Table Of ContentComputers in Health Care
Kathryn J. Hannah Marion J. Ball
Series Editors
Springer Science+Business Media, LLC
Computers in Health Care
Series Editors:
Kathryn J. Hannah Marion J. Ball
Dental Informatics
Integrating Technology into the Dental Environment
L.M. Abbey and J. Zimmerman
Aspects of the Computer-based Patient Record
M.J. Ball and M.F. Collen
Nursing Informatics
Where Caring and Technology Meet, Second Edition
M.J. Ball, K.J. Hannah, S.K. Newbold, and J.V. Douglas
Healthcare Information Management Systems
A Practical Guide, Second Edition
M.J. Ball, D.W. Simborg, J.W. Albright, and J.V. Douglas
Strategy and Architecture of Health Care Information Systems
M.K. Bourke
Information Networks for Community Health
P.F. Brennan, S.J. Schneider, and E. Tornquist
Introduction to Medical Informatics
P. Degoulet and M. Fieschi
Patient Care Information Systems
Successful Design and Implementation
E.L. Drazen, J.B. Metzger, J.L. Ritter, and M.K. Schneider
Introduction to Nursing Informatics
K.J. Hannah, M.J. Ball, and M.J.A. Edwards
Computerizing Large Integrated Health Networks
The VA Success
R.M. Kolodner
Organizational Aspects of Health Informatics
Managing Technological Change
N.M. Lorenzi and R.T. Riley
Transforming Health Care Through Information
Case Studies
N.M. Lorenzi, R.T. Riley, M.J. Ball, and J.V. Douglas
Knowledge Coupling
New Premises and New Tools for Medical Care and Education
L.L. Weed
Robert M. Kolodner
Editor
Computerizing Large
Integrated Health Networks
The VA Success
With the Assistance of Judith V. Douglas
With 82 Illustrations
Springer
Robert M. Kolodner, MD
Associate Chief Information Officer
Veterans Health Administration
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420, USA
Series Editors:
Kathryn J. Hannah, PhD, RN Marion J. Ball, EdD
Leader, Health Informatics Group Professor, Department of Epidemiology
Sierra Systems Consultants, Inc. University of Maryland School of
and Medicine
Professor, Department of Community and
Health Science Vice President
Faculty of Medicine First Consulting Group
The University of Calgary Baltimore, MD, USA
Calgary, Alberta, Canada
Library of Congress Cataloging-in-Publication Data
Kolodner, Robert M.
Computerizing Large Integrated Health Networks: the VA success/Robert M. Kolodner.
p. cm.—(Computers and health care)
Includes bibliographical references and index.
ISBN 978-1-4612-6858-1 ISBN 978-1-4612-0655-2 (eBook)
DOI 10.1007/978-1-4612-0655-2
1. United States. Veterans Health Administration—Data
processing. 2. Health services administration—United States—Data
processing. I. Title. II. Series.
UB369.K65 1997
362.1'1'0285—dc20 25988
Printed on acid-free paper.
© 1997 Springer Science+Business Media New York
Originally published by Springer-Verlag New York, Inc. in 1997
Softcover reprint of the hardcover 1st edition 1997
In recognition of the authors' work undertaken as part of their official duties as U.S. Govern
ment employees, reproduction of this work in whole or in part for any purpose of the U.S.
Government is permitted.
All rights reserved. This work may not be translated or copied in whole or in part without the
written permission of the publisher, Springer Science+Business Media, LLC
except for brief excerpts in connection with reviews or scholarly
analysis. Use in connection with any form of information storage and retrieval, electronic
adaptation, computer software, or by similar or dissimilar methodology now known or here
after developed is forbidden.
The use of general descriptive names, trade names, trademarks, etc., in this publication, even
if the former are not especially identified, is not to be taken as a sign that such names, as
understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely
by anyone.
While the advice and information in this book are believed to be true and accurate at the date
of going to press, neither the authors nor the editors nor the publisher can accept any legal
responsibility for any errors or omissions that may be made. The publisher makes no warranty,
express or implied, with respect to the material contained herein.
Production coordinated by Chernow Editorial Services, Inc., and managed by Francine
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Typeset by Best-set Typesetter Ltd., Hong Kong.
9 8 7 6 5 4 3 21
ISBN 978-1-4612-6858-1
To Ted O'Neill and Marty Johnson, whose
vision, efforts, and careers laid the founda
tion for the accomplishments described in this
book, and to the thousands of programmers
and users since 1977, both inside and out
side V A, whose dedication and contributions
brought V A to the forefront of medical
computing.
