Well,
perhaps state of the art was the wrong phrase. But simply because something is riding on an old, antiquated language that hasn't seen the light of days in years doesn't take aways from it's capabilities, which I maintain are state of the art. I'll give you two quick examples, from the last few days, but experiences like what i'll describe are a daily occurence for 1000's of our providers every day.
A patient reported to me that their health and functioning have recently become worse, but that they can still do the things they needs to do to live independently. Now, it was painfully obvious just looking at at the patient that they were not capable of living independently. Their spouse reported that the patient's functioning is no worse now than it was three years ago, that the patient essentially requires total care, they have a history of anger, and is cognitively impaired. Not surprisingly, the patient disagreed with all of this. The patient has a degenerative disease, and knowing the progress is important diagnostically. The problem is that the patient was seen at three different VA's in two different states. I was easily able to pull up the patient's record from each of the other VA's, review it, and determine that the spouse's report was spot-on, despite what the patient was reporting. There was additional information contained that was important for care planning, that hadn't yet been discussed. It took maybe 1 minute to access the other sites and get to all the records.
The second example involved a patient who was reported to have been refusing medications. I pulled the patient's chart up, and reviewed each of their medications. I can tell what medications the patient is on, when they were given to the patient, who exactly gave it to them, and whether the patient takes the medication or refuses the medication. The patient, a diabetic, was only refusing their oral diabetic agent and insulin. I then pulled the lab results up, and plotted the last month of HGA1c values and could see that, while somewhat erratic, their blood sugars were still within normal limits. I spoke with the patient and their mother. Because their diet had been altered in the hospital, it was the patient's opinion that their blood sugars were relatively controlled and therefore there was no need for diabetes medication. I don't know that I necessarily *agree* with the patient's opinion, but at least I understand it. More importantly, five minutes after it had been reported that the patient was refusing medications, I knew exactly what he was refusing, and had a block of lab values to get a sense of the immediate impact the patient's decisions were having on his health. This makes a big difference when I go to speak with the patient.
The important thing is that the system we use is *all* electronic entry. Therefore, it's readable. Second, it's practically (not completely yet) universal in that no matter what VA the patient was seen at, I can get their records in a matter of minutes. Third, because it's electronic entry, there can be all kinds of checks and balances built into the system to reduce data entry errors. Take the first example, had the patient been moving through the private sector, even if they had been taking their medical records with them and happen to have them at the time I saw them, I still would need to plow through a hand written record. Even if it was digitized, that often means scanned paper/pencil records which I can assure you is a total bear to disentangle. We get referrals from the private sector all the time, and it can be a nightmare determining what's been going on with a patient.
We track pracically everything related to the health care of a patient: meds, labs, orders, notes, diagnosis, imaging, imaging results, surgery reports, pathology reports, admissions, discharges, providers, etc... And we do it for the entire system, making it all available no matter where the patient is seen. And because we track it electronically at the patient level, it can be mined at the aggregate level for systemic planning and outcomes research. One thing I do appreciate are the issues of privacy. This is *a lot* of information about an individual and we take privacy and security seriously, although I am perfectly aware of our data loss issues in the past.
I've worked at (and continue to work at) a number of major academic medical centers in a major metropolitan area, and nothing touches our system. Further, I've demo'd the system for large health care consulting firms looking to deploy similar systems to large hospitals (I'm just a little biased at how good I think our system is :-) ). They *always* walk away with this realization; they are a long way off from pushing something out remotely close to what we have in terms of integration and thoroughness. And it's not surprising. The VA's system was pushed out in 1996 (at that time, all entry was using a text editor through a terminal emmulator), with a GUI front end rolled out in 1999(?). So we have at least 10-12+ years development under our belts.
Anyway, that's the story. Although Longman's book isn't great, he does go through a fairly detailed description of our EMR and it's benefits, both short-term and long-term. This essay (I think):
http://www.washingtonmonthly.com/features/2007/0710.longman.html
was the genesis for the book.
take care,
jeff