25-Jun-16D. Protti - City University London & University of Victoria 1 THE IMPACT OF INFORMATION TECHNOLOGY ON QUALITY AND SAFETY IN PATIENT CARE: THE MOST IMPRESSIVE CASE STUDY - THE VETERAN’S ADMINISTRATION IN THE USA? THE IMPACT OF INFORMATION TECHNOLOGY ON QUALITY AND SAFETY IN PATIENT CARE: THE MOST IMPRESSIVE CASE STUDY - THE VETERAN’S ADMINISTRATION IN THE USA? WORLD MEDICAL ASSOCIATION Copenhagen, Denmark October 4, 2007

25-Jun-16D. Protti - City University London & University of Victoria 2 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 3 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 4 Patient Safety - The Problem Not New Schimmel (Ann. Int. Med.) –20% of Univ. Hospital Admissions Injured 20% of those serious/fatal Steel (NEJM) –36% of Teaching Hosp. Admissions Injured 25% serious or life threatening Harvard Practice Study (NEJM) –4% of Admissions Injured approx. 0.5% fatal IOM Report –Deaths due to Preventable Adverse Events greater than, MVA, Breast Cancer, or AIDS

25-Jun-16D. Protti - City University London & University of Victoria 5 Risk of Death as an Airline Passenger and as a Patient Admitted to an Acute Care in Hospital in Canada Airline industry1 death in 2 million passengers 1 Air Canada0.67 deaths in 2 million passengers 2 South West Airlines0.0 deaths in 9.5million flights 2 Canadian acute care hospitals7,400 – 19,000 deaths in 2 million patient admissions 3 1.Leape LL et al Reducing Adverse Drug Events, IHI, According to AirSafe.com 3.By extrapolation from Baker GR, Norton PG et al The Canadian Adverse Events Study, JMAC 25 May 2004; 1684.

25-Jun-16D. Protti - City University London & University of Victoria 6 Safety & Human Factors: Challenges People do not come to work to hurt someone or make a mistake Systems vs. individual is at fault Healthcare views errors as failings which deserve blame

25-Jun-16D. Protti - City University London & University of Victoria 7 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 8 Veterans Health Administration Veterans Health Administration (VHA) –The branch of VA that provides healthcare to American veterans and selected family members ~ 8 million patients Locations & Affiliations (today) – ~ 1,400 sites-of-care Including 154 hospitals, ~ 875 clinics, 207 counseling centers, plus long-term care, domiciliaries, home-care programs Nearly half US health professionals (>65% physicians) have some training in VA

25-Jun-16D. Protti - City University London & University of Victoria 9 VA Health Care Users Compared to Veteran VA Non- users and the General Population Veterans Non-Vet VANon- General UserUser Population 65 or older35.6%31.3%17.0% Non-Caucasian Not married Education < HS Income < $20, Income < $10, No health insurance Unable to work for pay or limited ADLs

25-Jun-16D. Protti - City University London & University of Victoria 10 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 11 VA Health Care – Assets (1994)  172 hospitals  >600 ambulatory care and community- based outpatient clinics  131 nursing homes  40 residential care facilities  73 primary care at home programs  206 counseling centers

25-Jun-16D. Protti - City University London & University of Victoria 12 VA Health Care – Problems (1994) VA Health Care – Problems (1994)  Hospital-focused, specialist-based, episodic treatment of illness  Independent, competing medical centers (not a “system”)  Too much inter-facility variation  Care too difficult to access  Staff demoralized  Centralized, hierarchical, micro-management  Reams of rigid policies and procedures  Capital investment decisions too political  Organization too inwardly focused  Inadequate funding (??)

25-Jun-16D. Protti - City University London & University of Victoria 13 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 14 VA Transformation… Critical Strategic Goals (Vision) VA Healthcare will:  Provide a seamless continuum of care;  Provide high quality patient- centered care “consistently and predictably”; and  Provide superior value.

