An evolutionary tale: EMR system at VA hospitals
'No innovation is born perfect'
In perhaps a perfect illustration of the risks associated with technology, Hospital Peer Review spoke with the VA hospital system about its home-grown electronic medical record (EMR) system, VistA, initiated in 1982. At press time, the Associated Press reported that the House Veterans Affair Committee, led by Rep. Bob Filner (D-CA), was launching an investigation into alleged errors caused by "software glitches" in the hospital systems' EMR program.
The AP said, "there is no evidence that any patient was harmed," but goes on to say patients at VA health centers received incorrect doses of drugs, necessary treatments were delayed, and other errors might have occurred as a result of these glitches.
Questioning the forthcomingness of the VA hospital system, in a release Filner said, "The VA has been plagued by poor leadership and management. It is troubling to learn that the Under Secretary of Health did not approve the field release of the new upgrade. No one expects new software to operate perfectly, but confidence must be inherent in any electronic medical records system. VA bureaucrats consistently refuse to provide necessary information regarding the serious problems that affect veterans and this pattern of secrecy is disconcerting and does enormous harm to all stakeholders. I expect an attitude of leadership and transparency with the Obama administration."
Mark Graber, MD, FACP, chief of medicine at the Veteran's Administration Hospital in Northport, NY, says the VA has been transparent about the issue, which is yet a further example of how "no innovation is perfect."
In response to the AP story allegations, Graber says: "The Version 27 software problems with the computerized patient record system were recognized at several VA sites across the country; the patient safety concerns were conveyed through established channels, national alerts were issued to make sure everyone knew about the problems, and the software was repaired. No patients were harmed. The episodes illustrate VA's capability to effectively learn from, and respond to, close calls, recognizing that any problems in our electronic health records system can imperil our patients."
As he explains to HPR, the EMR system was initiated in 1982, imaging was added in 1992, and in 1994 the VA hospitals started using electronic orders. "Within a couple of years," Graber says, "it went from being optional to required."
Now, 15 years later, reluctant staff members who were oft heard saying things such as, "I'm not a typist. I can't use this system," are huge champions, Graber says.
The system is in its 27th version of the VistA program. When you design systems such as EMRs, Graber says, "it's impossible to design them perfectly on the first try. People who study design find that it takes, on average, seven iterations before you find a design that's workable... It's an innovative process that evolves all the time."
Lydia Washington, MS, RHIA, CPHIMS, director, practice leadership for the American Health Informatics Management Association (AHIMA), says the alleged errors could have been a result of inadequate testing of a new version of a system that had been in operation for awhile.
"It sounded like there were overlays of patient records — wrong patient, wrong record," which she says is nothing entirely new for the health informatics field. It is important, she points out, to have a designated person in the health informatics department assigned to fix those types of problems.
"If you're lucky," Graber says, "you have a system for feedback so that people who notice problems can bring it to attention. We definitely have that set up at the VA."
EMR adoption has been a positive step for the VA. "Overall, it's a tremendously positive experience. It frees up my time as a clinician and everything I need is at my fingertips. And the safety issues are incredible. There's just so many built-in safety features that keep me from making mistakes that might otherwise happen."
He applauds President Barack Obama's push to implement EMRs nationwide in the next five years. "I would be a strong proponent of universal adoption as soon as we can. But you do have to watch out for these, we call them 'innovation surprises,' and they're very real," Graber says.
He points to bar code medication administration systems as a "perfect example of innovation. If you look at it at a global level, it's been enormously successful in preventing medication errors. Is it 100% successful? Absolutely not. New innovation, no matter what kind of innovation it is, no matter where it's implemented, creates some problems that didn't exist before."
If you have a smart health care record, he says, you would build in alerts or checks that would ask the clinician, "did you really mean this medicine?" Alerts are a powerful tool to improve safety but can also cause a problem in their own right, he said, if there are too many order checks and staff begin to ignore them.
EMRs, Graber says, have helped the VA in its pursuit of performance improvement initiatives. "The minute you have electronic systems, it becomes much easier and faster and more accurate to look at performance data, quality data, safety data."
For example, the VA had as a goal to make sure patients were screened for colon cancer. Staff embedded in the EHRs a reminder system to ask patients if they are interested in having the screening. By using the system, in 2004 the system was at a 76% success rate in colon cancer screening, when the rest of the country, Graber says, was at about 50%.
By embedding these types of reminders, Graber says, you can have a pretty powerful quality measuring tool — including alerts and smart orders, which when you're ordering a high-risk medication such as an anticoagulant for which there are many dosing regimens you can build pre-selected orders for the individual patient's weight and condition.
(The VA's VistA system, which includes the EMR system, computerized order entry, bar code medication administration, electronic prescribing, and clinical guidelines, is available for free download at www1.va.gov/CPRSdemo/page.cfm?pg=1.)
In perhaps a perfect illustration of the risks associated with technology, Hospital Peer Review spoke with the VA hospital system about its home-grown electronic medical record (EMR) system, VistA, initiated in 1982.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content