Advantages and Disadvantages of Advanced Information Systems

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Let us look at the The Veterans Health Administration (VHA) as an example of an information system that has improved access and service in the health care industry in the United States.

The Veterans Health Administration (VHA) uses its $21 billion budget to operate the largest complete health service system in the United States. Over 25 million service men and women are eligible for VHA care; five million of these received care in 2003, including three quarters of all disabled and low-income veterans. VHA currently employs approximately 180,000 health care professionals at 163 medical centres and hospitals, more than 800 community and facility-based clinics, 135 nursing homes, 43 domiciliaries, 206 readjustment counseling centres and various other facilities.

The following article, written by Professor Denis J Protti describes the benefits of a single 'National' health record system:

The most broadly implemented and currently functioning health Information Technology (IT) system in the world today is that of the VHA. The clinical computer system, known as Veterans Health Information Systems and Technology Architecture (VistA), covers more than 1,200 sites of care, including acute care hospitals, ambulatory facilities, skilled nursing facilities, and pharmacies. At this time, the system contains a single health record of 8.5 million veterans in 22 regions across the entire United States. Authorised clinicians have access to any veteran's record, regardless of which region they reside in.

The Computerised Patient Record System (CPRS), initially released in 1996, represented a dramatic upgrade in the steady evolution of VistA. First, in the early 1990s, it advanced a patient-centred approach to clinical computing rather than a department-centred approach; this is an approach which is based on the value of one record and which is independent of provider, function or location. Second, it was VHA's first concerted effort at applying client-server technology with its much easier to use graphical user interface - an approach which is commensurate with the architecture and applications used in most modern offices and homes. Third, its deployment at the VHA medical centres enabled a major change in work process - namely shifting from paper-based records charting to computer-based records charting. Crucially, CPRS includes provider order entry and provider entered electronic progress notes - both of which are often believed to be difficult to deploy. CPRS was mandated nationally in 1999 and virtually all clinicians in the VHA now use it.

At almost all VHA sites, virtually all clinical documentation is entered and accessed using CPRS, including all forms of clinical notes, doctors' orders, consultations, procedure reports, radiology and pathologic examinations. Most sites maintain a small single notebook for so-called 'wet-signed' patient documents (eg patient consents, living wills) for all inpatients on a particular ward. All remaining documentation is electronic. At most sites, no past paper charts need to be retrieved for outpatient clinic visits - the majority of the information that clinicians require is stored in the single electronic record. This revolution in medical documentation is without precedent in such a large and diverse health care system such as the VHA.

CPRS provides a single interface for all authorised health care providers to review and update a patient's medical record and to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests. A detailed audit trail of all transactions records who has accessed what data for what purposes - providing a means of assuring that patient data is kept confidential and secure. The system is flexible enough to be implemented in a wide variety of settings for a broad spectrum of healthcare workers and provides a consistent, event-driven, Windows-style interface. CPRS permits VHA clinical staff, at the point-of-care, to access a patient's record from anywhere within the Veterans health system across the United States. To prevent concerns related to privacy and access to patients' health information, the CPRS uses a reliable method for identifying who is authorised to look at what data and to modify clinical documents.

CPRS organizes and presents all relevant data on a patient in a way that directly supports clinical decision-making. The comprehensive cover sheet displays timely, patient-centric information, including active problems, allergies, current medications, recent laboratory results, vital signs, hospitalisation, and outpatient clinic history. This information is displayed immediately when a patient is selected and provides an accurate overview of the patient's historical and current status before clinical interventions are ordered. CPRS capabilities include:

---A Real-Time Order Checking System that alerts clinicians during the ordering session that a possible problem could exist if the order is processed

---A Notification System that immediately alerts clinicians about clinically significant events

---A Patient Posting System, displayed on every CPRS ...