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The American Journal of Managed Care November 2004 - Part 2
Screening for Depression and Suicidality in a VA Primary Care Setting: 2 Items Are Better Than 1 Item
Kathryn Corson, PhD; Martha S. Gerrity, MD, MPH, PhD; and Steven K. Dobscha, MD
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The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care
Jonathan B. Perlin, MD, PhD, MSHA; Robert M. Kolodner, MD; and Robert H. Roswell, MD
Variation in Implementation and Use of Computerized Clinical Reminders in an Integrated Healthcare System
Constance H. Fung, MD, MSHS; Juliet N. Woods, MS; Steven M. Asch, MD, MPH; Peter Glassman, MBBS, MSc; and Bradley N. Doebbeling, MD, MSc
Dual-system Utilization Affects Regional Variation in Prevention Quality Indicators: The Case of Amputations Among Veterans With Diabetes
Chin-Lin Tseng, DrPH; Jeffrey D. Greenberg, MD, MPH; Drew Helmer, MD, MS; Mangala Rajan, MBA; Anjali Tiwari, MD; Donald Miller, ScD; Stephen Crystal, PhD; Gerald Hawley, RN, MSN; and Leonard Pogach, M
Assessing the Accuracy of Computerized Medication Histories
Peter J. Kaboli, MD, MS; Brad J. McClimon, MD, PharmD; Angela B. Hoth, PharmD; and Mitchell J. Barnett, PharmD, MS
The Relationship of System-Level Quality Improvement With Quality of Depression Care
Andrea Charbonneau, MD, MSc; Victoria Parker, DBA; Mark Meterko, PhD; Amy K. Rosen, PhD; Boris Kader, PhD; Richard R. Owen, MD; Arlene S. Ash, PhD; Jeffrey Whittle, MD, MPH; and Dan R. Berlowitz, MD,
Designing an Illustrated Patient Satisfaction Instrument for Low-literacy Populations
Janet Weiner, MPH; Abigail Aguirre, MPA; Karima Ravenell, MS; Kim Kovath, VMD; Lindsay McDevit, MD; John Murphy, MD; David A. Asch, MD, MBA; and Judy A. Shea, PhD
Problems Due to Medication Costs Among VA and Non-VA Patients With Chronic Illnesses
John D. Piette, PhD; and Michele Heisler, MD, MPA

The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care

Jonathan B. Perlin, MD, PhD, MSHA; Robert M. Kolodner, MD; and Robert H. Roswell, MD

The performance contract is created as a collaborative process involving central management and field leaders. The Performance Measurement Work Group is both co-chaired by and comprised of central and field leaders, and it includes both clinicians and administrators. The group serves as a mechanism for vetting and prioritizing measures for inclusion in a performance contract recommended to the Under Secretary for Health. Thus, the ultimate contract established between the Under Secretary and VISN leaders, and then cascaded to clinicians and managers throughout the system, is a collaborative product, which is thought to reduce the traditional "us-them" tension between central and field leadership or between administrators and clinicians.

Results of the performance contract form the basis for quarterly management reviews. Although extremely modest management incentives exist, the performance results are broadly distributed within the VA and are known to key stakeholders such as Congress, veteran advocacy groups, and the Office of Management and Budget. The performance data that result are published in hard copy quarterly and annually and, since 2002, are increasingly available as they accrue in real time on Intranet sites.

INFORMATION SYSTEMS TO MONITOR AND SUPPORT PERFORMANCE

Performance Data for the Value Domains

Effective information systems are the prerequisite for the effective delivery of services that maximize value in each of the domains, as well as the source of data for operation of the Performance Management Program. The VA's clinical information system is remarkably well designed to support patient care; however, the system's capacity for national "roll-up" of all discrete data elements desired is currently limited. So, although most clinical data and patient records are fully electronic, the VA has invested in an audit program to assess clinical performance. Using VA performance criteria, audits are performed by an independent external contractor under the External Peer Review Program (EPRP). This program provides data to support measurement primarily in the more clinical domains of quality and function, as described elsewhere.9 The VA's new health data repository will markedly expand the capacity for automated aggregation of national performance data.

In the domain of satisfaction, traditional event-driven surveys of satisfaction with ambulatory-care visits, hospitalizations, or other services (eg, prosthetics, spinal cord injury, pharmacy) have been used. However, recognizing that satisfaction is only 1 component of the patient experience, a new omnibus Survey of Health Experiences of Patients has been introduced to acquire data about general healthcare experiences (eg, waiting times) and satisfaction, patient functional status (the veterans SF-1210), and health risk behaviors (eg, nutrition, exercise, tobacco) that link with clinical information acquired through external peer review. These pooled data more richly support improvement, program planning, policy development, and (with all identifying information redacted) health services research. Corporate data from scheduling and fiscal systems (and some survey information) are used to support measurement and improvement in the domains of access, cost, and community health.

