Albert Napoli was just 17 years old when he joined the U.S. Navy. On Oct. 30, 1944, his ship, the USS Belleau Wood, was struck by Kamikazes in the Leyte Gulf, Philippines. Napoli was loading 20-millimeter cannons when flames from a direct hit overtook his station. Feeling a burning sensation across his back, Napoli jumped overboard—a 60-foot plunge. He then helped others in the water onto a rescue ship.
Sitting beside his walker last week at the Long Island State Veterans Home (LISVH) at Stony Brook University, Napoli, now 84, of Patchogue, recalled the tale following a Memorial Day ceremony. Though much time has passed, the day is forever etched in his mind.
“We lost about 100 of my shipmates,” Napoli said, pausing for a moment before repeating the line.
Napoli is one of about 26 million veterans across the United States, an estimated 280,000 of whom live on Long Island. Though these service men and women have left the battlefield, many veterans such as Napoli find themselves entrenched in another struggle: the quest for affordable, efficient health care. President Barack Obama has made expanding services to veterans a top priority and views the computerization of medical records—not just for vets, but for all citizens—key to improving health care quality while lowering costs. In January, the then-president elect set the goal of computerizing all medical records within five years. In April, he announced efforts by the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) to create a Joint Virtual Lifetime Electronic Record, which would contain medical and administrative information from an individual upon enlistment, through, and after his/her military career.
Earlier this month, the VA announced that the president proposed a 15.5 percent, or $15.1 billion, increase in its 2010 budget. More than $3 billion of those funds are earmarked for ensuring accessible, reliable and secure computer systems. This includes upgrades to its electronic health records system, known as VistA (Veterans Health Information Systems and Technology Architecture).
VistA, recognized as one of the most quality-controlled and cost-efficient electronic medical health systems in the world, is an open-source software—meaning it’s free in the public domain through a Freedom of Information Act request. There is currently a global movement by the software’s architects and supporters to spread it outside the VA and across the health care spectrum. The technology was paid for by taxpayers. It has been adopted by other countries—Finland, for example, has implemented VistA within its public health care system. Yet health care providers in the United States have been slow to adopt the software system and electronic health records (EHRs). And few outside the VA knew that the system was a result of a battle waged within its walls for more than 30 years—mostly in secret and in defiance of the government itself—by an underground network of doctors and computer programmers who refused to give up. And it’s a battle that continues today, against the threat of proprietary software systems, with perhaps even more hanging in the balance in the wake of the president’s electronic health records goals.
REVOLUTION
With a few clicks of his mouse, David Lin, M.D., a primary care physician at Northport VA Medical Center, knows the entire medical history of his patients. One of those patients, Joe Sledge, a veteran and spokesman for the Northport VA, allows Lin to share his records with this reporter. Within seconds of logging into the VA system, Lin knows everything about Sledge thanks to VistA: what medications he takes; what, if any, operations he’s had and where, by whom, when, what time, and more. Lin can even view X-rays, radiology reports and electrocardiographs. He can zoom in, focus on a particular area, change the resolution or control its brightness—advances not possible only a short while ago, he says.
Lin shifts the mouse slightly and a rainbow of colors in the shape of Sledge’s torso appears. A few seconds later and Lin is graphing Sledge’s cholesterol levels. In 2004, Sledge traveled to Florida and was examined at a VA hospital there. It’s all at Lin’s fingertips. He can tell whether Sledge is allergic to a particular medicine or due for a refill. He can chart the data to visualize it historically for further analysis or to measure performance. He can see lab test results. He can access this crucial data from any one of the hundreds of computer throughout the 201-bed hospital, extended care facility and outpatient pavilion’s extensive campus. Lin can even access the files remotely from home.
The benefits, says Lin, and many other proponents of VistA, are many.
Electronic medical records save time and cut down on costs and the chance for errors, proponents say. Paper records don’t travel with a patient. In the past, if someone sought medical attention somewhere other than where they were regularly treated, the patient’s chart would have to be tracked down. The other doctor’s handwriting would have to be deciphered—no easy task admits Lin. Files may not have even been complete, he adds. For X-rays and other radiological imaging, physicians in the past may have had to contact that particular department or wait for the files. This could have resulted in another test being done, so it also cuts down on duplicity of studies and services. It also helps in decision-making, says Lin.
