A Salute to the VA on Memorial Day—Part 1

In 2007, a book by Phillip Longman sent lasting ripples through the U.S. health care establishment. The title was audacious: Best Care Anywhere. But it was the subtitle that shocked: Why VA Healthcare is Better than Yours.

Was Longman suggesting that the Veterans’ Health Administration provides better care than the treatment that millions of well-insured Americans typically receive in the private sector? Yes.

Longman had uncovered what one reviewer called “the biggest untold story of the past decade,” the quality revolution that Dr. Ken Kizer launched when he took over the VA health system in 1994. And Longman had eye-popping evidence to back up his claims: overwhelming hard-core data from the most prestigious peer-reviewed medical journals. The research revealed that when it comes to everything from outcomes to patient satisfaction, and patient safety, the VA outperforms.

Most people don’t associate the VA with innovation. But the majority of its doctors have faculty appointments at academic institutions, one reason that the VA is on the cutting edge of evidence-based, patient-centered medicine. And over the years, Longman reports, the VA has been responsible for developing the CT scanner, the first artificial kidney, the cardiac pacemaker, the first successful liver transplant, and the nicotine patch.

When I saw Longman’s first story about the VA’s turn-around in a January/February 2005 Washington Monthly article, I was finishing my book, Money-Driven Medicine. I pored over the studies Longman cited, comparing care at the VA to care elsewhere, and realized that everything he said was true. After visiting a VA hospital and interviewing Kizer, I wrote about the VA in MDM and went on to describe its successes on The Health Care Blog, here and here, where I explained that the Army, not the VA, runs Walter Reed, and that the VA had nothing to do with the scandal about care at the Army hospital.

The 2010 Edition of Best Care Anywhere

Today, Longman, who is a fellow at both the New America Foundation, and the Washington Monthly, has revised The Best Care Anywhere. In this second edition, the author doesn’t just update the stats: he offers news, and new ideas.

First, Longman reveals how the VistA software program which is the centerpiece of the VA’s electronic medical record system is now being used outside the VA. Ken Kizer, the doctor who transformed the VA, is now CEO* of Medsphere Systems, a company that is adapting the VA’s software (VistA) for other doctors and hospitals. The software itself is free—anyone can download it online. But a hospital still needs to install VistA, adapt it, and learn how to use it. Medsphere offers those services to customers like Midland Memorial Hospital, a 371-bed, three-campus community hospital in Southern Texas.

In 2007 Midland installed VistA, and since then, Longman reveals, the new system has had “dramatic effects” on quality and patient safety. For example, “the system prompts doctors to follow guidelines when dressing wounds or inserting IVs, which in turn, caused infection rates to fall by 88 percent.”

Over the Memorial Day weekend, I spoke to Longman, and he told me that today "Some thirty hospitals and clinics are now using VistA. In terms of applying the software to the private sector," he said "it’s a proven concept."

The advantage of using VistA is that it’s “open source” software which means that it’s available at no or minimal cost, and allows different IT systems to operate compatibly. Because anyone can download it, the software is not controlled by Medsphere or any single company. Instead, a community of users can work to improve the code simultaneously, sharing ideas, and speeding development. Finally, unlike the proprietary software that most vendors sell, VistA is "software written by doctors for doctors."

A New Context: Health Care Reform Is Now a Reality

In January of 2007, when the Best Care Anywhere first appeared, the idea of universal coverage could best be described as a gleam in presidential candidate Hillary Clinton’s eye. (Both Edwards and Obama would back reform, but Clinton’s efforts in the early 1990s made her the Mother of all health care reform.)

When Longman revised his book, he was writing at a very different time: reform was about to become a reality. He tells me that his deadline for the 2nd edition forced him to turn in his manuscript shortly before the final vote on reform. This must have been enormously frustrating. But, wisely, Longman bet on passage—and this optimism animates the 2010 edition.

Longman updated Best Care Anywhere with an eye to what the VA can tell us about health care reform. As he explains in his new introduction, the VA has done virtually everything that we want to do nationwide: “Health care quality experts hail it for its exceptional safety record, its use of evidence-based medicine, its heath promotion and wellness programs, and its unparalleled adoption of electronic medical records and other information technologies. Finally, and most astoundingly, it is the only health care provider in the United States whose cost per patient has been holding steady in recent years, even as its quality performance is making it the benchmark of the entire health care sector.”

