> *Nancy Clum, RN, MN
> *Electronic Health Records at the VA*
> In 2006, the Department of Veterans Affairs (VA) received the
> prestigious “Innovations in American Government” Award from Harvard’s
> Kennedy School of Government for its advanced electronic health
> records and performance measurement system, one of the most
> comprehensive and sophisticated electronic systems for patient records
> in the nation. VA clinicians began using computerized patient records
> in the mid-1990s for everything from recording examinations by doctors
> to displaying results of lab tests and x-rays.  Now, patient records
> are available 100 percent of the time to VA health care workers.
> Nancy Clum, Chief Health Informatics Officer at the Palo Alto VA,
> will describe the VA’s electronic health records system and, as noted
> in a recent study in the New England Journal of Medicine, how use
> of the comprehensive system has significantly enhanced the quality
> of patient care by largely eliminating errors stemming from lost or
> incomplete medical records, making the VA one of the safest systems
> in the health care industry.

Nancy began by explaining that in the olden days the VA's records were paper filing cabinets full of information. When patients moved from one service area to another their files would frequently get lost. Some technical people figure out that electronic records with information in one place that could be accessed over a network might work as a better system. Electronic records at the VA had started as a "skunk works" project back in the '70s, but by the late '80s it was a full fledged text based whose goal was to serve all patient records needs electronically. In 1998 they switched to graphical user interface, which is available in all 153 VA facilities nationwide.  VA Palo Alto serves 3 inpatient facilities, a number of outpatient clinics, and 85,000 enrolled patients.

The current system does much more than just make it easy for the doctor to access records about previous patient visits and medications. It also has medical images (X-rays, electronicardiograms, etc.) on file and easy to see. In addition there are checklists to remind doctors to ask all patients in target groups to get (whatever the test is). For example, all male patients over 65-75 who have a history of smoking should have screening for abdominal aortic aneurysm, so when a patient falls into that group the doctor is reminded to request that. It also flags dangerous drug-drug combinations and other known problems.

Nancy described the system terminal as a computer with a monitor and a keyboard on a pushcart. The thing also has a bar code reader to input medication labels without mistakes. When the computer system first got adopted there was much adjusting to be done, but now there is lots of confusion when the system goes down, which doesn't happen often. Improvements for they system Nancy is looking forward to include better integration with other systems, better mobile computing support, and better task management tools. The system is open source. There is a detailed article about electronic medical record use in U.S. hospitals in New England Journal of Medicine, March 2009 issue. Please see that for more information.

During Q&A the following came up:

Interns can learn the thing with just an hour of training, which happens often.

Records are more electronic in Europe than they are in the USA.

The Department of Defense has a totally different record structure than the VA.

Drug companies love getting reminders to check for stuff their product is good for solving in front of doctors. Sometimes doctors complain of reminder overload though.

A Coast Guard serviceman who is about to retire and go into the VA system was advised to keep a paper copy of his medical file because Nancy was unsure if Coast Guard records would be accessible with other DOD records.