Health IT at the US Department of Veterans Affairs

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Abstract

Health Information Technology has been a key debate in the health sector in the US for a couple of decades now. Much of the discussion has been on the recording of health data in a safe and secure manner. It is agreed that long gone are the days when data recording was manual. Characterized by errors and unnecessary paperwork, the use of pen and paper to record health data has been criticized by many experts in the field. Interestingly, some experts also criticize the use of technology in health data management.

The Obama administration ensured that myths on the digital recording of health data were demystified. One way the said administration ensured this is through the adoption of Electronic Medical Record or Electronic Health Records. Whereas some health facilities embraced the technology, many were against it, claiming that loss of sensitive and private health care data through hacking was a serious threat.

Regardless of the numerous challenges identified with a digital system, the US Department of Veteran Affairs embraced the technology and customized it to fit its target population. The health challenges faced by veterans re unique; thus, the customized approach was deemed fit to solve some of the external health challenges observed among the target audience. Impressively, the department was able to prove that Health Information Technology can work. It recorded better uptake of health care services among veterans after the implementation of the system. Despite the success observed by the department, one cannot be oblivious to the limitations of the system. To ensure desired results from the innovation, it has to be used correctly, and security measures put in place to avoid loss of health care data.

Introduction

Health Information Technology supports information management in health care services through the application of computerized services (Melas, Zampetakis, Dimopoulou & Moustakis, 2014). Commonly referred to as HIT, the application brings together the critical shareholders in health care, providing necessary information when needed. The stakeholders include patients, doctors, monitors, and insurance providers (Melas et al., 2014).

It is necessary to point out that HIT should be secure enough to allow the different shareholders identified to only get access to information relevant to their role in the system. For instance, doctors should be able to see the patient’s health history, but not their financial statements. The doctors then provide the insurance providers with the hospital bills, but should not be able to give out the private health history of the patient, unless the patient agrees to the same.

HIT has been described as one of the best health care innovations of all time. The innovation has helped users manage sensitive health care data effectively. The system works by providing linkages to all health care stakeholders in an easy to understand, easy to access, and easy to retrieve manner. Two examples of the linkages can be provided for further clarification. In the first example, a veteran with a chronic health condition goes to the hospital to seek services.

The veteran has been using a different doctor, but the private doctor has moved to a different state. The patient does not have any records from the previous doctor, and the new one has to “guess” the different treatments and medications that the patient was using. In the second example, the veteran is enrolled in the HIT, and the new health care provider can log in and get all the health data saved on the patient’s profile. Better health care decisions can, thus, be made in the second example, as the doctor has all the needed information about the health history of the patient.

The US Department of Veterans Affairs has invested heavily in HIT. The investment is intense as compared to both the private and public sectors. The intensity is measured by both the amount of money that was used and the extent of overage that was covered. Suffices to note, the US Department of Veterans Affairs only introduced HIT several years back. There are various reasons why the department deemed it fit to do so. The said reasons will be highlighted and analyzed later on in the paper.

The essay will also look into the value realized by the department after the investment, and analyze whether the investment was worth it. Additionally, a look into how the veterans served through the system appreciate it will be presented. Many health services that are provided rarely analyze the opinion and experience of the target audience. However, to measure the extent of success and applicability of such a system, it is important to also evaluate the experience of the veterans.

Literature Review

Rittenhouse et al. (2017) argue that there are two main ways in which HIT can be implemented. The first way is through the Electronic Health Record (EHR) or the Electronic Medical Record (EMR) platform, where data is uploaded onto a system that has various levels of access. Rittenhouse et al. (2017) agree that there have been numerous instances where health care providers have made avoidable errors due to a lack of correct data.

With the EHR errors from wrong prescriptions, errors related to poor preventive care, and errors related to tests and procedures have reduced (Melas et al., 2014). The reduction has been attributed to the efficiency of the platform. The second way of implementation of HIT is the clinical point of care technology. According to Silverman (2013), the Institute of Medicine estimated that one patient is exposed to a clinical error every day during his or her stay in the hospital. The clinical point of care technology uses the computerized provider order entry (CPOE). Parente and McCullough (2009) explain that CPOE reduces minor clinical error rates by 80% and reduce major clinical harm to patients by 55%.

