Veterans Affairs Committee on March 23rd, 2009

[Ben Lobb, Conservative, Huron—Bruce, ON]

That's impressive. Do you have a rough idea of approximately how long it took to implement all that throughout the close to 900 locations plus the long-term care facilities?

[Gail Graham]

It is a two-stage approach. The initial implementation of the core system, the VistA system, happened almost 30 years ago. I'm not sure how long that took. I have a colleague in the room with me who may know.

[A voice]

It was incrementally dealt with, the core applications first and then additional applications built on top of that. It started in the early 1980s.

[Gail Graham]

Then the electronic health records system began in Tuscaloosa, Alabama, at a smaller location. Then during the next two years we rolled it out across the country using what we called key sites, which were divided into 22 veterans integrated service networks. I think Ms. Patterson talked to you about that. Each of those networks had a lead site or a key site where they had a clinical champion and a team that actually did the implementation.

So the complete implementation of our electronic health record was about a two-year timeframe. Then over the last decade it increased incrementally over time with the components that are used, until finally seven or eight years ago it was mandated for complete use. We had challenges. For example, it was easier to get the primary care and medical physicians using the system than it was to get the surgeons to use the system. We had different challenges in different parts of the medical centre itself.

[Ben Lobb, Conservative, Huron—Bruce, ON]

There's an online for your medication and so forth through the pharmacists. Are the medications dispensed through Veterans Affairs, or are they also dispensed from a regular pharmacy?

[Gail Graham]

The majority of the medications that we dispense are for some of the veterans who are using contract services. They may get an interim dosage, such as an antibiotic that is needed right away. This is really a big area of cost savings for us. We disseminate medications either from the medical centre or, mostly, out of our consolidated mail-out pharmacies, where we process the refill prescriptions, and those are mailed to the veterans.

[Ben Lobb, Conservative, Huron—Bruce, ON]

On the software, I'm reading between the lines here, but the government developed this software?

[Gail Graham]

Correct.

[Ben Lobb, Conservative, Huron—Bruce, ON]

As time has gone on, have you had any third party affiliations? I notice your reference to Google and Microsoft. I just wondered if there are any other software vendors you've dealt with.

[Gail Graham]

There's actually a whole vendor organization called the VistA Software Alliance. Our software is available because it's in the public domain. This VistA Software Alliance and organizations that belong to that actually are resellers of our software. The big thing they offer is the support to install the software and maintain it. We have several state veterans homes in Oklahoma; there's a hospital in Midland, Texas; and Mexico has looked at our system. So there has been a fair amount of private sector interest.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I didn't quite catch it before. Is the software system real time? Is it a live software system? Or do you batch update at night or a couple of times a day?

[Gail Graham]

No, it's real time. The only batch processing we do is this. We have national databases in Austin, Texas, and some of the more administrative data are batch processed and transmitted to Austin. But everything else in the electronic health record is in real time.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I know this is the world of applications with your PDAs and so on. With the iPhones and the BlackBerrys of the world, do you have applications for either of those devices for your technology guru veterans?

[Gail Graham]

For the veterans right now, we're looking at some examples of using it, for example, with the home health nurses. The local medical centre in Washington, DC, is actually using BlackBerrys to transmit EKGs from the emergency room to the on-call cardiologist so they can do an immediate reading of the EKG and start ordering interventions before they can drive to the hospital. We're exploring a lot of those technologies right now, predominantly on the side of clinicians using those devices.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Interesting. Is there anything else new and exciting for either 2009 or 2010? And just to build on that, where is that driven? Is that driven by our users or your veterans? Is that driven by the clinical staff? Where do the new ideas come from?

[Gail Graham]

Both. When you have this many trainees coming through--new residents and nurses--they're living off their personal devices so they're always looking for different, innovative ways they can do their work. The veterans do keep us aware and alert of things they would like to see. Certainly a lot of them are happy that things can be accessed through a PDA or through an iPhone, for example. So we get them from both.

I wanted to address one of the other questions you had. Currently most of our system has been developed by VA. So many of the different medical technologies are becoming so specialized that, for example, right now we're looking at replacing our old laboratory system with a commercial laboratory system. In the area of the intensive care unit, we're looking at commercial intensive care unit software that would be interfaced into our system.

[The Chair, Conservative, David Sweet]

There are two spots here and there are seven and a half minutes. If there's another Conservative with a question, you can go ahead and use the last two and a half minutes. No? You've exhausted all questions.

Okay, we'll move on now to Mr. Stoffer for five minutes.

[Peter Stoffer, NDP, Sackville—Eastern Shore, NS]

I'm okay, sir.