Most importantly, having a patient’s medical information easily accessible and in an electronic format such as VistA saves lives, according to Lin.
“It’s one of the best tools to obtain medical information about our patients,” says Lin. “It’s really one-stop shopping. Now, instead of going to different departments to get information, going down to radiology to get an X-ray, going down to maybe cardiology to see their EKG for whatever reason, you can just come to one place and get everything.
“Especially in emergency situations, whenever you have an EKG or an X-ray, you want to be able to act as soon as possible,” he adds. “And if you’re in the emergency room and somebody’s broken a hip or something like that, you want to be able to say, I’ve seen it, you pull it up… We can go as far back as he’s had a record… And it doesn’t get lost to some file room that sometimes they can’t pull up.”
There are added safety benefits.
In Bar Code Medication Administration, implemented throughout the VA network, patients and their medication are electronically documented with bar codes to ensure they’re receiving the correct dose at the correct time. Patients wear the codes on a bracelet. When an order for a specific medication is written, a bar code for that patient is created and attached to the meds. Before the medication is administered, both the patient and the meds are scanned. A mismatch will give a visual warning not to give the medicine.
But this state-of-the-art system wasn’t always such, explains Sledge.
“There was a time when medication errors were a huge problem, not only in the VAs, but all hospitals,” says Sledge. “So this is a phenomenal tool to help reduce the possibility of having a medication error in the medical center.”
Another benefit of the VistA system, says Sledge and Lin, is the ability to identify trends, since the VA network is essentially a massive database of medical information, easily searchable. Doctors can see what works and what doesn’t. They can also analyze commonalities among patients to pinpoint potentially dangerous factors. For example, according to multiple sources, the VA was one of the first medical institutions to recognize a link between the prescription of Vioxx, an arthritis medicine, and an increased risk of serious heart attacks.
NEVER SAY DIE
VistA began in the late 1970s, out of a shared desire among doctors, nurses, pharmacists and physicians at hospitals throughout the VA network to better its health care system, according to Phillip Longman, a Schwartz Senior Fellow at the New America Foundation and author of 2007’s Best Care Anywhere: Why VA Health Care Is Better Than Yours. Unequipped to deal with the tens of thousands of Vietnam veterans returning home and in working conditions he describes as “horrible,” like those depicted in the movie Born on the Fourth of July, a group of them took it upon themselves to do something about it. Not even aware of each other at the beginning, they built and used primitive computers and even word processors to create medical record programs. Eventually, they discovered each other and an underground community formed. They began sharing files and collaborating on applications for it. This was all against their central office policy, says Longman.
The current VistA is the evolution and constant adaptation of the efforts of those first crews, who became known as the Hard Hats. The system in progress was called the Decentralized Hospital Computer Program (DHCP).
“What VistA is, essentially, is 18,000 different programs, many of which were written on Radio Shack kit computers—late 1970s, but written by doctors for doctors and continuously improved and integrated into practice,” explains Longman. “These things didn’t have a hard drive. They didn’t even have a floppy. What they had was cake trays-sized silicon wafers. And they’d download their programs onto that and put it under a trench coat and get on an airplane and deliver it to some guy on the other side of the country.”
Members of this “underground railroad,” as it became known, carried secret ID cards—emblazoned with an image of a locomotive—so they could identify each other, says Longman. And despite a crackdown on the renegade developers by their higher-ups in administration, they continued. Kenneth Dickie, M.D., a former physician at Washington VA, now retired, was part of this underground network. He describes the experience as “kind of fun” and “kind of nerve-wracking.”
“Yeah, we kind of took on the government at that stage and it caused us all a lot of stress, but nevertheless we managed to get the [VistA] system in,” he laughs. “It developed a long way since then.”
Dickie describes his role as being on the clinical and political side. Without naming names, he says things were on a need-to-know basis among the different factions, and that it was all a team effort.
“None of us individually were totally responsible,” Dickie tells the Press. “We all had our part to play. And the cooperative effort was what we were doing in the electronic side, as well as the political side. [Each] had their role to play and we let the other people who knew what they were doing, do it. And that’s still what the system does, I believe.”