Byrne et al. (2010) argue that the potential value of the VA’s health IT investments is approximately US$3.09 billion in cumulative benefits net of investment costs. To health economists, the said amount has to be worth it, and to provide the required services in order to be justifiable. According to Rittenhouse et al. (2017), the amount used, and the investment made, are justifiable. The literature review will analyze the ideas and opinions of experts on the VA intensive health IT investment. Arguments for and against the investment will be presented.

Silverman (2013) is of the opinion that the VA’s investment is not only justifiable but should also be emulated by other government agencies. The premise is made based on the idea that HIT has a lot of potentials. Thus, in order to understand the argument raised, the benefits of the system have to be addressed. The first major benefit of the investment is that it culminates all health records in one platform. It can be argued that by doing so, data management becomes easier and more efficient. The importance of proper health data management cannot be overstated. Such information is crucial in both improving individual health indicators, and also the creation of viable community health management strategies.

Crucial to state, tracking of patents health records is a major challenge in both the private and public service. Rittenhouse et al. (2017) argue that health care providers have had to go through hundreds of paperwork to attain some of the health diagnostics done on their patients. HIT innovations such as Electronic Medical Records (EMR) have made tracking easier, thus, leading to lower rates of hospital-acquired infections. Towards this end, therefore, it can be stated that the investment was worth it.

There are several arguments that have also been made on the issue of linkages. From the description given of HIT, it is clear that there are various linkages encouraged by HIT. One such linkage is between the patient and the other stakeholders in the platform. The patient is easily linked to the doctor/health care provider, to the insurance company, and to the monitor. Such a linkage allows for better planning and communication between the patient and the identified stakeholders. A link can also be drawn between the insurance provider and the health care provider. Such a link is crucial in assuring health financing for the patient. Additionally, a link can be drawn between the insurance provider or the doctor and the monitor. The said link is critical in ensuring quality of service offered.

Silverman (2013) explains that the VA’s decision to take up HIT, was critical as it complimented other government services that veterans did not have access to previously. For example, veterans with metal health conditions were given more attention through established systems compared to those with other chronic diseases such as Asthma and Diabetes. Wu and Lewis (2015) through a scientific research study, recognizes that the most common veteran chronic health condition is hyperlipidemia. Despite this, it is the least treated. Neugaard, Priest, Burch, Cantrell and Foulis (2011) add that with HIT, generalizations on needs of veterans is resolved, and doctors make health decisions based on the information they get in the system.

Quality improvement also comes into question when discussing HIT. As Neugaard et al. (2011) observe, quality improvement is a key component of HIT. HIT became one of the Obama’s administration strongest selling point. In selling their idea, the administration stressed that the HIT would ensure quality improvement. Towards this end, there are two main factors to consider. The first is the quality of services offered while the second is the overall quality improvement of wellness for both the patient and the other providers on the platform. The first factor, which has been mentioned through the essay, the quality of service arguably increases through HIT.

The second factor, overall quality improvement of wellness for both the patient and the other providers on the platform has also improved. Doctors and other care provides are able to save time by making evidence based decisions, thus, are able to enjoy the services they offer.

The role of the nurse in the HIT is also made easier and due to the effectiveness of the systems as encouraged by HIT, allow the nurse to be fully involved in a patient’s health recovery journey. The nurse in charge of the patient is able to implement the health care directions proposed by the doctor, and also prove that instructions were followed, through the platform. Since the platform is all inclusive, the nurses can contact the doctors and all other health care providers treating the patient, in case he/she needs clarifications.

Important to note, HIT has several key opportunities in the use of data science and machine learning (Melas et al., 2014). One key opportunity is in regard to health monitoring and diagnosis. As stated, one of the stakeholders in the HIT platform is the monitor. Health monitoring and diagnosis system revolves around three elements namely field monitoring system, remote service system, and collaborative management system (Miao, Zou, Gao, Li & Liu, 2016). HIT combines all these factors. The second key opportunity is medical treatment and patient care. As has already been described through the first part of this literature review, medical treatment and patient care has improved, and is complimented through the different linkages already established.

Pharmaceutical research and development is the third key opportunity of HIT. The US Department of Veteran Affairs, through the platform, is able to gather information needed to further research and development. Important to note, there are ethical considerations to think about when discussing use of the data in research and development. Neugaard et al. (2011) explain that the department does not have the right to use the personal data unless authorized by the patients.