As Dr. Donald Berwick, President Obama’s candidate to head the Centers for Medicare and Medicaid observes on the back cover of the new edition: “The improvement of the VA healthcare system in the past decade is one of the most impressive stories of large-scale change . . . in modern times. Students of quality improvement will find lesson after lesson in this important case study.” The VA can show us how to turn a very large ship.

But the VA will serve as a model for national reform only if more reformers understand how the VA has changed the practice of medicine. Most journalists under the age of 50 who write for national publications don’t know any vets, which helps to explain why so few fully understand how the VA has used information technology, both in treatment and in research, to effectively manage chronic diseases. "Comparatively few Americans, especially among coastal elites, have any contact with the VA these days," Longman observes. Yet despite the VA’s low profile in the media, Longman realizes that the veterans’ health care system is an "example that shows that it is possible to make vast improvements in the quality, safety and effectiveness of the healthcare that all Americans receive, and to do it for but a fraction of what an unreformed health care system would cost." This isn’t a theory; at the VA, it’s a reality.

In other words, reformers don’t have to start from scratch. The VA already has laid out a roadmap and it would be happy to share the comparative effectiveness research that it has gathered with the rest of the nation. We don’t have to look to Europe to find examples of systems that work. I believe that studying care in Europe can be extraordinarily useful, but on the phone, Longman confided that, as a young journalist, he was told, "Never start a sentence, ‘In Sweden, they . . .’" Americans are more likely to be persuaded by home-grown solutions.

The VA under Bush vs. Obama

In the 2010 edition of Best Care Anywhere Longman also recounts how the Bush administration attempted to dismantle the open-source VistA software culture that Kizer had built, "doing its best to recreate the dysfunctional VA of the 1970s." Meanwhile, as more vets turned to the VA for care (in part because the care was so much better than it had been in earlier years), the Bush administration failed to provide enough funding, leading to long lines and not a few complaints. Nevertheless, Longman told me, "although the VA 'took a lickin,’ it kept on tickin'."

Now, he poses the pivotal question: Will the Obama administration re-commit to VistA? Or will it cave to the “heavy-weight” vendors who hope to reap billions selling hugely expensive proprietary “closed-source” software supporting electronic medical records that won’t be able to talk to each other.(I’ve posted about that danger here.)

Longman hasn’t given up hope. "The Obama administration is sending mixed signals," he told me. But he is encouraged by the legislation that Senator Jay Rockefeller introduced in April, a bill that would subsidize a roll-out of VistA and other open-source software “as a public utility,” that could save taxpayers billions.

Growing the VA

In his new book Longman also describes how the VA might expand. First, he suggests that the VA begin offering care, not just to Vets but to their spouses and children. If a family chooses the VA, family practitioners could treat the problems that vets and their spouses share.

In our conversation, Longman acknowledged that, in many regions, the VA doesn’t currently have the capacity to take on more patients: "In Florida, Arizona, Nevada, they are strained to the seams. But in Boston, they have more VA hospitals than they need." And because the VA already knows how to offer better care for less, over time, it would make sense for Washington to use funding already available in the reform legislation to help the VA expand.

Going a step further, Longman suggests that the VA might serve as the “blueprint” for a separate, “civilian VA” that could provide care for a vastly expanded pool of newly insured patients. He envisions an integrated health delivery system that he calls the "VistA Health Care Network." This national network would use VistA software. "The VA would help individual doctors, public hospitals and charity care hospitals install the free VistA software," Longman suggests, "as long as they would agree to adhere to the VA’s guidelines for evidence-based 'best practice' care.”

In Part 2 of this post, I will lay out Longman’s vision for a "civilian VA." I also will explain what Longman has to say about the importance of the decision that the VA should treat all Vietnam vets exposed to Agent Orange—many of whom are now developing Parkinson’s Disease—and the implications for expanding the VA. Finally, I’ll explain why The Best Care Anywhere is being translated into Chinese. (Hint: China, which owns a huge share of this nation’s debt, has a vested interest in whether we begin to figure out how to rein in runaway health care inflation.)

*EDITOR'S NOTE: Ken Kizer is now chairman of the board of directors at Medsphere Systems Corporation.

Click on Maggie Mahar's Health Beat to read more, including some pertinent comments on this topic, or add your own comments.

Click on Washington Journal to access a video of C-SPAN's May 29, 2010, broadcast interview with Longman in honor of Memorial Day.