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WHAT A VHA PATIENT’S BAR-CODED WRISTBAND CAN SHOW:
Who he is // What he’s taking // What he should not be taking // Why this is the future of health care.

The Digital Hospital

By John Rubino // Photographs by Amy Sinisterra // Winter 2006
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The robot” at the Spokane Veterans Affairs Medical Center

No human hands, no human errors. At the Spokane Veterans Affairs Medical Center, "the robot" prepares to dispense the right drug in the right dose for the right patient.

In 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.”

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Going Paperless

In hospitals worldwide, conversion to digital ranges from the futuristic to the pragmatic. Here, a sampling of progress.

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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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