I n many ways, it was an utterly commonplace encounter. During 20 minutes with nurse
practitioner Les Peters, Tom Townsend answered questions about his health and submitted to a few basic tests while Peters updated Townsend's medical records.
But in several other respects, the encounter was extraordinary. For one thing, it took place in a converted Greyhound bus parked next to the 4-H building in Moscow, Idaho. The bus is a traveling branch of the Spokane Veterans Affairs Medical Center, where Townsend, a 75-year-old veteran of the Korean and Vietnam wars, has been treated for a variety of conditions. Crisscrossing the region, Peters and his crew offer follow-up visits to patients who might otherwise have to drive long distances on less-than-ideal roads.
Also notable—in fact, unusual in medical care as practiced in this country—is that Townsend's records are on Peters's laptop, linked via the Internet to the medical center's database. During the exam, Peters updated the file and renewed several of Townsend's prescriptions without touching pen to paper. Though Townsend can scarcely believe it, this isn't how things get done in most of American medicine, where paper files remain the norm, prescriptions are still written by hand and then deciphered by pharmacists, and physicians don't carry computers wherever they go. Fewer than one in five U.S. hospitals have the information-processing capabilities that Veterans Health Administration patients have come to take for granted.
With 157 hospitals, nearly 900 outpatient clinics, 5.2 million patients and a budget of $30 billion in the 2005 fiscal year, the VHA is really a big, sprawling HMO, comparable in scale to such industry giants as Kaiser Permanente. And during the past decade—virtually overnight, in government time—its reputation has morphed from one of the nation's worst health-care providers into one of the best. Now it's leading the medical world into the era of digitized medicine, where sophisticated databases and high-speed computers will, in theory, produce a quantum leap in the quality of care.
Like many parts of the federal government, the VHA was born small and fragmented and gradually coalesced, gaining its current name and cabinet status in 1989. But the VHA's operating model was stuck in the 1950s: top-down, assembly-line-like, impersonal. Many decisions that ought to have been judgment calls were etched in bureaucratic stone. For example, "federal law required admission to get a prosthetic device, which meant if you sprained your ankle and needed crutches, you had to be admitted to the hospital, because crutches were considered a prosthetic device," recalls Kenneth W. Kizer, a physician who was Under Secretary for Health in the Department of Veterans Affairs and CEO of the VHA from 1994 to 1999. The result of this and other arbitrary rules was that a lot of beds were occupied, at taxpayers' expense, by veterans who should have been home with their families.
Beyond racking up unnecessary costs, all those hospitalizations exposed patients to potentially deadly perils. Spreading infections, incorrectly prescribed or administered medications, botched operations—the horror stories were so common that some politicians wanted to reform the whole system. Alabama senator Richard Shelby argued in 1992 on the Senate floor, "Peace for veterans in our VA hospitals is a hotter and deeper hell than the hell of war."
But democracy often requires crisis to produce consensus, and 1994 was one of those rare times in the life of a bureaucracy when radical change was possible. Kizer was able to sit down with a blank sheet of paper and start sketching. In 1998, he recruited Jonathan Perlin (now the VHA's Under Secretary for Health) to oversee quality and performance, and James Bagian, a former astronaut, to direct the VA National Center for Patient Safety.
To learn what they were up against, Kizer and his colleagues put in place quality-of-care measurements that had been developed but not yet widely deployed in the private sector. Held up to those metrics, the VHA system proved just as dysfunctional as its reputation suggested. Only one patient in four was getting the right immunizations, heart attack patients weren't receiving lifesaving beta blockers, staffers were touching patients without washing their hands, and surgeons were operating on the wrong patients—or the wrong body parts.
As a government agency, the VHA couldn't use stock options to change the behavior of its staff, all of whom were federal employees. But it could pound home the relevant ideas at staff meetings and publicize who was falling short. "Not all doctors were enthusiastic," says Kizer. "Sometimes they didn't like the performance measures we were using, so we said, ‘If it's not a good measure, pick a better one, but we're going to measure your performance and insist on the things that we know equate with good outcomes.'"
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