However, there are generic data that can be used for research purposes. In particular, the use of medication and the implication of medication can be used by the department. Byrne et al. (2010) explain that clinic performance optimization is the last key opportunity for HIT. Initially, the department was using manual methods to record and track patients. Such manual methods allowed for poor clinical performance, with many errors, as stated.

Apart from the EMR, nurse charts are also a very critical element of HIT (Byrne et al., 2010). Nurses are the first contact for a patient, and also act as a link between doctors and patients. Apart from patient care and interaction, nurses also take down orders and instructions provided by doctors. In the initial system, where doctors had to write on paper, nurses recorded many errors due to complications of handwriting. Through the HIT, both nurses and doctors have the ability to type in instructions in a clear manner.

Wu and Lewis (2015) also agree that the investment made by VA was worth it. However, the scholar cautions on patient safety. Since 2009, there have been discussions on the importance of patient safety in regard to health economics. True, many scholars who have debated on concepts encouraged in health economics, tend to leave out patient safety. In the use of HIT, however, both patient safety and health economics are considered. Health economics come into play through the service insurance and monitoring elements of HIT. Proper data management makes it easier for health insurance providers to determine the type of insurance the patients under review require. The process also makes it easier for the insurance providers to review the payment status of their clients in an easier and efficient manner.

Payne et al., (2013) go further and explains that the use of HIT will lower the money required by government to aid in health financing. Payne et al., (2013) explain that by 2008, health care spending in the US had risen three times since 1990, to an estimate of approximately $2.3trillion. The expenditure cost has preceded the overall cost inflation and GDP growth in the last 10 years. To be more precise, 31% of health care financing goes to hospital care, 21% is used on physician services, 10% on prescription medications and 8% on nursing home care (Payne et al., 2013). Payne et al., (2013) explain that the remaining 30% of health care financing goes to capital investments, insurance profits, administrative costs, home health, and public health. Further, much of health care financing goes to preventable services caused by clinical errors. Through the efficiencies of HIT, much of the said money could be saved.

Implications of the Issue for Health Services and Health Economics (Pros and Cons in Health Economics)

The use of HIT in the US Department of Veteran Services has had several implications. The implications are both positive and negative. Starting with the positive implications, it can be argued that the use of the system has increased efficiency in the services provided. Quality improvement has been encouraged through HIT. Suffices to note, all the involved providers on the platform are able to access data that they need in a timely fashion, which in turn allows them to make better decisions on behalf of the patient. In the same breath, quality improvement and efficiency have also encouraged better use of resources, thereby, having a direct impact on health economics.

HIT achieves proper resource utilization through less wastage and also by making right health decisions. In the first case, waste in terms of unnecessary medication and treatment options due to lack of knowledge on medical history, is avoided. In the initial examples given, where a patient goes to a new doctor without any medical records, the doctor will be forced to resolve to testing the patient for any illness that they might have. The process of “fishing” for the illnesses, and guessing the kind of medications that were given tends to be very expensive. In the same breath, one has to consider that many veterans suffer from trauma and other mental conditions that might make them forget the kind of medication and treatment they have been previously subscribed to.

HIT also allows for proper resource utilization through better decision making. It can be argued that the clinical errors made lead to higher expenses both for the patient and the government. The health care providers are able to assess the right information on the patient, thus, have better chances of diagnosing and treating the conditions within the shortest time possible, and with the right tools and medications. Towards this end, the US Department of Veteran Affairs saves more money and is able to offer more services to the veterans. Important to note, theoretically, the platform is very efficient as it encourages checks and balances at all stages of implementation.

A second implication of use of HIT for health services and health economics is the proper linkage with health insurance providers. Insurance providers have a hard time getting the right medical information they require to process payments from hospitals. The difficulty can be attributed to the fact that the finance department, especially in public hospitals and health facilities, lack accountability and responsibility. The platform allows for the insurance providers to get the information they require at a fast and efficient manner. Additionally, doctors are made more cautious and accountable as errors they make cannot be paid by the patient’s insurance. More so, for the patient, the records are well saved such that he/she ca easily access the information needed to claim from their insurance providers.

One negative implication of the platform is that just like all other computerized systems, the HIT can be hacked. In such instances, private and sensitive health records can be stolen and made public. The next section of the paper will analyze the chances of such a situation and give some of the solutions that can prevent hacking of the system from happening.

Privacy and Ethical Concerns of HIT

As mentioned, there are some privacy and ethical concerns on the use of HIT. This section is divided into two parts to address the two elements mentioned.