25-Jun-16D. Protti - City University London & University of Victoria 15 VA Transformation... A New Operational Model Veterans Integrated Service Networks (VISNs)  Based on patient referral patterns  Able to provide a continuum of primary to tertiary care  Geographical/political boundaries  7-10 Hospitals  Ambulatory care clinics  5-7 Nursing homes  1-2 Residential care facilities  Counseling centers

25-Jun-16D. Protti - City University London & University of Victoria 16 VA Transformation... Key Structural & Process Changes  Change Governing Laws Eligibility reform Contractual authority Enrollment system  Rationalize resource allocation Design and implement a new resource allocation system (VERA) Diversity funding base

25-Jun-16D. Protti - City University London & University of Victoria 17 VA Transformation... Rationalize Resource Allocation Veterans Equitable Resource Allocation (VERA) – a capitation-based resource allocation system. Funds allocated to the VISNs according to the number of patients who were provided care (averaged over the prior 3 years) and adjusted according to acuity and certain other factors.

25-Jun-16D. Protti - City University London & University of Victoria 18 VA Transformation… Key Structural and Process Changes  Implement a performance management system Align vision and mission with quantifiable strategic goals Link performance measures with strategic goals Track performance Hold managers accountable for achieving results

25-Jun-16D. Protti - City University London & University of Victoria 19 VA Transformation... Key Structural & Process Changes W Modernize information management Implemented an electronic health record system-wide Standardized information systems system-wide

25-Jun-16D. Protti - City University London & University of Victoria 20 VA Transformation… Key Structural and Process Changes  Reform the organizational culture Safety Quality Patient-centered Value driven Transparent Accountable  Re-educate users about expectations

25-Jun-16D. Protti - City University London & University of Victoria 21 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 22 RESULTS AFTER FIVE YEARS (and today)

25-Jun-16D. Protti - City University London & University of Victoria 23 VA Transformation… Selected Results:  Implemented universal primary care  Closed 55% (28,886) of acute care hospital beds  Reduced Bed days of care (BDOC ) per 1000 patients by 68%  Increased patients treated by >24% (700,000)  ~350,000 (36%) fewer admissions per year  48% increase (25 to 37 million) in ambulatory care visits  Decreased staffing by 12% (25,867 FTEs)

25-Jun-16D. Protti - City University London & University of Victoria 24 VA Transformation… Selected Results:  Increased ambulatory surgery from 35% to >75% of all surgeries  Established 302 new community-based outpatient clinics  Merged the management and operations of 52 hospitals into 25 locally integrated systems  Eliminated 72% (2,793) of all forms and automated the rest  Universal access and identification card  25% decrease in per patient costs (constant dollars)

25-Jun-16D. Protti - City University London & University of Victoria 25 VA Transformation… Surgical Mortality and Morbidity Rates  Overall 30-day mortality and morbidity rates dropped 9% and 30%, respectively, from 1994 to 1997 with no change in patient risk profile  Mortality rates lowest or equal to U.S. lowest for Colectomy Abdominal aortic aneurysm repair Carotid endarterectomy Cholecystectomy Hip replacement

25-Jun-16D. Protti - City University London & University of Victoria 26 VA Transformation… Quality Indicators: VA vs. Medicare  Significant to marked improvement in all indicators in VA  VA’s performance superior to Medicare FFS on all indicators and on 12 of 13 in 2000 Jha, et al. NEJM 2003: 348:

25-Jun-16D. Protti - City University London & University of Victoria 27 VA Transformation… Vaccinations and Pneumonia Admissions  Influenza vaccination rose from 27% (1995) to 70% (2003)  Pneumococcal vaccination rose from 28% (1995) to 85% (2003)  Variation in rate due to geography, indication and type of facility nearly eliminated  Hospitalization due to CAP fell by 50% in VA (compared to a 15% increase in Medicare) Jha, et al. NEJM 2003: 348:

25-Jun-16D. Protti - City University London & University of Victoria 28 VA Transformation… American Customer Satisfaction Index  80 percent of VHA users experience more satisfied now than two years ago.  VHA’s score on the index is 79 (the score for private hospitals is 70).