The VA's approach to both improvement of healthcare delivery and improvement of information systems is reflected well in models identifying the convergence of patients, providers, and the health system for optimal outcomes, as articulated by Glasgow and colleagues.11 These models suggest that the most productive interactions occur when prepared, proactive providers and informed, activated patients interact in the context of a supportive, informed health system.11 The VA's clinical information system provides support for improvement for the system, for providers, and for patients. Standardized data elements can be aggregated to assess performance on a clinical measure at the team, clinic, facility, network, or system level. These same data elements serve as the basis for implementing clinical reminders used to support immediate feedback and improvement for care providers. Finally, these data increasingly will serve as the basis for online health assessment and education for patients and caregivers, who ideally will use that knowledge for more effective management of their health needs.

The Electronic Health Record for Clinical Data Management

The VA has had automated information systems providing extensive clinical and administrative capabilities in all of its medical facilities since 1985, when its decentralized hospital computer program began operating. The veterans health information systems and technology architecture (VistA), which supports ambulatory, inpatient, and long-term care, provided significant enhancements to the original system with the release of the computerized patient record system for clinicians in 1997. The computerized patient record system (CPRS) was developed to provide a single, highly graphical interface for healthcare providers to review and update a patient's medical record and to place orders for various items including medications, procedures, x-rays and imaging, patient care nursing orders, diets, and laboratory tests. The computerized patient record system is flexible enough to be implemented in a wide variety of settings, both inpatient and outpatient, ranging from home and long-term care to operating rooms and intensive-care units. It serves a broad range of healthcare workers, and provides a consistent, event-driven, Windows-style interface across functions and locations.

The computerized patient record system organizes and presents all relevant patient data in a way that directly supports clinical decision making. Its comprehensive cover sheet displays timely, patient-centric information including active problems, allergies, current medications, recent laboratory results, vital signs, hospitalization, and outpatient clinic history. This information is displayed immediately when a patient is selected and provides an accurate overview of the patient's current status before any clinical interventions are ordered.

Today, the CPRS is fully operational at all medical centers and most other VA sites of care. VistA Imaging, which provides a multimedia, online patient record that integrates traditional medical chart information with medical images of all kinds (eg, x-rays, pathology slides, video views, scanned documents, cardiology exam results, dental images, endoscopies) is also now operational at VA medical centers (Figure 3).

Figure

Electronic Health Information to Support Performance Improvement

Beyond serving as a complete electronic health record, other capabilities in the CPRS support performance improvement, including computerized provider order entry, critical alerts, remote data view to access health information from other VA facilities, and a clinical reminder system to provide real-time decision support.

Computerized provider order entry has been shown to decrease rates of adverse drug events.12 The VA's computerized provider order entry, with real-time order-checking system, alerts clinicians during the ordering session that a possible problem could exist if the order is processed (eg, drugódrug interactions, duplicate laboratory values). Since implementation, order checking has required some reengineering to ensure that attention to important alerts is not diminished by frequent, trivial messages. Currently, 94% of all pharmacy orders throughout the VA are electronically entered directly by the prescriber.

Other features of CPRS include a notification system that immediately alerts clinicians about clinically significant events such as abnormal test results, a strategy that helps prevent errors by requiring an active response for critical information.13 A patient posting system, displayed on every CPRS screen, alerts clinicians to issues related to the patient, including crisis notes, special warnings, adverse reactions, and advance directives. The remote data view functionality allows clinicians to view a veteran's medical information from another VA facility or from Department of Defense medical treatment facilities to ensure the clinician has access to all clinically relevant data.

The clinical reminder system allows caregivers to track and improve preventive healthcare and disease treatment for patients and to ensure that timely clinical interventions are initiated. The clinical decision support it provides is context sensitive (eg, it recognizes that the patient has a particular diagnosis such as diabetes), and time sensitive (eg, 12 months have elapsed since the service, such as an influenza vaccination, was last provided). The clinical reminder system is now the VA's preferred mechanism for implementing clinical practice guidelines, and facilitates linking the evidence with the real-time clinical reminder, with the action (eg pneumococcal vaccination in elderly or chronically ill patients), and with the automatically generated documentation as well as with a trail of standardized performance data (Figure 4).

Figure

A more recent addition to CPRS provides a multipatient view for follow-up on clinical interventions. A list of patients can be generated based on abnormal test results, or based on a clinic schedule, inpatient ward census, or team roster. Using this new care management software, clinicians can manage a group of patients—seeing and taking action on test results, signing notes, or generating new tasks.

NEW DEVELOPMENTS TO SUPPORT CONTINUING TRANSFORMATION

HealtheVet and My HealtheVet

The VA is currently transforming the architecture underlying its health information systems to more effectively serve the needs of patients, providers, and the health system. The new architectural strategy, known as HealtheVet, fully integrates a health data repository with registration systems, provider systems, management and financial systems, and information and education systems.

 
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