VA home finds you really can get doctors to use keyboards

Who says doctors can't type? At the Veterans Affairs
Department's residential center for homeless veterans in White City, Ore., it's a
requirement for all 15 physicians and the other 212 clinical staff members.

Since August, the staff has been relying only on its PC network running the VA's
home-grown Decentralized Hospital Computer Program to handle all administrative and
patient information.

"It has basically saved me," said staff physician William B. Allen. "I
can communicate more easily with my colleagues."

True to the stereotype of doctors, "my handwriting is like a monkey's," Allen
said. Having patient records on computer "really does improve intra-hospital

About 90 percent of all patient records at White City now are electronic, and plans are
under way to convert the rest to images. The cost of treatment per patient has gone down,
and in September the domiciliary care center received the VA's highest award for quality,
the Robert W. Care Quality trophy.

"It is really the attitude of the staff that has made this a success, rather than
the technology," said Ray Sullivan, IRM chief at the White City facility.

VA has developed DHCP over the last 15 years. It now provides a package of health care
applications that includes 70 clinical, administrative and fiscal functions.

But the system is not generally used throughout VA medical centers; the most resistant
staffers have been VA doctors. Physicians were reluctant to adopt the DHCP clinical
package introduced in 1985 because it required typing patient chart entries themselves,
said Sharon Ruyle, management analyst for VA's IRM field offices.

The adage that "docs don't type" often is true, she said.

"Pretty soon the administrative package matured, and the clinical packages were
underdeveloped," Sullivan said. "That was frustrating to me."

But the White City chief of staff wanted to expand the use of technology at the
facility. When Dr. Michael J. Kelley stepped into that position eight years ago, he made a
commitment to developing the electronic medical records system.

Three years ago, use of DHCP became a condition of employment for physicians hired at
White City. Then in August he made the system's use mandatory.

Although initially reluctant to adopt the new technology, a recent survey of the
physicians showed that none would choose to return to paper records.

Originally written in M, a programming language widely used in health care, DHCP now
contains many off-the-shelf office automation applications, said Robert Kolodner, acting
chief information officer of the Veterans Health Administration.

"They are all in the public domain," Kolodner said. "The system runs on
a huge variety of platforms" under most operating systems. "It's really

At White City, it is running under Microsoft Windows on a client-server network of 486
PCs from Dell Computer Corp. Doctors and staff can access the three file servers from any
of 427 terminals, using TCP/IP or Local Area Transport protocols.

The home's first step in switching to a paperless system was to define its goals,
Sullivan said. "We visited 14 facilities, and I got 14 definitions of what a
paperless record was," he said.

A panel of medical professionals defined the elements necessary for a complete patient
record. A key component, electronic progress notes, was tested in 1991 and 1992. An
automated discharge summary and an intake package completed the essential items.

"We knew you couldn't force physicians to use something," Sullivan said.

Some doctors grumbled about being turned into clerks by the system. So the center gave
the programs to two who showed interest in using it, Sullivan said. "Pretty soon
their counterparts saw they had something they didn't have, and they asked for it,"
he said.

Each doctor received 16 hours of training. A typing tutorial was installed on each
terminal so staff members could learn at their own pace. When the user level hit 80
percent, Kelley mandated the system's use. Now every staff member has nearly all of each
patient's records available at a keystroke.

"Intake is a little longer at the front end, but it averages out in the end,"
Sullivan said.

White City recently upgraded its system from a network of PDP-11 minicomputers from
Digital Equipment Corp. to the Dell 486 PCs. One unexpected advantage of having doctors
using DHCP is that Sullivan has new allies in IT budget battles.

When upgrades are needed, "now I have the physicians fighting for me,"
Sullivan said.

About the Author

William Jackson is a Maryland-based freelance writer.

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