran focus groups and veteran advisory groups that tell us what they would like to see.
We believe these two tools are complementary. For example, we're doing more monitoring in the patient's home through our telehome health. So if we have a chronic disease patient with congestive heart failure and we want to monitor their vital signs daily and just generally how they're feeling, we transmit all of that information to a nurse, who may be monitoring 200 to 300 patients. She can intervene at any point when seeing any of the indicators going in the wrong direction.
Then they maybe contact someone else, the nurse picking up a phone and calling the veteran. We've found that this has avoided hospitalizations, has reduced lengths of stay, and has had a positive impact. It's possible because of these two technologies that support alternative treatment modalities, bearing on the electronic health record and the personal health record.
We also use this to remind the veteran when preventative services are due, and we find it to be an effective way to do these reminders— for vaccinations, or to remind patients to wear a seat belt or to quit smoking. We are adding reminders to the functionality.
The other thing we're adding to our electronic health record is an indicator to the provider. This way they know that the patient they're dealing with has a personal health record that can be used for communication, to examine results, or to access health information resources available through My HealtheVet.
Let me now turn to future releases. There is secure messaging, which has been highly requested. We had problems doing that via regular e-mail, so we looked in the United States and other places and found providers that were more experienced in using electronic communication with their patients, and we decided on the secure portal approach. We're also adding things like MyRecoveryPlan to use as an education tool between the provider and a patient recovering from surgery or other interventions. In the future, we hope to add components that will enable the patients to request appointments and do some other health care business online. There are some veterans who have co-payments that are due, and those co-payment balances can also be monitored online.
I'm ready to answer your questions.
So the access, for example, in our medical centres is actually governed by what your role is in the medical centre. It's done through a series of menus and keys for specific access. For example, only physicians who have medication ordering authority have a key to do medication ordering. So in many cases the electronic access gives us the ability to limit and control access in a way that we were never able to do in a paper environment. This comes not just with the technology, but we also do a lot of training with our providers on what is appropriate for them to access, what they need to know, how they determine the “need to know” of information, both by administrative staff and by clinical staff. So it's a combination of technology limiting access and educating those who use the system on what's appropriate to access.
We tried for many years moving the paper record around and trying to keep it secure, and in no way do I believe that this paper record was more secure than the electronic environment we're in today. So right now the access to the system would be limited to those who have a relationship with VA, either a VA employee or someone who's contracting on behalf of VA to provide those services. We do have mechanisms to control access down to individual patients. So for example, in this country veterans' service organizations assist the veterans in preparing their claim files, and that is done by issuing a power of attorney between the veteran and the veterans' service organizations. In those cases, they only have access to those veterans. The same is true for our quality and oversight groups. We will limit those to the “need to know”, as is also the case for research. We can limit research down to those who are participating, for example, in a research study.
On the second question, on whether there are things that cannot be put into a client file, I know there are some organizations that do not put HIV results, for example, in their electronic health record. This is not the case for VA. We do include what we would call sensitive laboratory results or test results. One area in which you may not see all of the information is mental health. Mental health may put in summaries of information but retain detailed client notes separately from the electronic health records system. So this is an area that very likely may just have summary information and not all the details.
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I'll answer the second question first.
By law, our retention of records, paper and electronic, of the patients' medical records, is 75 years after the last date of inactivity. When patients expire, we have an obligation to retain their records for a period of 75 years. Much of this has to do with spousal requests for benefits and for research purposes. And much of that came after it was determined that ionizing radiation exposure, for example, had harmed individuals and that many of their records had already been destroyed. So for about the last 20 years, we've had a 75-year retention requirement for our medical records, regardless of the medium they're in, whether paper or electronic.
Our electronic system has a security foundation--we talked a little bit about this earlier--that works with a series of menus relative to the job within the facility. For example, the housekeeper doesn't have the laboratory menu and the nurse doesn't have the physician ordering menu. That's one level of the security that's applied. All the individuals who work for the VA or who have access to computer systems have background checks. They have to take privacy and security training. And then the system itself has security safeguards. The first level of that is the menus, subject to the job.
The second level of that security is known as security keys, specifically keys that have to be granted to you to do certain functions. The example I used was the ability to order medications. That has to match up with what you are authorized to do by your licence within the organization.
To speak to who's accessing, one of the advantages of the electronic health record is that it's not only in one place at a time. If you are an in-patient and your physician wants to review your chart, but you also are in radiology receiving a procedure, both of those providers could be looking at your record at the same time. So this multiple access was intentional.
We do lock the system in certain areas. Two providers cannot be ordering on one patient at the same time, so there cannot be conflicts between the orders.
The ability to access from multiple points is certainly a benefit. Also, the ability to audit who's accessing the record is another benefit of the electronic health record. You know who accessed the record and when it was accessed, along with the components of the record accessed.
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Certainly. The system takes into consideration the veteran's age, sex, and chronic diseases. For example, just general preventative medicine may be reminders for the annual flu shot, or if they happen to know that this patient has congestive heart failure, it may also include their pneumococcal vaccination.
These reminders are shown to the clinician, and in My HealtheVet now, we also show them to the veteran if things are due. They also include things like talking to the patient about whether they smoke and, if they do, offering intervention to stop smoking. It may be the use of seat belts. It may be that they live in a certain part of the country and are exposed to different diseases in that part of the country. It can be logic based on any information about the veteran—their age, their sex, their personal health history, their family health history.
