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

The health data repository creates a true longitudinal healthcare record including data from VA and non-VA sources, supporting research and population analyses, improving data quality and security, and facilitating patient access to data and health information. With an emphasis on "eHealth," a secure patient portal known as My HealtheVet provides patients access to their personal health record, online health assessment tools, mechanisms for prescription refills and making appointments, and access to high-quality consumer health information. The consumer information is evidence based, consistent with clinical practice guideline recommendations (made proactive through clinical reminders), and ideally, inspires the patient to act. Although deployed nationally, a major barrier to the complete penetration of CPRS and HealtheVet extensions at every VA site is the challenge of an inadequate high-speed telecommunications infrastructure in more remote and rural parts of the country. Otherwise, My HealtheVet is available to veterans wherever Internet access is possible.

Patient-centered Care Coordination

Safety and effectiveness are fundamental expectations for healthcare services, but do not independently constitute patient-centered care. VHA aspires to provide healthcare that is safe, effective, and meaningfully patient centered. Such care is organized so that the locus of control is the patient and the experience of care is seamless across environments. Furthermore, the environment of care now extends beyond the provider-centric domains of the hospital and clinic to the patient's home, work place, and community.

Patient-centered care coordination extends the focus of disease management to better and more efficiently integrate every patient's disease-specific and general health needs with the resources of the health system. A patient with diabetes and heart failure is no longer managed with separate but overlapping services for each disease; instead, care coordination seeks to rationalize and unify the care approach. In an environment of constrained resources, care coordination also seeks to ensure that healthcare is provided when the patient needs it, and is not determined by arbitrary, provider-based rules.

The VA's approach to care coordination uses technology to support patients' ability to successfully age and manage disease in their own homes. Using its broadly deployed electronic health record as a foundation, the VA has the unique capacity to use advanced technologies to enable the patient to be seen "just in time" rather than "just in case." Using My HealtheVet, a patient with heart failure can enter her daily weight from home for review by a care coordinator. Should her weight exceed a critical threshold, she would then be called to visit a clinic or even be visited at home. Some pilot programs in the VA now use electronic scales attached to the patient's computers or phone systems to forward weight recordings automatically to care coordinators. Thus, a patient with advanced heart failure is most ideally seen just as she begins to retain fluid, not on an arbitrary schedule that typically fails to identify an impending crisis. The VA's pilot programs in Florida have demonstrated improved patient satisfaction as well as improved physical and mental health functional status for patients enrolled in care coordination.14

Given the VA's older population and the trebling of the numbers of veterans more than 85 years old from 380 000 to 1.2 million by 2010, the VA has identified care coordination and supportive technologies as its preferred mechanisms to preserve functional independence and postpone or even obviate the need for institutional care for many who are frail from chronic illness or advanced age. Unlike institutionalization, this approach will allow veterans to maintain their relationship with their spouse and their social roles in their communities. In addition, this approach is more cost-effective than institutional care, especially when combined with simple supportive technologies. Currently, the VA uses standard telephone service for simple, daily voice or text queries (with an interactive "caller ID" type device) to assess the patient's status, compliance with medications, and symptoms. The VA defines this emerging strategy of coordinated, patient-centered care as care that is both safe and effective, and is delivered in the time, place, and manner that the patient prefers.


The active management of quality and value through performance measurement, timely data feedback, and information systems that increasingly support clinicians, managers, and patients in achieving the benefits of evidence-based practice has improved the VA's outcomes in each value domain. For example, in the domain of quality, pneumococcal vaccination of at-risk patients is an evidence-based practice that reduces excess morbidity, mortality, and cost.15 In 1995, the rate of pneumococcal vaccination in eligible VA patients was 29%. Today, it is 90%. The trends are identical in each of the preventive services encompassed by the prevention index (Figure 4).

Performance improvement and achievement have similarly occurred in the areas of disease treatment encompassed by more than 20 clinical practice guidelines such as coronary artery disease, heart failure, diabetes, and major depressive disorder. Increasingly, VA performance compares favorably with the best performers in areas where performance is, in fact, measured and performance data are available (Table 2).19


Veterans are increasingly satisfied by changes in the VA health system. On the American Customer Satisfaction Index,20 the VA bested the private sector's mean healthcare score of 68 on a 100-point scale, with scores of 80 for ambulatory care, 81 for inpatient care, and 83 for pharmacy services for the past 3 years. Similar improvements have been achieved in each value domain.

It also is worth emphasizing that since 1996, improved outcomes have been achieved in each of the value domains, while simultaneously reducing the cost per patient by more than 25%. Returning to the value equation, it would seem evident that the numerator (outputs) rose while the denominator (resource inputs) dropped, signifying enhanced value.

Although the VA healthcare system has changed substantially over the past 8 years, the specific basis of improvements cannot be causally inferred. Two important limitations to understanding the basis of improvement must be noted. First, change was initiated as a strategic and operational imperative, and not structured as an experimental design. Interventions such as new information technologies and performance measurement were not isolated as discrete interventions, but occurred simultaneously. Thus, it is difficult to understand their independent effects. Second, although information technologies such as computerized decision support and provider order entry have been shown to improve quality and decrease adverse events in other environments,12,13 more analysis of their specific impact on quality in the VA is needed.

