This combination of measurement and accountability brought changes that were at once commonsensical and profound. Kizer and his staff closed underutilized hospitals and reassigned patients. Many wards once packed with rows of beds—all the better for airborne pathogens—were converted to semiprivate rooms. Administrators put alcohol-cleansing-agent dispensers in or outside each room, making hand washing easier. Health-care workers began asking patients for name, birth date and Social Security number before putting them under. Outpatient procedures nearly doubled, while inpatient procedures declined by a third.
It worked. Infections and surgical mistakes fell, and the number of patients getting the right immunizations rose from 27% in 1995 to 80% in 2000. "And it's very homogeneous across the system," adds Kizer. "There used to be big differences between rural and urban, inpatient and outpatient groups. But today about 80% of all the VHA's subgroups are immunized for influenza. That is radically better than in the private sector."
These behavioral shifts could just as easily have been made in the 1950s. But the true agent of change was only starting to emerge as the VHA began restructuring. For more than a decade, VHA clerks had been entering paper records into a vast electronic database. For a private hospital, whose patients can move to another provider whenever they want, converting records for a computerized system has an uncertain payoff. But the VHA's captive audience made such a project essential. Recognizing its value, Kizer's team sped development of the database and implemented it systemwide.
From their laptop keyboards, VHA doctors can now order lab tests and medications and enter progress notes. The system also offers basic decision support, flagging patient drug allergies and potential drug interactions. Today a doctor who prescribes Coumadin for a patient on Motrin will be informed that she's risking intestinal bleeding.
All of this may seem terribly basic, when businesses from Wal-Mart to the corner store went digital long ago. But for medicine, these technological upgrades have been revolutionary. Two decades ago, the Spokane Veterans Affairs Medical Center was, by VHA standards, a smallish facility, with 132 inpatient beds. But in terms of its operating protocols—and shortcomings—it was typical. Everything ran on paper, with charts, updated by hand, following patients from room to room. Handwritten prescriptions were passed to pharmacists, who counted pills and filled bottles. X-rays were developed on film and physically carried from laboratory to office, where they were analyzed on backlit screens. Nurses dispensed medication after a cursory check of the chart at the foot of a patient's bed.
Today, patient records reside in a central server, accessible via laptop, and radiology images show up instantly on high-resolution computer screens. When a prescription is entered into a terminal and verified by a pharmacist, it goes to "the robot," a glass-walled unit in the hospital pharmacy that sorts and packs the requested medication before sending it to a human pharmacist for inspection. And instead of fretting about giving a patient the wrong medication, nurses count on the system to watch their backs.
Eric Knievel, the Spokane hospital's clinical applications coordinator, demonstrates by scanning a bar-coded patient bracelet into a wireless terminal on a cart. Then he scans the bar code on a medication vial. "The software checks to see whether it's a valid order for that drug at that time in that dose by that method of administration," Knievel says.
Spread across VHA facilities nationwide, these changes have transformed the hospital system from laggard to leader. In 2003 the New England Journal of Medicine judged the VHA'S system superior to fee-for-service Medicare on all 11 similar quality-of-care indicators from 1994 through 1999; in 2000 the VHA outperformed Medicare on 12 of 13 indicators. And in the 2003 State of Health Care Quality report published by the National Committee for Quality Assurance, the VHA reported scores that met or exceeded the ninetieth percentile for commercial plans in many categories.
Digitization saves money as well as lives. After sinking more than $1 billion into its information system, the VHA reportedly spends an estimated $78 per patient per year to run it. That's a fraction of the savings it achieves by reducing unnecessary tests and avoidable admissions. Proper pneumonia and influenza vaccinations alone save the VHA more than $100 per year for each patient who gets the shots. The result is a trend line not often seen in health care: falling per-patient expenditures.
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