Bill's first day on board

Bill Fariello was a little bit insane.

He was a nice enough guy so long as you didn't cross him. But it was important to avoid crossing him. He was a little guy, about 5'5", but muscular with a quick reaction time.

He established himself quickly when he first arrived on the ship. He'd spent a couple of years driving a forklift at a Navy warehouse in Pearl Harbor before arriving on board so he was far from new to the Navy even though this was his first sea duty.

His first day on board he was working on deck on the 01 level when a signalman walked by. The signalman was a tall guy, well over 6 feet tall, and he towered over Bill. Bill was blocking his way to a ladder up to the signal deck and when the signalman told Bill to move he did so while calling Bill a "little shit". Without uttering a word Bill punched him. He did a quick little crouch and sprung up into the air so that his 5'5" frame came up off the deck and he could deliver a straight on punch flat into the signalman's face.

The signalman actually went down from that one punch and Bill just walked off.

His reputation was permanently established.

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This story, and others like it, can be found in Navy War Stories.

Free Lunch

Veterans get a free lunch at Applebee's on Veteran's Day, Mov. 11.

Computerized health records

The Wall Street Journal seems to like the way the VA does things.

As health-care providers gear up for a digital overhaul, they could learn important lessons from an early innovator in the field—veterans hospitals.

The government is spending nearly $20 billion in stimulus funding to help hospitals and doctors switch to digitized records, and Medicare will start penalizing those who don't use them in a meaningful way by 2015. The goal is to boost the quality of care and slash costs by keeping better track of patients.

But the Department of Veterans Affairs made that digital switch years ago—with striking results. Independent studies show that the VA system does better on many measures, especially preventive services and chronic care, than the private sector and Medicare. VA officials say its technology has helped cut down hospitalizations and helped patients live longer.

Even though the sprawling health-care industry faces lots of challenges as it goes digital, advocates say that the VA's experience shows the technology, combined with quality measurements, can work on a large scale.

The records system, which also delivers an easy way to track physician performance, has been a boon to patients, says Ashish Jha, associate professor of health policy at the Harvard School of Public Health and a staff physician at the VA hospital in Boston. Over the years, he says, "quality goes up, but cost stays flat, compared to the rest of the country."

Healthy and Efficient

The VA's system allows doctors and nurses at more than 1,400 facilities to share a patient's history, which means they can avoid ordering repeat MRIs or other unnecessary tests. But the system isn't just a warehouse to store patient data. More important, it has safeguards to improve care quality. The system warns providers, for example, if a patient's blood pressure goes beyond a targeted level, or if he or she is due for a flu shot or cancer screening.

It also helps the VA monitor patient care at home, especially for people with complex, chronic illnesses, such as diabetes and heart failure. The VA gives those patients special gadgets free of charge to measure weight, heart rates, blood pressure and other conditions, and the daily results are automatically transmitted into the VA's medical-record system, says cardiologist Ross Fletcher, chief of staff at the VA medical center in Washington. If the numbers exceed target levels, a nurse is notified.

Dr. Fletcher recently pulled up the record of a 59-year-old man from Maryland for a demonstration. The record listed his health problems, such as hypertension and diabetes, and data for his weight and blood pressure since he first became a patient at the VA. The doctor could also open digital images of the patient's past X-rays, lab results and other materials, and zoom in for details.

A reminder also popped up, warning Dr. Fletcher that the patient's blood-sugar control level was above 8%, according to a home-measurement device and a test at the clinic. The reminder will stay there for all providers in the system to see until the patient brings it below 8%. He also has other services due, such as a flu vaccine. Before the appointment, he'll get a reminder call—and if he misses the visit, he'll get a call to reschedule it.

Also on the screen: a list of the patient's medications, including insulin, the pain medication Oxycodone and heart-failure drug Furosemide. Dr. Fletcher can reorder a drug through the system and have the request show up at the pharmacy; the patient can also order refills through an online portal. And if the doctor orders a new medication that interferes with something the patient is already taking, a warning pops up.