Privacy Concerns

One privacy concern, as mentioned, is hacking. All components of HIT are computer-based. From the nurse charts to the prescription description, everything in the platform relies on internet technology to function properly. As is evident with other platforms that use digital or internet solutions, thereby, HIT can be interfered with from an external source.

The system has been criticized toward this end, with many critics claiming that a hack would be disastrous due to the access of personal health information. However, despite the challenge, or rather, privacy issue, one can argue that the advantages of the system outweigh the disadvantages. Having stated so, it is important to also provide a solution to the observed privacy concern.

Through proper security systems, it can be argued that HIT can be very secure. Use of anti-virus and anti-spyware can ensure that the data generated and saved in the platform are not accessed by anyone. It can also be argued that access to the information should be granted only upon receiving permission. Crucial to point out, the idea of permission should only be used in regard to sensitive data on issues health. General data that would allow a physician to do first aid, in case the patient is unconscious and cannot give permission, should be easily retrievable. It can also be argued that access to the data should be only within hospital premises, in regard to the doctors and health care providers’ role. The limited access will arguably make it harder for external forces to hack the system.

Ethical Concerns

Apart from the privacy concerns that have been addressed, the use of HIT also has ethical concerns. First, the issue of emergency services comes into mind when discussing accessibility of the system. In the event that a veteran is injured and unconscious, and cannot give permission for access of his/her personal health data, would the VA override the guidelines and access the information, or would they let the patient’s health deteriorate? The VA finds itself in such unique positions more often than desired.

The issue of ethics also goes hand in hand with the legal concern of people who are in comas and do not have a power of attorney policy. Getting the insurance information, the contact detail and even making decisions for such a person becomes challenging due to both ethical and legal reasons. Again, upon weighing the pros and cons of the use of HIT, one can confidently state that the ethical and legal concerns can be addressed to make the system more effective.

One suggested way of solving the legal concerns is to have policies that address every possible scenario that can be identified. Such policies should be communicated to the VA, and to any other department or hospital that will use the system in order to ensure compliance. Ethical concerns are, unfortunately, difficult to address as different people have different ethical preferences. Despite this, it can be recommended that the department come up with general ethical guidelines for HIT.

Uptake by Veterans

Silverman (2013) argues that despite the efforts of the US Department of Veteran Affairs, a majority of veterans still do not take up health services as expected. There are several reasons that have been identified as to why veterans do not seek health care services they need. The first reason is the fact that many veterans need specialized treatment, which is expensive. In line with the premise that many veterans do not earn enough money to keep afloat, it can be stated that the target audience cannot afford health care.

Secondly, there is a lot of stigma that is associated with health care systems for veterans. As earlier explained, many of the said veterans suffer from mental conditions as well. Important to state, mental conditions in the US are associated with a lot of stigma, not just in regards to veterans. Towards this end, therefore, veterans refuse to seek professional help in an attempt to retain their status.

According to the US Department of Veteran Affairs (2017), approximately 62%, which makes 1,218,857 veterans have used the VA system since 2001. Interestingly, 738,212 of the said number used the system between June 2014 and June 2015 (US Department of Veteran Affairs, 2017). The statistics prove that indeed, the system is working, and that it has encouraged the uptake of health services among veterans. Additionally, it proves that veterans prefer the system compared to seeking private services on their own. It is due to the said statistics that the importance of HIT, particularly for the US Department of Veteran Affairs, is stressed.

The US Department of Veteran Affairs (2017), however, confirms that since the inception of HIT, many veterans are taking up health services they require. One reason that has been identified as to why this so is the fact that the veterans mainly get such services from specific health care facilities, where they deem safe. The health care facilities are usually approved by the US Department of Veteran Affairs. However, patients are still not taking up the services in private health facilities.

The lower uptake of health services through the private doctors and health facilities can be attributed to two things. The first is the fact that a majority of the private health facilities do not use HIT. Silverman (2013) explains that the US Department of Veteran Affairs is currently the only unit/entity that has fully embraced the use of HIT. The use of the system is far less common in both private and public hospitals.

Crucial to note, due to the status associated with the veterans, it is challenging for the patients to explain their health issues to the doctors or health care providers. With HIT, there is no much need for the patient to explain the condition he/she has, as the doctor or health care provider is able to access all the necessary data via the system. However, since doctors in the private institutions do not have access to the platform, the patients have to explain their conditions. It is such fear that encourages the affected to not seek health care services in private institutions. The argument provides the second attribution mentioned.