25-Jun-16D. Protti - City University London & University of Victoria 29 Every VA Medical Center has Electronic Health Records and Computerized Provider Order Entry

Scope of use Single patient record immediately available in real time, supports both continuity of patient-centric care across continuum Inpatient: all wards, critical care, specialty care, Bone Marrow Transplant Unit, surgery Outpatient: Primary Care, Specialty Care, Allied health, Community Based Outpatient Clinic Emergency room Nursing Home Home Care Home Telemonitoring

25-Jun-16D. Protti - City University London & University of Victoria 31

VHA – Benchmark for Quality Clinical Indicator VA 2002 VA 2003 Medicare 03Best Not VA or Medicare Advised Tobacco Cessation (VA x3, others x1) (NCQA 2002) Beta Blocker after MI (NCQA 2002) Breast Cancer Screening (NCQA 2002) Cervical Cancer Screening (NCQA 2002) Cholesterol Screening (all pts)91 NA73 (BRFSS 2001) Cholesterol Screening (post MI) (NCQA 2002) LDL Cholesterol <130 post MI (NCQA 2002) Colorectal Cancer Screening64 67 NA49 (BRFSS 2002) Diabetes Hgb A1c checked past year (NCQA 2002) Diabetes Hgb A1c > 9.5 (lower is better)17 15 NA34 (NCQA 2002) Diabetes LDL Measured (NCQA 2002) Diabetes LDL < (NCQA 2002) Diabetes Eye Exam (NCQA 2002) Diabetes Kidney Function78 70* 5752 (NCQA 2002) Hypertension: BP < 140/ (NCQA 2002) Influenza Immunization74 76 P68 (BRFSS 2002) Pneumocooccal Immunization87 90 P63 (BRFSS 2002) Mental Health F/U 30 D post D/C81 77* 6174 (NCQA 2002)

25-Jun-16D. Protti - City University London & University of Victoria 33 Presentation Outline  Setting the Scene  Overview of the VA healthcare system  Problems with the system in 1994  Re-engineering strategy and key changes  Evidence of change  Lessons learned  Questions

25-Jun-16D. Protti - City University London & University of Victoria 34 VA Transformation… How was the change achieved?  The time was right for change  Having a clear vision  Alignment of key change levers Changing the structure to facilitate process and culture change Performance measurement and reporting Modernization of information technology Rationalization and alignment of finances with desired outcomes Promoting a culture of quality Changing user expectations and awareness  Capitalizing on external circumstances

25-Jun-16D. Protti - City University London & University of Victoria 35 VA Transformation… How was “buy-in” achieved?  Combination of “stick and carrots” – (e.g., change in MD policy, limited $$, early retirement) every way possible  Doing the right thing clinically  Taking advantage of all opportunities to market the change  Selection of personnel  Alignment of structure, process and incentives

25-Jun-16D. Protti - City University London & University of Victoria 36 From not only the VA, but also from other leading jurisdictions who are improving patient safety through the use of Information Technology and process changes Final Lessons

25-Jun-16D. Protti - City University London & University of Victoria 37 The IT Value Iceberg Computers are just the catalyst Value comes from: – People who know what to do with the information – People who can effect change and innovation

25-Jun-16D. Protti - City University London & University of Victoria 38 In Perspective - Goethe “Knowing is not enough; we must apply. Willing is not enough; we must do." Johann Wolfgang von Goethe German Playwright, Poet, Novelist and Dramatist

25-Jun-16D. Protti - City University London & University of Victoria 39 The challenges in improving quality and safety by using IT in the health care sector can be overcome. “Never doubt that a small group of thoughtful committed people can change the world; indeed it’s the only thing that ever has!” Margaret Mead American cultural anthropologist

25-Jun-16D. Protti - City University London & University of Victoria 40 Finite