Nevertheless, it is likely that some aspects of the contribution of the electronic health record are self-evident. For example, patient records are available virtually 100% of the time today, in contrast to approximately 60% of the time in 1996. Similarly, in circumstances where quality indicators were measured, the VA's clinical performance (eg, in diabetes care) has improved more rapidly and substantially than the clinical performance in other healthcare settings.21 Measured performance also improved more substantially than unmeasured performance, even within the VA.22,23

It should be noted that this period of transformation was not without difficulties and performance challenges. The VA experienced unprecedented growth, with more than 800 000 new enrollees in 2002 alone. As of July 2002, the VA had accumulated 317 000 nonurgent new patients waiting 180 days or more for their first visit. Deploying advanced clinic access techniques and performance measurement as the primary strategies, the VA eliminated the entire backlog by March 2004.24 The VA now measures in terms of average waits, with the goal and actual performance averaging under 30 days for new appointments.

In summary, electronic health records, performance management, and a patient-centric focus have been critical transformational strategies for the VA. They have been utilized to support achievement and are associated with measurable progress in each of the VA's value domains. The VA's value domains are remarkably consistent with the ideal health system aims recommended in the Crossing the Quality Chasm,1 providing additional evidence for the report's premise that adoption of these aims will result in more effective healthcare delivery.

From the Department of Veterans Affairs, Washington, DC (JBP); the Veterans Health Administration, Washington, DC (RMK); and the University of Oklahoma College of Medicine, Oklahoma City, Okla (RHR).

Two of the authors served previously (RHR) or served at the time of publication (JBP) as Under Secretary for Health, Department of Veterans Affairs, and provided first-hand knowledge of policy decisions for this article. Where not otherwise referenced, data cited are from Department of Veterans Affairs corporate management information systems.

Address correspondence to: Jonathan B. Perlin, MD, PhD, MSHA, Acting Under Secretary for Health, Department of Veterans Affairs (10), 810 Vermont Ave NW, Ste 800, Washington, DC 20420. E-mail:

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

2. Johnson CL, Carlson RA, Tucker CL, Willette C. Using BCMA software to improve patient safety in Veterans Administration medical centers. J Healthc Inf Manag. 2002;16(1):46-51.

3. Institute of Medicine. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: National Academy Press; 2002.

4. Kizer KW. Vision for Change: A Plan to Restructure the Veterans Health Administration. Washington, DC: Department of Veterans Affairs; 1995.

5. Kizer KW. Prescription for Change: The Guiding Principles and Strategic Objectives Underlying the Transformation of the Veterans Health Administration. Washington: Department of Veterans Affairs; 1996.

6. Nelson EC, Mohr JJ, Batalden PB, et al. Improving health care, part 1: the clinical value compass. Jt Comm J Qual Improv. 1996;22:243-258.

7. Demakis JG, McQueen L, Kizer KW, et al. Quality Enhancement Research Initiative (QUERI): a collaboration between research and clinical practice. Med Care. 2000;38(6 suppl 1):I17-I25.

8. Lomas J. Health services research: more lessons from Kaiser Permanente and Veterans' Affairs healthcare system. Br Med J. 2003;327:1301-1302.

9. Sawin CT, Walder DJ, Bross DS, Pogach LM. Diabetes process and outcome measures in the Department of Veterans Affairs. Diabetes Care. 2004;27(suppl 2):B90-B94.

10. Jones D, Kazis L, Lee A, et al. Health assessments using the veterans SF-12 and SF-36: methods for evaluating outcomes in the Veterans Health Administration. J Ambul Care Manage. 2001;24(3):68-86.

11. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q. 2001;79:579-612.

12. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311-1316.

13. Bates DW, Gawande AA. Improving safety with information technology. New Engl J Med. 2003;348:2526-2534.

14. Ryan P, Kobb R, Hilsen P. Making the right connection: matching patients to technology. Telemed J e-Health. 2003;9(1):81-88.

15. Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med. 1999;159:2437-2442.

16. National Committee for Quality Assurance. The State of Health Care Quality: 2004. Washington, DC: National Committee for Quality Assurance; 2004. Available at: Accessed October 22, 2004.

17. National Committee for Quality Assurance. The State of Managed Care Quality, Industry Trends and Analysis. Washington, DC: National Committee for Quality Assurance; 2001.

18. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System survey from the National Center for Chronic Disease Prevention & Health Promotion. Atlanta, Ga: Centers for Disease Control and Prevention; 2001. Available at: Accessed October 22, 2004.

19. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of transformation of the veterans health care system on the quality of care. N Engl J Med. 2003;348:2218-2227.

20. University of Michigan School of Business. American Customer Satisfaction Index. Ann Arbor, Mich: University of Michigan; 2000, 2001, 2002. Available at: Accessed October 22, 2004.

21. Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs health care system and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141:272-281.

22. Pogach L, Charns MP, Wrobel JS, et al. Impact of policies and performance measurement on development of organizational coordinating strategies for chronic care delivery. Am J Manag Care. 2004;10(2 pt 2):171-180.

23. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the veteran's health administration and patients in a national sample. Ann Intern Med. In press.

24. Schall MW, Duffy T, Krishnamurthy A, et al. Improving patient access to the Veterans Health Administration's primary care and specialty clinics. Jt Comm J Qual Saf. 2004;8:415-423.

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