Millions of US veterans get medical care through a government-run, single-payer system. They are financially less well off than average, but research indicates that they stand a better-than-average chance of getting appropriate care.
That's partly because the US Department of Veterans Affairs (VA) boasts the nation's largest and most comprehensive paperless medical records system. It's called the Veterans Health Information Systems and Technology Architecture - VistA.
For each patient, all diagnoses, notes, lab results, medical images and prescriptions originating from any of the 1,400 or so VA clinics and hospitals throughout the country are contained within a single electronic medical record. Important information is not lost, and it is less likely to be overlooked.
According to Paul Volberding, MD, chief of the Medical Service at the San Francisco Veterans Affairs Medical Center and professor and vice chair of the Department of Medicine at UCSF, "If people were more aware of how big a problem medical records systems have been historically in terms of improving the quality of care that's delivered in hospitals and clinics in the US, and in terms of our ability to measure the quality of the care, more people would look to the VA and VistA as the model."
But Volberding wants to lift the bar higher. He is interested in ways the medical record can be used to support medical education. He aims to hot-rod VistA so that it can be used as a teaching tool to continually educate physicians. The system could provide "teaching moments" in the midst of patient care.
"Because of the academic affiliation that we have with UCSF, the quality of the physicians that we can bring to the VA and the quality of care we are able to deliver are the best," Volberding says. "And because the VA is a fully sponsored health care system, we have time to do a good job of teaching the UCSF medical students and residents who come here."
But why not further extend the reach of this high-quality teaching and medical care throughout the VA system - to rural clinics as well as major teaching hospitals?
Like many other computer-based systems, VistA already is programmed to warn physicians if they try to order drugs that have adverse interactions, for instance.
"But we're looking to see if the medical records system could be much smarter -actually providing teaching to the physician appropriate to a particular moment during the patient's care," Volberding says.
Physicians would remain on their toes and better informed, thanks to computerized queries, prompts and updates on current treatment. Patients would benefit from better care and even fewer physician errors.
On a larger scale, with VistA, it should be possible to track whether physician practice actually reflects this new form of instruction, and whether patients do truly benefit, Volberding says.
Education Module on HIV Treatment Will Be the First
Volberding is one of the world's leading experts on treatment for patients infected with HIV, the AIDS virus, and he is a member of two major committees that draft HIV treatment guidelines based on clinical research results. So, not surprisingly, he and his research team plan to begin this new computerized teaching experiment by developing a module on HIV.
"We have known for years that physicians learn best when instruction centers on experiences with patients," he says. "I don't think an electronic education system would replace the role of attending physicians in teaching medical students and residents at hospitals, but it would augment the teaching."
Volberding asserts that for physicians in practice, who often are without any supervision, this form of teaching could replace the current system of continuing physician education. "Studies show that continuing education in the form of stand-up lectures by talking heads does not successfully transmit information in ways that change physician practice," he says.
"As the electronic medical record gradually becomes the norm in American medicine, education coupled to the medical record can become a part of every physician's lifelong learning."
VistA Also Advances Research Knowledge
Using VistA as a research tool to track patient outcomes may also lead to further upgrades in treatment standards, Volberding suggests. Already, researchers have used the data, stripped of patient identifiers, to study the usefulness of prostate-specific antigen tests for prostate cancer, the association between hepatitis C infection and subsequent lymphoma risk, and heart disease risk among HIV patients.
Volberding wants to use VA data to further study HIV and heart disease, a link about which many questions remain. HIV infection affects the metabolism of fats that play a role in clogging arteries. Evidence suggests that some drugs used successfully to keep HIV in check also affect fat and glucose metabolism, and perhaps diabetes and heart disease risk in turn. Long-term side effects of various drug regimens warrant additional study, Volberding says.
"Approving drugs based on company-sponsored trials isn't enough; we have to continue to track these drugs' effects in the real world," Volberding says
Baby boomers hardest hit by the AIDS epidemic are at an age when heart disease already is common in the broader population. That's a complication in sorting out the effects of HIV or HIV drugs on heart disease. Studies require large numbers of HIV patients, large control groups and good treatment records - criteria that the VA's VistA meets.
The VA cares for about 90,000 HIV patients nationwide, Volberding notes. About one-third of the HIV patients also are infected with hepatitis C, another focus of Volberding's research. The hope is that VA data will yield new clinical insight for the treatment of hepatitis C patients, with or without HIV.
Photo by Majed
UCSF Center for HIV Information
San Francisco VA Medical Center