The Hard Hats continued their work through the Reagan and Bush Sr. years. By the 1990s, under the Clinton administration, their efforts were embraced by Kenneth Kizer M.D., the undersecretary for health in the VA, who was a proponent of electronic health records. Kizer, as the CEO of the VA healthcare system, was charged with restructuring what many in Washington viewed, overall, by 1994, as a “fundamentally flawed” system that “didn’t have much of a future,” he explains. He was pleasantly surprised to find the computerization of medical records already underway.
“It was already ahead of the curve, certainly ahead of where the private sector was in having a clinically relevant information management system for electronic health records,” says Kizer, now a consultant and chairman of the board of Medsphere Systems Corporation, a company that adapts the VistA software for use in private or commercial hospitals. “I quickly learned of it, found out what was going on, saw that what they had was at least a kernel, or at least the basis, of what was needed.”
Kizer renamed the DHCP “VistA,” and formally launched it in 1997, he tells the Press. Over the following three years it was deployed to every VA facility.
ROCK PAPER SCISSORS
Despite its benefits and low start-up costs, the U.S. health care system has been slow to implement VistA technology or EHRs. A recent study in the New England Journal of Medicine found that only 1.5 percent of U.S. hospitals have a comprehensive electronic records system and only 7.6 percent of those surveyed have a basic system. The study also discovered that computerized medication orders had only been implemented in 17 percent of hospitals. Why?
Longman suggests that one reason is psychological: the perception that in order for a system to be of high quality, it’s got to cost an arm and a leg, and if it doesn’t it’s probably no good.
“Imagine yourself, you’re the administrator, or you’re vice president or something in a hospital and your CEO tells you, ‘Go out and investigate what’s the best IT options for us,’” says Longman. “And you come back and you say, ‘Well I’ve made a thorough study of it and actually, it’s this one that’s free that’s best.’ Right… The more you charge for it, the more people want it. And if you’re giving it away for free they just assume it’s no good.”
Longman adds that proprietary, or private, software vendors also have deep pockets and conduct substantial lobbying efforts.
Another reason, explains Kizer, is that open-source technology is a significant, fundamental change to the current business model of the health care IT industry. Open-source software’s code, such as VistA, is free. It’s given away. You don’t make money off it. The business model becomes how well you support the system and new developments. Private software companies, which charge hefty fees for software licensing, would be left on a sinking ship. The growth of open-source technology threatens their very existence.
“In the U.S, where you have all these companies, the U.S. and Western Europe, open source is a direct threat to their business model,” he says. “If it works, then they are going to basically lose all those millions of dollars of licensing fees that they get from owning the code. If the code is out there in the public domain where anyone can work on it and use it, then how do they make money?”
VistA supporters add that proprietary software restricts users by not allowing them to improve the system but instead charges users more for the company to do so.
Opponents of VistA are critical of the language it is written in, MUMPS (Massachusetts General Hospital Utility Multi-Programming System), a language used by doctors beginning in the 1960s. Doctors, on the other hand seem to prefer it because it is software by doctors written for doctors. But critics also raise red flags about the security of electronic records keeping, which was a concern even among early VistA engineers, such as Dickie.
“When you automate something and have information available, we were right from the beginning, we were concerned that it could be misused,” he says. “So whatever system you put in, anybody puts in, you have to be very careful that it’s not misused. Most people don’t care what [information] I got, but they do care what President Obama has.”
Although the initial VistA software is free, investments must be made on training and maintenance. K.S. Bhaskar, president of WorldVistA, a nonprofit organization that works to promote and improve VistA EHRs around the globe, explains that it’s really the user’s business needs that dictate the level of its implementation.
“If you’re really using it to its full capability, then essentially the complexity is the complexity of your business,” says Bhaskar. “Installing VistA is easier than installing [a Microsoft] Office suite. But the challenge of VistA is setting it up to match the business of the health care processes of the care that you’re giving.”
Dave Whitten, WorldVistA’s chief technology officer, adds that training is a cost really for any computer system.
For those who know the technology, VistA’s benefits are far worth it.
“What we need to do is take this gem of a system and grow it,” says Longman.
Meanwhile, as WWII vet Napoli sits among other veterans from wars past at the Long Island State Veterans Home and remembers those who didn’t make it back, the battle for the computerization of his medical records rages on.