For example, we may do a preventative reminder for mammograms on women veterans over forty. If it takes into consideration your personal health history or your family health history, that you have a history of breast cancer in your family, it may do that reminder when you're thirty, for example.
It's the same thing with colonoscopy or colon evaluation after the age of 50, with those things that are recommended through different clinical means. We work with the Department of Defense and with the private sector on what are the interventions, at what time. This then expands into chronic care. For example, diabetics, under our quality measures, are required to have an annual eye exam and an annual foot exam.
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Sir, I certainly understand that. There have been large and published electronic health record implementation problems around the country. They've been in the newspapers and the trade magazines.
With VA, I think we started very small and very slowly. We started at one of our smaller, less complicated facilities when we went down the road of a true electronic health record, with the clinicians actually ordering through the electronic health record. I think that was an advantage.
It was also important not only that the nurses and doctors adopted this, but that administrators recognized that, for example, when we implemented the electronic health record in a medical centre or clinic, many times that required that the appointment time be extended from 20 minutes to 30 minutes, for example, because it took longer for the clinician to interact with the system, especially during the learning time.
We talked about these preventative reminders. All of those reminders come with some time impact to the clinician. We believe that impact is positive, that it maybe avoids illness or patients returning unnecessarily. So certainly that recognition that it requires time for the clinicians to adapt to this technology and that it may require longer time permanently is important. Many of our clinics still run 30-minute instead of 20-minute clinic appointments.
We had some pretty widely publicized problems a few months ago with the latest release of our electronic health record system--problems that were not found during testing. For example, we had a flaw in the latest release that changed the viewing of the discontinuation of medication orders, and nine patients received IV infusions and infusion heparin for hours after the physician discontinued the order. We identified the problem. We have mechanisms in place for the medical centres and the physicians and the nurses and the clinical application coordinators to report suspected problems immediately so we can research them.
Certainly you have to put in an infrastructure that allows providers to report problems with the system. For us, it created a whole new occupation called clinical application coordinators, who are available to help clinicians should they have problems with the system. I think that's absolutely necessary. We can anticipate that's going to be one of the challenges as electronic health records go into small physician offices that really can't afford full-time support.
We've had lessons learned in deploying slowly, giving time for clinicians to be trained and use the system, taking care and testing the system thoroughly, and making sure when we develop systems that we take heed that clinical practice is not uniform at every medical centre and clinic. It all requires that we do our due diligence and that we be good stewards of this technology. It's a tool, but it's just a tool, and it is still required to work well within the flow of clinical practice.
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Actually, we don't have provisions today to have doctors who don't participate. This is how they access their results. This is how they order their medications. We gave them a period of time for the conversion, during which we accommodated both processing orders--non-electronically and electronically. But as I stated earlier, about seven years ago we really had to make the full conversion over to the electronic environment. A lot of that was prompted by physician colleagues. It was really a dangerous situation not knowing if what you were looking at electronically was complete or having to look at both the paper record and the electronic record. Really, when you make the conversion, you have a period of time with both, but to prolong that period of time really creates a very dangerous situation.
In this country, we have an oversight body called the Joint Commission. This is really an area they watch closely to make sure that as organizations convert to electronic situations, providers are well informed about how they access information.
I'm sure there were some providers who retired during this conversion, but to say that it was only our older physicians would not be the case either. What we see now is that it's a big recruiting tool for young physicians. Many of our physicians, when they go out into private practice, are very upset that they don't have access to electronic health records, as they did during their VA experience.
We see it today as more of a recruitment tool. As I said, during the last decade I'm sure there were physicians for whom it prompted retirement from VA, but it was not a mass exodus of clinicians. Some of that may be attributed to the fact that for two decades before we moved in the direction of their actually interacting with the computers to enter their orders and their progress notes, our clinicians had been accustomed to looking up information. We still allow, in some areas, some dictation of longer reports, such as discharge summaries or operative reports or histories and physicals. And some of our clinicians use voice recognition software to enter their progress notes, for example, so that you may see different flavours in how they interact with the computer.
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Other organizations similar to us, like the Indian Health Service, which provides care on reservations and non-reservations, have had an electronic health records system for some time. The Department of Defense was an early adopter of the core systems and has gradually moved to the electronic health records system. Organizations such as Kaiser Permanente and other large health care providers have seen that this enhances their ability to manage patient populations. We see the adoption more prevalent in organizations that reap the benefits in financial and quality performance.
I think in the VA there was a perfect storm of technologists who were interested and innovative, together with clinicians who saw that there was a better way of delivering care. Putting the two together created a perfect storm, out of which this system came. It wasn't perfect out of the box, but our providers know that it will be improved as time goes on and that we will listen to their input and make changes incrementally.
So I think it was all those things combined. In the long run, this is not easy. You have to think about the different ways clinicians practise and make sure that what you're introducing is a help and not a hindrance. You also have to educate patients. If this is something consumers want, they have to drive it. For those with chronic diseases trying to maintain continuity between physicians and carrying around boxes of paper documents, this is definitely something that will make their lives easier.
In the future, I think a lot of this will be driven by the consumer. But it takes care and planning in respect of how you want to roll it out. You have to determine the needs of the different specialties. Mental health, for example, was one of the first software packages we released, and that's not a common component in most electronic health records systems.
The seamlessness between in-patient, outpatient, and long-term care is also important. Many times we see that vendors are only selling outpatient records, in-patient records, or long-term care records. Integration, though, is really the key to both the usage and the continuity of care for the patient.