Still, as sleek as the current VHA electronic health-record system is when compared with the U.S. health-care norm, "it's a Model T compared with what we'll have in the future," says Robert Kolodner, the VHA'S acting chief health information officer. Illustrating the gap between what is and what should be, a recent study of a Salt Lake City VA medical center published in the Archives of Internal Medicine found that while the current system eliminates the risk of illegible handwriting and flags such simple issues as drug allergies, it doesn't necessarily help a doctor decide whether a particular drug is the best choice or is being administered in the ideal dosage.
The VHA's current decision-support capability "isn't a substitute for a functioning brain," says Kizer. But the next iteration might help considerably if it develops as planned. Called HealtheVet, it's an information technology system that provides guidance for health-care providers and is designed to be continuously upgraded with such new technologies as voice recognition and remote diagnostics.
Phase one of the project is building a better database. Today's VHA information systems are local, not national, with patient data residing in 128 different servers. And though those servers contain 650 million documents, clashing formats and protocols are making it difficult for computers to "understand" information from these different places.
"When we built the system twenty-some years ago, each hospital created its own database with its own terminology," says Kolodner. "One facility may call a test ‘sodium,' another ‘serum sodium,' and another something else." Doctors are used to this variability, but it's a problem for software designed to provide doctors with automated clinical decision support.
"At the local level, they're cleaning up the data, domain by domain," says Kolodner. When each hospital has standardized its allergy files, for example, the data will flow into a central repository. When all domains are cleaned and collected, the system will become hub-and-spoke, with transactional computing and decision-support analysis done regionally and storage done centrally. The data gleaned from the regional HealtheVet system will alert doctors when a patient's dosage needs adjusting or prompt them when an equally effective generic is available.
Meanwhile, entering a patient's information into a central database shifts the emphasis from facility to patient. Today a VHA patient's data is on the hard drive of each hospital at which he was treated. If he shows up at the emergency room of a different facility, this information must be retrieved from the other hospitals and is available only as text-based reports and results. With a central database, all patient information will be available to any VA facility. Moreover, each patient can have his own VHA online account. "Patients will have the same kinds of decision support their doctors do, so when they come in they'll know these are the five things their provider should be doing for them," says Kolodner.
With HealtheVet, the VHA could take medicine across the next digital frontier, ushering in an era in which telemedicine (by which patients are monitored and diagnosed at home via the Internet), ever more sophisticated decision support and other high-tech capabilities combine to provide a quality of care that's closer to Star Trek than to Marcus Welby, M.D. The benefits of this initiative should eventually become available to community hospitals and other financially strapped oper-ations, much as the VHA now makes its electronic health record software available for a nominal fee.
But this quantum leap has to be funded, and that's not assured. Citing an outside study that found HealtheVet to be risky and poorly planned, the House Committee on Veterans' Affairs recommended withholding development funding in fiscal year 2006. Kolodner's response is that something this multifaceted is bound to have speed bumps. "There are funding issues for all government programs," he says. "But one way or another, we have to make HealtheVet happen." 
 Dossier
1. Digital Medicine: Implications for Healthcare Leaders, by Jeff Goldsmith (Health Administration Press, 2003). A helpful overview.
2. The Veterans Health Administration: Quality, Value, Accountability and Information as Transforming Strategies for Patient-Centered Care, by Jonathan B. Perlin et al., The American Journal of Managed Care, November 2004. A detailed account of the VHA's transformation, from several of its chief architects.
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