Policy Implications

Whereas there is very little evidence supporting the premise that IT leads to better and effective health care provisions, there is ample of evidence supporting the use of technology for effective systems. In this regard, therefore, it can be argued that the use of HIT allows for effective systems, which, if utilized properly, lead to quality management. Important to note, also, is that the positive implications of HIT are observed over a period of time.

One of the policy implications that arises from the discussion is the patient safety metrics. Silverman (2013) explains that it is currently very difficult to determine patient safety in a heath care setting due to the numerous factors that are in play. The outcome measures proposed as part of the patient safety metrics guidelines as provided by the government, need to be revised in order to ensure inclusivity.

Another policy implication that has to be noted is the inclusion of a policy on health insurance. In health economics, health financing is key. For veterans, health financing becomes a major concern due to lack of proper health insurance. Silverman (2013) asserts that health insurance for veterans tends to be expensive as they are classified as high risk. Indeed, a veteran can be diagnosed with more than three chronic health conditions, all of which require specialized treatment.

It is up to the state to ensure that the veterans have the right insurance covers to aid their different treatments. The US Department of Veteran Affairs invested heavily in HIT and similar vigor should be observed in regard to health care financing for the veterans. The structure of HIT allows for insurance providers to also receive the information they need about the patient, in order to facilitate payment claims.

It is recommended that a policy be introduced on the provision of health care insurance for veterans through the system. Particularly, the suggestion made is that government provided health care insurance, such as the Affordable Care Act, or Obamacare, should be accessible through the platform. The policy should denote that all civil servants, including veterans, get their health insurance primarily through the government.

Additionally, in order to increase the uptake of health services by veterans, a policy should be introduced to encourage the use of HIT in all public health facilities. Since the government has control of the public health facilities, it is crucial that demands be made in regard to usage of HIT. One major advantage of such a policy is that it will also aid other patients, and the different target communities in general, as service uptake will be increased, alongside better quality management. The policy suggestions made should then be scaled up to ensure that all citizens in the country enjoy the effectiveness of HIT.

Conclusion

The US Department of Veteran Affairs took a risk in health economics by investing so heavily in the Health Information Technology. However, an analysis of the system used, and the achievements realized through the system indicates that the investment was worth the resources and the time used for implementation. The US Department of Veteran Affairs has come out and stated that more veterans are using the system after the inception of HIT.

Statistics provided indeed show that between 2001 and 2015, approximately 1,218,857 veterans used the department to access needed health care services. However, a majority of the said number, 738,212 members, approached the department for health care services between 2014 and 2015, several years since the inception of HIT. To the department, the use of HIT encouraged the service uptake.

There are numerous advantages and disadvantages of HIT. One major advantage is the fact that it streamlines systems allowing for better quality management. The linkages that are provided through the platform ensure that health care service provision is as efficient as desired. One disadvantage of the system is that just like other computer systems, it can be hacked.

In regard to health economics, the linkages between the state, the hospital, and the insurance providers allows for better managing of health financing options. The state, which offers a national health insurance coverage, can keep track of the patients and other insurance providers. The insurance providers, on the other hand, also get information on patient health that is critical in ensuring they offer the best possible coverage. In line with the stated, it is recommended that a scale up of HIT be encouraged country wide, and not just in the US Department of Veteran Affairs.

References

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Neugaard, B. I., Priest, J. L., Burch, S. P., Cantrell, C. R., & Foulis, P. R. (2011). Quality of care for veterans with chronic diseases: Performance on quality indicators, medication use and adherence, and health care utilization. Population Health Management, 14(2), 99–106.

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Rittenhouse, D. R., Ramsay, P. P., Casalino, L. P., McClellan, S., Kandel, Z. K., & Shortell, S. M. (2017). Increased health information technology adoption and use among small primary care physician practices over time: A national cohort study. Annals of Family Medicine, 15(1), 56-62.

Silverman, R. D. (2013). EHRs, EMRs, and Health Information Technology: To meaningful use and beyond. Journal of Legal Medicine, 34(1), 1-6.

US Department of Veteran Affairs, (2017). VA health care utilization by recent veterans. Web.

Wu, L., & Lewis, W. M. (2015). Disabilities among veterans and their utilization of health care. Health Psychology and Behavioral Medicine, 3(1): 17-46.

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