Foreword
This book has been a long time in the making. The computerization activi
ties described in these pages began in 1977 at the Department of Veterans
Affairs (VA), but we devoted most of our focus and efforts to building and
then implementing the extensive hospital information system known as the
Decentralized Hospital Computer System (DHCP) throughout VA. Deliv
ering the product has been our primary goal. We spent relatively little time
documenting or describing our experiences or lessons learned. Except for
some presentations at national meetings and a relatively few publications,
almost none of which were in the standard trade journals read by Chief
Information Officers (CIOs) and equivalent top managers in the private
and nonprofit sectors, VA's accomplishments remained a well-kept secret.
In 1988, Helly Orthner encouraged VA staff to consider writing a book, but
the press of day-to-day activities always seemed to take precedence, and the
book languished on the back burner.
Due to changes since that time in both VA and the rest of the healthcare
system, VA's experience in creating, maintaining, and, most importantly,
evolving an extensive, clinically oriented healthcare information system has
become even more relevant to other large integrated healthcare organiza
tions. Today, the information needs of VA and other healthcare institutions
are much closer to each other than they were previously. An important
difference between them is the direction from which their information
systems grew. V A's advantage is that its information system is built on one
that is rich with clinical information and that has been expanding and
improving for the past 15 years, rather than being based on systems that
started out being primarily financial in nature. It is our firm belief that a
clinical system can be extended to generate management and financial
information far more easily and effectively than a financial system can be
extended into becoming a clinical one.
In 1988, a billing system was not an essential function in the initial
implementation of DHCP, because the vast majority of VA's budget is
based on· its allocation from Congress. This contrasted with most other
hospital information systems, with a few notable exceptions, whichconcen-
vii
viii Foreword
trated on billing and financial functions. Instead, V A addressed challenges
in the implementation of clinical and management systems in a large
healthcare network. We concentrated on the needs of the individual
healthcare facility for patient identification and tracking (registration,
admissions/discharge/transfer) and for efficiently managing high-cost op
erations, such as laboratory and pharmacy, which are often the profit cen
ters in other institutions. For these latter services, the emphasis was on
managing and recording the workload and on decreasing the costs, includ
ing the distribution of results to the front-line clinicians, rather than gener
ating a bill. As new modules were added, a similar focus was maintained.
Moreover, front-line V A users, including clinicians, were involved in the
design of the software in order to improve the volume and accuracy of the
information they needed to deliver care to veterans. The result is a com
bined clinical and management information system that is firmly based on
gathering information during the course of clinical care and deriving man
agement data as a byproduct of these interactions.
As V A established the authority and mechanisms for collecting reim
bursement from the subset of veterans who were not entitled to free care,
billing became a more important consideration. As VA reorganizes into its
multi-facility networks (see Chapter 1 for more details), accurate manage
ment data across facilities become not just desirable, but vital to its future.
Emphasis in the networks has been shifting from inpatient care to ambula
tory care settings and to the formation of both integrated and virtual
healthcare networks. Today, V A is moving into a managed care operation,
charged with meeting the needs of its enrolled population. Now that VA no
longer simply takes and reacts to whoever comes in the door for care, a
managed care information system capability is becoming a necessity. Thus,
V A's information needs are moving closer to those of other healthcare
institutions, even though its budget currently remains primarily dependent
on congressional appropriations.
At the same time that VA has been changing, other healthcare organiza
tions have been shifting their emphasis from pure financial information
systems to those that are more clinically oriented. As healthcare becomes
more competitive and forces increase to consolidate resources and decrease
costs, more and more healthcare institutions are recognizing the critical
importance of their information systems and are increasing their invest
ments accordingly. The most effective information systems will be those
that contribute not only to cutting costs, but also to increasing both access
to and quality of care. These multiple goals require that clinical information
systems be an integral part of healthcare information systems.
The VA experience, detailed in this book, offers a model based on a long
track record of developing and implementing a low-cost, highly integrated
healthcare information system that has been designed to evolve and grow
gracefully-changing hardware platforms, operating systems, and com
puter languages, and integrating a variety of commercial technologies-
Foreword ix
without requiring the gut-wrenching and expensive conversion from one
computer system to another. Moreover, the information system is remark
ably robust and locally extensible, meeting the needs of an impressive range
of healthcare facilities. These facilities range from outpatient clinics and
nursing homes to large, multi-divisional tertiary care medical centers. A
variety of foreign countries have even adapted portions of the system to use
in their native languages, such as German, Spanish, Arabic, and Chinese.
