1. Lawrence Deyton, MSPH, MD
VA Overview
Lawrence Deyton, MSPH, MD
Chief, Public Health
With thanks: Dr. Gary Roselle, Syed Tirmizi, Gail Graham, John Quinn, Linda Danko, et al

2. History Veterans programs date back to Colonial times
VA created in 1930 as an independent agency
Cabinet-level department created in 1989
Major eligibility changes in 1996
Now the 2nd largest Cabinet-level department (second to DoD)
Budget over $75,000,000,000
VHA $29 B, VBA $35 B
210,000 employees

3. VA Mission Motto: Abraham Lincoln
Serve America’s 25 million veterans and their families with dignity and compassion by providing health care services and benefits earned in service to this Nation
Motto:
“To care for him [and her] who shall have borne the battle and for his widow and his orphan.”
Abraham Lincoln

4. Missions of the Veterans Health Administration
Medical care
Graduate medical education
Research
Emergency preparedness

5. VA Medical Care The largest integrated healthcare system in US:
158 hospitals (18,828 beds, 5.4M BDOC)
132 nursing homes (33,408 ADC)
73 home care programs
43 domiciliary programs
206 veterans counseling centers
854 clinics (50 M outpatient visits)
186,600 employees (VHA)

6. Fiscal Year 2004 – VHA statistics
7.1 million total enrollees of 25 million US veterans
5.1 million patients treated
$29 billion total budget
200 million 30-day equivalent Rx’s dispensed
190 million lab tests performed

7. Who Are VA Patients? Older - 49% over age 65
Sicker - Compared to Age-Matched Americans
3 Additional Non-Mental Health Diagnoses
1 Additional Mental Health Diagnosis
Poorer
70% with annual incomes < $26,000
40% with annual incomes < $16,000
31% have no health insurance
Changing Demographics – 4.5% female overall
Females: 22.5% of outpatients less than 50 years of age

8. VA Medical Care
Enrolled veterans eligible for full spectrum of general and specialty medical/preventive services including drug benefit
Special focus on conditions related to military service:
Prosthetics, rehab and blind rehab
Environmental exposures (agent orange, Gulf War syndrome, depleted uranium & radiation, cold injury, etc.
PTSD and mental health issues
Special focus related to VA populations served:
Geriatrics/extended care
Women Veterans programs and services
Chronic diseases; diabetes, cardiac, kidney, cancer, infectious diseases, mental health/substance abuse, homelessness

9. Veterans Health Administration Education Mission
Affiliated with 107 of 125 U.S. Medical Schools and 1,200 education institutions
VA has more than 5,000 affiliation agreements for Associated Health Programs
84,510 Total trainees (Academic Year 2001)

10. Veterans Health Administration Research
FY04: 1.5 billion dollars of research
Mission: improve veterans health care
Medical Research
Rehabilitation Research
Cooperative Studies (large multi-center clinical trials)
Health Services Research
Accomplishments:
Invention of cardiac pacemaker, CT technology
First successful liver transplant, insulin pump
Multi-center clinical trials; Tb, MI & CHF tx, HTN, DM
2 Nobel Prize winners, 6 Lasker Awards

11. Emergency Responses
VA/DoD Contingency (PL ) – VA back up for DoD in event of war or national emergency involving armed conflict
NDMS – VA, HHS, DoD, FEMA (DHS) – assists state/local govts with medical & PH disasters and hospital capacity
DEMPS – VA part of Federal Response Plan when Presidential Disaster Declaration in made
Ad hoc – local responses to emergencies

12. 2004: Who is “VA”? Veterans Health Administration
Budget, Staff, & Patients:
~193,000 Employees (~15,000 Doctors, 56,000 Nurses, 33,000 AHP)
6% decrease since ,000 fewer employees than 1995
~ $27.4 Billion budget
42% increase since 1995: flat at ~ $19B from
5.1 million patients, ~ 7.5 million enrollees
104% increase in patients treated since 1995: from 2.5 million patients / enrollees in 1995

14. Success in Supporting Health Delivery for Millions of Veterans
VistA (veterans health information system and technology architecture)
Features Include:
100+ separate business packages that support day-to-day activities of healthcare operations, including
Registration / Enrollment / Eligibility Systems
Provider Systems for delivery of healthcare
Management and Financial Systems
And CPRS……

15. VistA / CPRS (Computerized Patient Record System)
VistA/CPRS supports the largest integrated
health system in the United States serving over
5 million veterans
Delivers an integrated record covering all aspects of patient care and treatment
Includes electronic order entry and management, narrative notes entry, laboratory results, consultation requests and reports, alerts of abnormal results, imaging, clinical reminders, and much more
VistA Web allows clinicians to see health data from any other VA facility where the veteran has received care

16. And CPRS Is Actively Used... National VistA Statistics (Total / Daily)
Documents (Progress Notes, Discharge Summaries, Reports)
658,000,000…… ,000 each workday
Orders
1.35 Billion…… ,000 each workday
Images
300,000,000………+475,000 each workday
Medications Administered with the Bar Code Medication Administration (BCMA) system
630,000,000………+605,000 each workday
as of March 2005

17. Success In Supporting Health Care Delivery For Millions Of Veterans
VistA is a success
Publicly owned by VA; plan to remain so for the next generation system
Strong interest by public/private in using VistA (IHS, DC Dept of Health, etc)
National software w/ local flexibility/innovation:
Innovation developed locally & enterprise wide
Standard packages distributed system-wide
Initial system ( ) built on “dumb terminals”
“Decentralized Hospital Computer Program (DHCP)”
Steady deployment of packages and enhancements
Applications separated out by Hospital/Clinic “Service”
Simple “roll-and-scroll” screens

18. In 1996, VA launched the “Computerized Patient Record System” -- CPRS-- a comprehensive, integrated Electronic Health Record (EHR)

19. How it all Began……
CPRS evolved from DHCP’s text-based Order Entry/Results Reporting
Initial design and subsequent enhancements guided by clinicians
“Visually” organizes and presents all relevant data on a patient in a way that supports clinical decision making
Phased implementation of CPRS
Placed in “production” at first VA site in July 1996
Began use at 3 more sites between August and December 1997
Installed in “lead” site in each of VA’s 22 regions by June 1998
Implementation completed at all VA Medical Centers (>170) in December 1999

20. VA Today
Every VA Medical Center uses Electronic Health Records

21. Electronic Health Records and Computerized Provider Order Entry (CPOE)
100 % VA Medical Centers have Electronic Health Record
CPOE is one of the Leapfrog Group’s “Top 3 Safety Strategies”
Outside of VA, CPOE < 8% nationally
< 30% among Academic Medical Centers
Nationally, 93% of all VA Rx’s by CPOE
Ultimate Goal: 100%
VA is the Benchmark for CPOE
All Medical Centers also have Desktop Imaging

22. Combining Text and Images

23. Clinical Reminders Links Reminder With the Action With Documentation
Contemporary Expression of Practice Guidelines
Time & Context Sensitive
Reduce Negative Variation
Create Standard Data
With the Action
With Documentation

24. Online Demo of CPRS
Try a working copy of VA’s Computerized Patient Record System (CPRS) at