Network turns around VA hospital system

Use of technology makes VA a pacesetter in health care IT

"Patients were being turned away until clinical referral information arrived. Use your imagination -- anything could happen. X-ray reports could take months. Beyond that, any chart a doctor needed was not available half the time."

That recollection by Dr. William Beer of the South Texas Veterans Health Care System in San Antonio may match some snippet from your last hospital visit, but at the medical centers of the Veterans Health Administration of the U.S. Department of Veterans Affairs, it's ancient history. Today, any VA doctor can call up the full record of any patient.

That's right -- having been a national embarrassment in the post-Vietnam era, as depicted in the movie Born on the Fourth of July -- the VA medical system is now a national model for health care IT.

"They are certainly leading the health care industry in terms of computer technology," said John Friedman, director of communications at the National Committee for Quality Assurance, a health care industry organization that grades and accredits health care plans. "While computerization has about a 10% penetration in the health care industry overall, it's 100% in the VA." Encompassing 154 medical centers and other clinics, nursing homes and rehabilitation centers, totaling nearly 1,400 sites, the VA served 5.3 million people last year.

"By all the measures we use, the VA offers superior care to what you can get in the general population," Friedman said. "The VA is now one of the premier places to get health care in the country. And we think that computerization has been a contributing factor. Their adoption of IT was part of their re-engineering the delivery of health care, using a systems- and process-based approach, with continuous quality improvement and measurement," Friedman said.

As early as 1996, the VA began integrating various applications into a client/server environment called the Veterans Health Information Systems and Technology Architecture, or Vista. The doctor's interface to it is a graphical system, brought out in 1997, called the Computerized Patient Record System (CPRS), which combines more than 100 different applications. (All the components are available for use by anyone under the Freedom of Information Act.)

Of course, simply having the system is not enough. It has to be used. "For years, we struggled to get the doctors to use the system," Beer said. "In 1998, I surveyed the doctors here and found that one-third were willing to computerize. Another third said they'd wait for it to go away, and the last third said they'd never do it and we'd have to wait for them to retire." But in 2000, computer use became a condition of employment, he noted.

The data offered by CPRS has evolved over the years as the network's capacity and use have grown, said Dr. Robert Kolodner, chief informatics officer at the VA. Initially, it offered only summaries of specified portions of a patient's medical file, later evolving to full medical charts. Images were added for same-facility users in the late 1990s, but as of September 2005, any doctor in the system can call up the X-rays, MRIs or other data of any patient, he said.

September saw another service milestone when the records for New Orleans veterans were online again less than 100 hours after Hurricane Katrina wrecked the VA facilities in the city. Local personnel were able to rescue the Vista backup tapes and get them to Houston to load them onto the servers there, said Dave Bradley, a VA technical adviser in Coatesville, Pa.

As for the network behind that data, it's been evolving for two decades, Bradley said. Having advanced from 9.6Kbit/sec. connections in the 1980s, to 1.54Mbit/sec. T1 connections in the mid-1990s, to managed 45Mbit/sec. Digital Signal Level 3 connections in the late 1990s, the VA system now has an Asynchronous Transfer Mode-based network, he noted. There are ATM switches at four data centers in Reston, Va.; Dallas; Kansas City, Mo.; and Sacramento, Calif. These connect to 19 regional networks, which support various numbers of medical centers. Clinics that are satellites of a medical center connect to the network through that medical center. Plus, there is a data storage center in Austin.

The backbone nodes usually use 20Mbit/sec. connections, with the medical centers connected to the backbone via 4Mbit/sec. to 10Mbit/sec. connections, Bradley said. Connections out to the clinics depend on local engineering decisions and often involve T1 lines, he said. All the circuits are arranged through standard federal government contracts, with Sprint as the primary vendor, he added.

More cultural hurdles than technical ones

Thanks to its slow evolution, and to its implementation being handled through standard federal contracts, most of the hurdles encountered along the way appear to have been more cultural than anything else.

For instance, transmitting images to other facilities had a low priority because a written description of what they showed was already available and often sufficed, Kolodner noted. And even though the VA now trades medical files with the U.S. Department of Defense (for military personnel leaving and then re-entering active service), it was first necessary to get legal opinions that doing so would not violate privacy laws.

"The biggest hurdle," said Bradley, "was when we went to frame relay and we had to convince the folks in management that the network would be a useful thing. We did white papers and pilots, just to get buy-in to acquire better technology. When we went to ATM later, it was less of an issue, since we had already done one jump.

"We still have some capacity issues today, and are not in a situation where we have all the bandwidth we need," Bradley said. "We have fixed circuits rather than bandwidth on demand. We can't support streaming video to all the medical centers, and in small facilities, someone can do something silly like pull a couple of gigabytes off a Web site and clog the line for a couple of hours," he said.

More diversity among carriers is another goal for Bradley, since it would increase the likelihood of continued operations through disasters like Katrina.

Concerning CPRS, Beer noted, "It took several years for the leadership to say that it was important and to have enough computers so that everyone could use it."

About 250,000 desktops are connected to the network, said David Cheplick, head of the VA's network control center in Martinsburg, W.Va. The biggest management issue facing the network is maintaining control over the various software development efforts under way throughout the VA system serving various groups of specialists, so management can ensure enough bandwidth for new applications, he said. Currently, they are adding full-fidelity telemedicine (which requires 1.2Mbit/sec. per session, he said) to allow a doctor in one facility to diagnose a patient using another enterprisewide business application, plus security that scans down to the desktops.

Spending on the data infrastructure, from the backbone down to (but not including) the desktops is about $150 million per year, Cheplick said. Voice services cost about another $100 million, and videoconferencing about another $20 million. He hopes to see these three functions converge over the next decade, although he does not expect that convergence will reduce spending significantly.

In the future, Cheplick also hopes to convert from ATM to Multiprotocol Label Switching for increased bandwidth and better quality-of-service controls.

At the data level, the next move will be to make clinical data "computable" so that the CPRS software can read anything that the doctors can read, Kolodner said. That should start as early as this summer, he added, but the effort also depends on an ongoing, industrywide standardization of medical terms.

No one can quantify how much benefit the network has brought to the VA system. But Kolodner said that industrywide, 20% of lab tests take place because the results of the previous test could not be located, and one in seven admissions take place because of uncertainty caused by the absence of the patient's records. That does not happen in the VA system anymore, he noted.

But Beer foresees a bigger impact than that.

"Most doctors who train in the U.S. work in the VA hospital system at some point and will learn our computers," he noted. "When they go out into practice, they will want electronic records," and maybe health care industry computerization will rise above 10%.

"It would be wonderful if that happened," agreed Friedman.

Lamont Wood is a freelance writer in San Antonio.

Copyright © 2006 IDG Communications, Inc.

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