The VA isn’t perfect, but definitely is better than other health care systems I have worked in so far. It embraces the idea of patient-centered medical home, where a primary care physician coordinates and takes responsibility for a patient’s care … the old-school definition of good medical care that has recently become popular again, especially because of its emphasis on preventive care and continuity of care.
I give much of the credit to the VA’s electronic medical record – the VistA CPRS (computerized patient record system). I think I had more fun playing with the CPRS and its magical abilities than I did actually learning about primary care during my 5 weeks at the Bronx VA outpatient clinics.
There’s no need to repeat tests unnecessarily. All the results of previous tests, at any VA hospital or clinic, are accessible with just a few clicks. No need to wait for reports to be faxed or mailed from another hospital.
You can graph lab values and vital signs over months and even years to see how it has changed over time, an easy way to see exactly what effect a new medication had on the patient’s blood pressure.
There’s continuity of care. Even when your patient goes from NYC to Florida for the winter, all of his records, including physician notes and imaging, are available to his Florida health team just as if he were on site in the Bronx. Cloud computing.
It’s easy to remind providers what the evidence says about what needs to be done at the current visit. Clinical practice guidelines (CPGs) are turned into reminders for the clinician.
This is a picture of the home screen that appears when you pull up a patient’s record in the CPRS. This is a patient with diabetes, HTN, hyperlipidemia, etc. And the system will remind the provider (so I don’t have to remember every evidence-based guideline out there) what goals haven’t been met, what referral appointments the patient needs, and what age-appropriate screening and vaccinations are necessary at this visit.
And if my patient was due for his screening colonoscopy, for example, all that had to be done was for him to agree to it. The primary care doctor would put in the order in the CPRS and then the GI department would call the patient to schedule an appointment. The patient didn’t have to remember to call — the doctors would take control, almost patronizingly but perhaps necessarily so, for the patient’s follow-up and follow-through. The initiative was on the part of the provider, perhaps because the provider is held accountable for some outcomes measures.
The VA is starting to implement some pay-for-performance/accountable care organization principles for its physicians, with incentives for meeting target hemoglobin A1c goals (markers for diabetes control) for a primary care doc’s roster of patients, etc. They can do this easily, because you can use the CPRS to look at population-level data and analyze outcomes.
“You can’t manage what you don’t measure.” Paul Levy, former CEO of Beth Israel Deaconness Medical Center in Boston, said that during a lecture to medical students about continuous quality improvements in patient care. And the VA CPRS is a measuring machine.
Suchita Shah is a medical student who blogs at University and State.
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