In October 2003, the Secretary of the U.S. Department of Veterans Affairs (VA) and the Under Secretary for Health issued guidance to its healthcare facilities across the country on a nationwide initiative to make the Veterans Health Administration's (VHA) Veterans Health Information Systems & Technology Architecture (VistA) and Computerized Patient Record System (CPRS) available for use by all interested state veterans homes.
The state veterans homes program is the oldest federal-state partnership in federal government and represents a sizeable commitment by VA to states for shared construction costs and ongoing per diem payments for veterans' care in long-term settings. This effort is part of the VA HealthePeople long-range strategy to pursue collaborative partnerships with other healthcare organizations in the public and private sector.
A report by the VA entitled, "VA Long-Term Care At The Crossroads: Report of the Federal Advisory Committee on the Future of VA Long-Term Care," recommended that the VA not build additional VA-owned and -operated nursing home beds to meet the growing needs for long-term care. Rather, it suggested that this need would be better met through expanding the role of state veterans homes and contract nursing homes.
Historically, state veterans homes managed a primarily medically stable population of veterans. Any change in a patient's medical condition necessitated an admission to a VA acute care setting, with return to a state veterans home only after the acute condition had been resolved. However, in the 1990's, the VA embarked on a program of utilization management — consistent with community standards — to reduce unnecessary length of stay in the hospital, thereby better matching clinical needs to resources. This resulted in a greater portion of the transitional care of veterans being delivered in the state veterans homes.
Being good neighbors
Of the many state veterans homes, some are physically located on the grounds of a VA Medical Center (VAMC). This close physical proximity led naturally to clinical staff at many state veterans homes requesting access to the VA VistA and CPRS systems, which are used at all VA healthcare facilities across the country.
The primary business office responsible for overseeing any sharing arrangements with state veterans homes is the Geriatrics & Extended Care Strategic Healthcare Group (GEC-SHG). In 2002, this office convened a task force to formulate all necessary considerations in providing access to VistA and CPRS for selected staff at the State Veterans Homes. They determined that there would be a number of benefits both to the VA and the state veterans homes if secure access to patient data contained in these systems was granted. These benefits included improved patient care by both institutions; enhanced productivity by professionals at both institutions; and a reduction in administrative and healthcare delivery costs.
Two overarching alternatives were identified for sharing VistA and CPRS functionality and data with state veterans homes.
In the first alternative, state veterans homes could obtain the VistA and/or CPRS software from the VA and operate their own systems using state or contract technical staff. Under the second alternative, VA Medical Centers could grant State Veterans Homes with secure read-only access to patient data in the VistA and CPRS systems. The read-only option meant that state veterans homes' staff could not write entries into the VA medical record.
In January 2003, the Health Information Technology Sharing staff within the VHA Office of Information completed a more detailed analysis into the feasibility of providing VistA and/or CPRS Read Only access to the state veterans homes. Some of the other issues and major concerns surfaced by this study included: complying with various accreditation requirements, e.g. Joint Commission on Accreditation of Healthcare Organizations and others; the need to build additional security features into CPRS to handle queries from an authorized external entity; and the need to address potential physician credentialing and privileging issues.
Survey says
Based on a survey of the state veterans homes completed in June 2003, there were eight states that expressed some interest in possibly acquiring and installing VistA for use as their own health information system. However, more than 90 percent of the states expressed a clear desire to have CPRS Read Only access only for a small number of key staff at their facilities. In addition, the survey found that approximately 30 state veterans homes had already been given CPRS Read Only access as a result of local sharing agreements.
Over a period of approximately 6 months, staff from the Offices of Information, General Counsel, Cyber Security, Geriatrics & Long Term Care, Medical Records Administration, and others helped to develop an implementation plan and detailed guidance needed to address these concerns.
The implementation plan recognized that providing VistA and/or CPRS Read Only access to staff at state veterans homes would allow front-line clinicians to provide better healthcare to our nation's veterans. A VHA Office of Information program manager was assigned to provide support to the Geriatrics & Long Term Care SHG in moving this national effort forward.
As of June 2005, the states that have completed obtaining CPRS Read Only access for their state veterans homes are listed below. There are more than 70 facilities in 20 states, Puerto Rico, and the District of Columbia. Numerous sites in many other states are in the process of being connected. There are 128 state veterans homes in 47 states and more being opened.
| All Homes W/ CPRS Read Only Access | Some Homes W/ CPRS Read Only Access | No Homes W/ CPRS Read Only Access |
| Alabama Arizona California Connecticut District of Columbia Indiana Iowa Kansas Kentucky Louisiana Maryland Missouri North Carolina Oklahoma Oregon Puerto Rico Rhode Island South Dakota Utah Vermont West Virginia Wyoming | Florida Georgia Idaho Massachusetts Michigan Minnesota Montana Nebraska New York Ohio Pennsylvania South Carolina Texas Washington Wisconsin | Arkansas Colorado Illinois Maine Mississippi Nevada New Hampshire New Jersey New Mexico North Dakota Tennessee Virginia |
This collaborative initiative between the VA and state veterans homes has proven to be very successful. In fact, it is a model for others to follow when attempting to pursue federal and state government partnerships.
The VA was able to share its systems with the states and did not have to expend significant resources in doing so. The state veterans homes provided the funding and resources needed to implement and use the VA systems. The veterans who received healthcare treatment at both the VA and state facilities ended up being the real winners.
As a result of Oklahoma's successful acquisition and implementation of the VistA system for its own use, it is anticipated that several other states may choose to follow suit in the coming years. It is also expected that over time, those state veterans homes that have CPRS Read Only access may want to work with the VA on next steps to take to obtain the ability to place orders and have other interactive VistA and/or CPRS system capabilities.
Over the long term, whether the state veterans homes are using VistA or a commercial electronic health record (EHR) system, it is anticipated that they will one day want the ability to share or exchange information on patients receiving care at both the VA and the State Homes.
Christine Sheehy , R.N., Ph.D., is the director of quality for the INOVA HealthSystem nursing homes.
Peter Groen, M.P.A., is the director of the national Health IT Sharing program within the Veterans Health Administration, U.S. Department of Veterans Affairs. He is also on the faculty of the Computer & Information Sciences Department at ShepherdUniversity in West Virginia.
