Electronic Health Records and Multi-Provider Use: Lessons from the VA

This post originally appeared on The Health Care Blog on 17 August 2009.

With billions of dollars of stimulus funds available and the President and state governors promoting them, electronic health records (EHRs) are likely to become commonplace in the U.S. health care system. To be sure the transition will be complex and costly, but incentives provided by insurers and the federal government for quality improvement tied to EHR use will encourage providers to enter the brave new electronic world and bring their patients with them. While EHRs are praised for their promise to increase efficiency and safety, it is still an open question how much of those benefits will be realized or when.

There is one clear threat to the fruition of EHRs’ potential for quality improvement: the inability of various EHR systems to share information with one another. This potential limitation is highlighted prominently in a new Congressional Budget Office (CBO) report Quality Initiatives Undertaken by the Veterans Health Administration (August 2009), principally authored by Allison Percy of CBO’s National Security Division.

The Veterans Health Administration (VHA) is the largest U.S. integrated health care system. With over 200,000 full-time-equivalent employees, each year it treats 5.1 million of its 8 million enrollees at 153 medical centers, 931 ambulatory care and outpatient clinics, 232 readjustment counseling and outreach centers, 134 nursing homes, and with 50 residential rehabilitation treatment programs and 108 comprehensive home-based care programs.

Facilitating its care of veterans, the VHA uses health IT infrastructure known as VistA (Veterans Health Information System and Technology Architecture). This open source EHR architecture was developed in a collaborative effort involving clinicians and programmers. The CBO report documents the now well-known quality improvement in VHA care since the 1990s and the key role in that improvement played by VistA, which permits the tracking of nationally recognized and internally developed quality indicators.

However, the CBO report also highlights VistA’s blind spot, one that may also plague EHRs to be developed for other facilities and health systems. VistA cannot exchange data between the VHA and private providers due to incompatible protocols and lack of data-sharing agreements. The implication is that care cannot be easily coordinated across providers and quality measures cannot be based on a complete set of information relevant to patient care: only care known to the VHA can be incorporated into VA physicians’ medical decisions and VHA’s quality measures.

This lack of inter-provider electronic communication is relevant to VHA care because the vast majority (80%) of VHA enrollees have access to care from other sources. Multi-system use is a well-studied phenomenon among VHA enrollees and recent findings pertaining to its extent and effects on outcomes are documented in the CBO report. A similar phenomenon, multi-provider use, will be relevant to care of non-veterans in non-VHA settings since many individuals receive care from different providers that operate within different systems. Even if each individual provider’s EHR system is well implemented, the potential inability of them to communicate with one another threatens the realization of EHR benefits and the accurate measurement and tracking of quality indicators.

Will the collective system of EHRs likely to be implemented in the U.S. be a nirvana of seamless electronic integration or a Tower of Babel? Likely it will start closer to the latter and, one hopes, gradually move toward the former. But it will only evolve toward integration if incentives to do so are established.

Fortunately this problem is anticipated and one the VHA has already started to address. The VHA has initiated efforts to coordinate the exchange of electronic health records with the Department of Defense (DoD), though more work remains. Less progress has been made integrating VHA data with those from non-DoD systems. However, the VHA has participated in the development of the National Health Information Network (NHIN) and expects to be exchanging data with Kaiser Permanente this fall using NHIN open source software called CONNECT.

EHRs have great potential to monitor and increase quality and to solve some of the coordination problems that occur across provider boundaries. But the extent to which they can facilitate improvements in quality and coordination will be limited by the degree to which data can be exchanged between the various EHR systems likely to be implemented. So long as EHR information remains within provider silos they will not fulfill proponents’ claims of overcoming the fragmentation of our current system and the problems to which it leads.

The CBO report documents the lessons learned and limitations encountered by the VHA in developing, implementing, and employing an EHR system and in integrating that system with others. Those are important lessons not just for the VHA but for health IT practitioners and proponents in general. The path to optimal use of EHRs to enhance patient care may be long and hard, but the VHA is already several steps along it.

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