Higher Quality

The VA says the system has brought dramatic improvements. Consider the VA's in-home monitoring program, which has about 40,000 patients enrolled. The VA says the program has reduced hospital admissions by 25% and length of hospital stay by 20%. The system's automated reminders have also boosted performance in many areas. For example, the percent of patients receiving a flu vaccine rose to 83% last year from 27% in 1995, says Fernando Rivera, the Washington VA hospital's medical director. Colon-cancer screenings increased to 84% from 34% during the same period.

What's more, the VA says it has reduced medication errors significantly since it introduced a scanning system in 1999. It requires nurses to scan tags for patients and medications to ensure that they are giving the right medication to the right patient at the right dose and time.

Patients notice the difference. When Dwayne Thompson went for a physical last month at the veterans hospital in Baltimore, he didn't have to fill out any paperwork. He checked in for the appointment using his last name and part of his Social Security number, and waited less than 20 minutes before he was called for a blood sample, a visit with a social worker and an ankle X-ray—which was immediately fed into the hospital's electronic health records.

"The process was effortless," says Mr. Thompson, a 42-year-old Persian Gulf veteran in Baltimore. "They seemed to have everything in order."

The situation at the VA stands in stark contrast to the rest of the nation's health-care system. Only 1.5% of U.S. hospitals nationwide have a comprehensive digital-record system, let alone share information among different providers, according to a recent study co-authored by Dr. Jha in the New England Journal of Medicine.

To be sure, the VA's health-care system isn't a perfect roadmap for the industry—since the agency is in a unique position. The VA, through the Veterans Health Administration, employs the doctors, nurses and other health workers, which makes it easier to mandate performance standards. The VA also has an incentive to keep patients healthier because it takes care of veterans for life and sicker patients eat up the VA's budget faster. (Indeed, some veterans have trouble getting into the system partly because of the VA's budget limitations.) Elsewhere, most doctors and hospitals work independently, making it harder to monitor patient care. And those providers are rewarded for simply providing more care, not high-quality care.

Still, there are signs that private providers are taking lessons from the VA. In fact, some hospitals are adapting the VA's record system, VistA, for commercial use. (Some applications of the software, which was developed by the government, are available free.)

A Vast Setup

The VA turned to electronic records out of necessity. It serves 7.84 million patients through 153 hospitals, 765 outpatient clinics and 230 veterans centers and other facilities, and many patients are seen at different facilities. The Washington VA hospital alone used to have between 4,000 and 5,000 folders, not including imaging files, and sometimes they got lost during file transfers, Mr. Rivera says. Now the storage room is used as office space.

The VA started developing the VistA system in the 1970s, and began sharing lab results and medication information in the 1980s, says Dr. Fletcher, who was involved in the development process. The system got a major upgrade in the mid-1990s, when it became easy to use for doctors and nurses, and added clinical reminders and other quality measures.

One of the next big steps for the system is allowing doctors to see information about patient care received outside of the VA, since most VA patients also use other health-care providers.

Already, the VA and the Defense Department are sharing information on 3.4 million patients treated both at the VA and military facilities, says Chuck Campbell, chief information officer for the Military Health System. In addition, he says, the department has collected information on 4.8 million patients from its various electronic systems since 2002 and forwarded it to the VA once they were discharged.

In January, the two systems and a private managed-care company, Kaiser Permanente in San Diego, plan to test a pilot on how to share information on patients seen by the three systems. If successful, it will be expanded to other insurers.

Mr. Campbell sees the test run as a harbinger of things to come. Once everyone uses the same standard for digital records, he says, "you can share information easily across the nation."

Flashbacks

I had a run in with a VA cop over the weekend and felt very threatened. I haven't written anything about it yet, but I'm working on it.

Tonite I couldn't sleep and kept thinking about something that happened 40 years ago. I can't get it out of my mind, I'm trembling and feeling extreme anxiety about some appointments I have at the VA today. I guess I'm afraid I'm going to run into that cop. I don't really know. I guess this is what PTSD is about.

