The American Journal of Managed Care November 2004 - Part 2
The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care
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
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.
SUMMARY AND CONCLUSION
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
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
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
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: email@example.com.
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: www.ncqa.org/communications/somc/SOHC2004.PDF. 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: www.cdc.gov/brfss. 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: www.theacsi.org/government/govt-ALL-03.html. 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.