Even the problems encountered as the system grew and changed over
these 15 years provide opportunities for CIOs and their counterparts in the
private sector to understand the potential pitfalls and successful strategies
for overcoming them. Our attempt has been to include these "warts" in our
presentations, so that others might learn from them.
These past 15 years, and the 5 years that preceded them before DHCP
was launched, have been an exciting journey for those of us who have
participated. We sometimes tried to do "impossible" tasks, such as imple
menting healthcare information systems in 169 facilities in a 3-year period
where no infrastructure or expertise existed before. And we often suc
ceeded. Our information system was originally designed for individual fa
cilities, yet it has been able to grow and evolve to support multi-facility
networks. Critics accused VA of using out-of-date technology or being a
closed system, often because they viewed DHCP at a point in time, rather
than as a large, dynamic system that was undergoing a metamorphosis over
time. Key components of the system were chosen because of their utility as
robust solutions, but our commitment is to the goal, not to the specific
solution. So, as better technologies arrived, such as client-server and
graphical user interfaces, we have moved on to incorporate these in VA's
healthcare information system. The flexibility derives, in large part, from
the creativity and dedication of the technical staff within V A, both at the
national and the local level, and at collaborative institutions such as the
Indian Health Service, who generate innovative ideas to overcome poten
tial barriers in the evolutionary process. Without them, DHCP would have
become just another short-term information system that would have had to
be discarded and replaced by yet another system with a typical life cycle of
development, maturity, and obsolescence over an 8 to 10 year period.
Instead, VA's system remains dynamic and vital today, even if every com
ponent has been or will be swapped out over the course of its evolution.
This book was constructed to provide the reader with an idea of the
breadth of the automation activities that have been underway at VA to
support the day-to-day operations at the local medical facility level. We
have not tried to describe either the myriad of national level databases or
the commercial decision support system that aggregates cost and workload
data so that management can determine the value of the care V A delivers.
Since 1982, DHCP has been central to facilitating this daily activity. Al
though DHCP represented the total automation activity at most VA medi
cal centers in 1985, it became clear that by 1996, DHCP-the national
x Foreword
system developed by VA staff-was only one part of the overall informa
tion resource at the local facility level. Office automation, local software
development, and commercial-off-the-shelf healthcare information systems
such as those used to support intensive care units, anesthesia services, and
telemedicine activities have been added to the mix of information resources
available today in V A medical facilities. Thus, by the time this book is
published, V A will be using a new term to encompass this broader informa
tion resource environment that is installed throughout V A. This new
term-the Veterans Health Information Systems and Technology Architec
ture (VISTA)-will be used to describe VA's healthcare information system
instead of DHCP. As such, VISTA incorporates all of the benefits of DHCP
as well as including the rich array of other information resources that are
vital to the day-to-day operations at VA medical facilities. The switch to
VISTA does not represent the discarding of DHCP. Instead, it represents
the culmination of DHCP's evolution and metamorphosis into a new, open
system, client-server-based environment, that takes full advantage of com
mercial solutions including those provided by Internet technologies. The
underlying principles, goals, and vision from DHCP form the heart of
VISTA as well.
Robert M. Kolodner
Series Preface
This series is intended for the rapidly increasing number of health care
professionals who have rudimentary knowledge and experience in health
care computing and are seeking opportunities to expand their horizons. It
does not attempt to compete with the primers already on the market for
novices. Eminent international experts will edit, author, or contribute to
each volume in order to provide comprehensive and current accounts of
innovations and future trends in this quickly evolving field. Each book will
be practical, easy to use, and well referenced.
Our aim is for the series to encompass all of the health professions by
focusing on specific professions, such as nursing, in individual volumes.
However, integrated computing systems are only one tool for improving
communication among members of the health care team. Therefore, it is
our hope that the series will stimulate professionals to explore additional
means of fostering interdisciplinary exchange.
This series springs from a professional collaboration that has grown over
the years into a highly valued personal friendship. Our joint values put
people first. If the Computers in Health Care series lets us share those
values by helping health care professionals to communicate their ideas for
the benefit of patients, then our efforts will have succeeded.
Kathryn J. Hannah
Marion J. Ball
xi