Leaving the hospital

Last Thursday afternoon I checked in the hospital for monitoring while my blood pressure and diuretic medications were being “adjusted”. I have heart and kidney problems and diabetes. The hospital staff took my BP, weight, etc when I checked in. My BP was very high, in the over 180 range. Earlier in the day it had consistently been in the 200 range (the DIA readings weren’t so bad, more like 80).
During the next 5 hours I received no treatment. None. No medications, no monitoring of any kind. Nothing. My nurse told me that nothing was scheduled for me. I’d been fed supper earlier (after complaining to the nursing staff of hunger) but it included milk and salty foods – things I knew I should not be eating.
I thought it was important to do something about the blood pressure so I went home simply because at least that way I’d be able to take some blood pressure medications and would be able to monitor my blood pressure. I thought that was medically important and I got no positive response at all from the staff when I brought it up.

VA management style

I was cleaning out a pile of old papers on my desk and ran across an old article from Computer World that I'd ripped out a while back (July 2007) intending to someday do a blog post about it.

So that someday finally came.

The article was about a GAO news release on "Inadequate Controls over IT Equipment at Selected VA Locations".

In July 2004, GAO reported that the six Department of Veterans Affairs (VA) medical centers it audited lacked a reliable property control database and had problems with implementation of VA inventory policies and procedures. Fewer than half the items GAO selected for testing could be located. Most of the missing items were information technology (IT ) equipment. Given recent thefts of laptops and data breaches, the requesters were concerned about the adequacy of physical inventory controls over VA IT equipment. GAO was asked to determine (1) the risk of theft, loss, or misappropriation of IT equipment at selected locations; (2) whether selected locations have adequate procedures in place to assure accountability and physical security of IT equipment in the excess property disposal process; and (3) what actions VA management has taken to address identified IT inventory control weaknesses. GAO statistically tested inventory controls at four case study locations.

And it's not just equipment that gets lost.

A weak overall control environment for VA IT equipment at the four locations GAO audited poses a significant security vulnerability to the nation's veterans with regard to sensitive data maintained on this equipment. GAO's Standards for Internal Control in the Federal Government requires agencies to establish physical controls to safeguard vulnerable assets, such as IT equipment, which might be vulnerable to risk of loss, and federal records management law requires federal agencies to record essential transactions. However, GAO found that current VA property management policy does not provide guidance for creating records of inventory transactions as changes occur. GAO also found that policies requiring annual inventories of sensitive items, such as IT equipment; adequate physical security; and immediate reporting of lost and missing items have not been enforced. GAO's statistical tests of physical inventory controls at four VA locations identified a total of 123 missing IT equipment items, including 53 computers that could have stored sensitive data. The lack of user-level accountability and inaccurate records on status, location, and item descriptions make it difficult to determine the extent to which actual theft, loss, or misappropriation may have occurred without detection. GAO also found that the four VA locations reported over 2,400 missing IT equipment items, valued at about $6.4 million, identified during physical inventories performed during fiscal years 2005 and 2006. Missing items were often not reported for several months and, in some cases, several years. It is very difficult to investigate these losses because information on specific events and circumstances at the time of the losses is not known. GAO's limited tests of computer hard drives in the excess property disposal process found hard drives at two of the four case study locations that contained personal information, including veterans' names and Social Security numbers. GAO's tests did not find any remaining data after sanitization procedures were performed. However, weaknesses in physical security at IT storage locations and delays in completing the data sanitization process heighten the risk of data breach. Although VA management has taken some actions to improve controls over IT equipment, including strengthening policies and procedures, improving the overall control environment for sensitive IT equipment will require a renewed focus, oversight, and continued commitment throughout the organization.

The entire report runs 53 pages and you can find it here.

Teeth Problems

I have diabetes, The VA considers it a service connected disability caused by exposure to Agent Orange, which is cool. But the diabetes has caused some problems with gum infections which lead to teeth falling out. That's not so good. In fact it's terrible because the OKC VA wouldn't provide dental care unless I was 50% disabled and it was service connected. Diabetes is only considered a 20% disability.

So I started checking into Mexican dentists for dentures and the possibility of payday loans to pay for it.

Then I discovered that the Wichita VA doesn't ration health care as badly as the OKC VA and I transferred all my health care to Wichita. Viola, new teeth, no charge, service connected.

So I'm getting dentures.