[The Chair, Conservative, David Sweet]

All right, Mr. Dhaliwal, for five minutes.

[Sukh Dhaliwal, Liberal, Newton—North Delta, BC]

Thank you, Mr. Chair.

I would like to welcome Ms. Graham on the teleconference with us today. I have a few questions, because I was going through this extensive document and I'm very pleased to see that the U.S. Department of Veterans Affairs is a world leader in the use of electronic health records.

My question to Ms. Graham is this. The Department of Veterans Affairs is working with the Department of Defense to make their health records interoperable. How will electronic records be reliably made accessible in challenging situations like theatres of combat across the globe?

[Gail Graham]

The Department of Defense probably needs to be the one to brief you on how they use their electronic health record system in combat areas. There is a component of their AHLTA system that actually has a theatre of combat component. At the VA, we can see the notes and documentation created in that theatre-based system, but really, DOD needs to be the one to speak to you directly about how that exactly works.

In those cases in which they do document electronically in combat zones, our providers and our adjudicators can actually see that information.

[Sukh Dhaliwal, Liberal, Newton—North Delta, BC]

Electronic technology is progressing every second, and some doctors might be unable to adapt to this electronic system. Are you aware of whether there are some of those doctors? Or are all the doctors able to access this system, and are all parties fitting in with this technology?

[Gail Graham]

Actually, we don't have provisions today to have doctors who don't participate. This is how they access their results. This is how they order their medications. We gave them a period of time for the conversion, during which we accommodated both processing orders--non-electronically and electronically. But as I stated earlier, about seven years ago we really had to make the full conversion over to the electronic environment. A lot of that was prompted by physician colleagues. It was really a dangerous situation not knowing if what you were looking at electronically was complete or having to look at both the paper record and the electronic record. Really, when you make the conversion, you have a period of time with both, but to prolong that period of time really creates a very dangerous situation.

In this country, we have an oversight body called the Joint Commission. This is really an area they watch closely to make sure that as organizations convert to electronic situations, providers are well informed about how they access information.

I'm sure there were some providers who retired during this conversion, but to say that it was only our older physicians would not be the case either. What we see now is that it's a big recruiting tool for young physicians. Many of our physicians, when they go out into private practice, are very upset that they don't have access to electronic health records, as they did during their VA experience.

We see it today as more of a recruitment tool. As I said, during the last decade I'm sure there were physicians for whom it prompted retirement from VA, but it was not a mass exodus of clinicians. Some of that may be attributed to the fact that for two decades before we moved in the direction of their actually interacting with the computers to enter their orders and their progress notes, our clinicians had been accustomed to looking up information. We still allow, in some areas, some dictation of longer reports, such as discharge summaries or operative reports or histories and physicals. And some of our clinicians use voice recognition software to enter their progress notes, for example, so that you may see different flavours in how they interact with the computer.

[Sukh Dhaliwal, Liberal, Newton—North Delta, BC]

As I mentioned in my preamble, the U.S. Department of Veterans Affairs is a world leader in the use of electronic health records. Why wouldn't other departments have followed that lead? Do you have any advice, not only for Veterans Affairs but for other health providers in general, such as provincial jurisdictions, if they go into a system like this?

[Gail Graham]

Other organizations similar to us, like the Indian Health Service, which provides care on reservations and non-reservations, have had an electronic health records system for some time. The Department of Defense was an early adopter of the core systems and has gradually moved to the electronic health records system. Organizations such as Kaiser Permanente and other large health care providers have seen that this enhances their ability to manage patient populations. We see the adoption more prevalent in organizations that reap the benefits in financial and quality performance.

I think in the VA there was a perfect storm of technologists who were interested and innovative, together with clinicians who saw that there was a better way of delivering care. Putting the two together created a perfect storm, out of which this system came. It wasn't perfect out of the box, but our providers know that it will be improved as time goes on and that we will listen to their input and make changes incrementally.

So I think it was all those things combined. In the long run, this is not easy. You have to think about the different ways clinicians practise and make sure that what you're introducing is a help and not a hindrance. You also have to educate patients. If this is something consumers want, they have to drive it. For those with chronic diseases trying to maintain continuity between physicians and carrying around boxes of paper documents, this is definitely something that will make their lives easier.

In the future, I think a lot of this will be driven by the consumer. But it takes care and planning in respect of how you want to roll it out. You have to determine the needs of the different specialties. Mental health, for example, was one of the first software packages we released, and that's not a common component in most electronic health records systems.

The seamlessness between in-patient, outpatient, and long-term care is also important. Many times we see that vendors are only selling outpatient records, in-patient records, or long-term care records. Integration, though, is really the key to both the usage and the continuity of care for the patient.