The Veterans Administration: the Linux of medical records

I just spent three weeks in our local Veterans Administration system. Mention "VA" to any group of doctors and you are sure to hear funny stories; a great many doctors have at least some of their medical training within VA hospitals, and those hospitals are full of characters among both their staff and their patients.

VA hospitals have various frustrating aspects you'd expect from a large federal bureaucracy. But they also share a common sense of purpose and community unusual in other hospitals. Because of their commitment to a particular group, they feel almost like massive community health centers, in which there is a sense of shared purpose built not on organizational advancement but on the welfare of the community which the organization serves. It's this part of the VA which makes it a great system.

Along the way, the VA has accomplished various things that other healthcare systems haven't. One possibly more broadly transformative innovation is VistA--the Veteran's Administration electronic health record software, now available as open source software for any organization that wants to use it. Revisiting VistA this last three weeks, I can testify: VistA really is the bomb-diggity.

I say this as someone who works in a hospital that regularly wins prizes and high rankings for its own electronic medical records and ordering systems. Our electronic medical record is easy to use and intuitive, the design has an Edward Tufte-style simplicity (though sadly without sparklines), and is full of useful features. I regularly use it as a selling point for medical students considering our hospital for residency. Having used various electronic medical records during my time as a medical student and in external rotations as a resident, I'd put our system against anyone's.

The VA's system is uglier-looking and harder to learn how to use. But even in three short weeks as a novice user, I found it quite powerful, especially when it allowed me to access veterans' health records scattered across various VA hospitals around the country. At the end of the day, any data storage system can only be as useful as the data it stores; when so many VA hospitals are linked, the software is more powerful partly because of the information it provides. And when I got past some of the difficulty in getting used to the program, some of the way it integrates information is actually more useful than the record system I use.

Most importantly, it is available as open-source software, which any medical organization anywhere can use. Its ordering system, once learned, is easily integrated into the rest of the record. I also liked its graphing features which allowed visual displays of prescriptions and lab values charted over time; many electronic medical records have this kind of feature, but somehow the VA's system works better than most to provide sensible x- and y-axes for the data which is being presented. Uploading radiologic images takes longer than I would have liked but this is likely a fixable problem.

The stimulus package of last year included a big bunch of money to support dissemination of electronic medical records. Spreading open-source VistA will likely be one of the cheapest ways to accomplish this. If I were a large healthcare system, I'd take this system and maybe put some extra money into building a more intuitive and lovely-looking graphical interface on top of it (the one in use at the VA is from 1997)--but I'd keep VistA.

Take it to the limits, one more time...

I page the infectious disease fellow, who's staffing the antibiotic approval pager. I know him: he was a resident when I was a medical student. He calls me back. I tell him briefly about the patient, and say, "We want IV vancomycin."

"When you were in medical school," he says, joking with me but also not, "You were this cool progressive socialist guy, ready to fight the system. Now you're calling me with this. So, I'll approve it, even though it's a NIMBY thing that will increase antibiotic resistance for other people. But what happened to you? What happened to the idealism?" He's making fun of me a little, but also I think wondering about the actual answer to the question.

"If I thought about health policy for more than a minute of my day," I tell him, "I couldn't get anything done."

I once heard an ICU nurse, frustrated with the night's project of keeping some very old and utterly unconscious person alive with expensive equipment and unclear benefit other than satisfying the person's relatives that "everything is being done", and she blurted out, "This is insane. We should be taking this money and investing it in children." Fair point. But either she ignores that point of view for most of her day or she's going to have to get a new nursing job.

I send people to MRIs all the time; as one attending of mine said, Boston probably has more MRI machines than all of Ontario. The availability of MRIs drives our willingness to order new studies; if it was harder to get someone into an MRI, we'd accept the slightly less exact findings of a CT, and so on.

Obviously from a policy point of view this suggests we should probably send less people to MRIs. But as an intern, my job is to carry out the medical plan, and to suggest aspects of that plan. I don't have the final authority over that plan. It is usually not for me to decide if someone gets an MRI or doesn't, at least not on a policy basis. It might not even be for the attending to decide: if other people in the area usually get MRIs for a particular problem, it begins to become negligence if the attending doesn't get their own patients the MRI.

Either way, I order IV vancomycin and MRIs all the time, among many other things, much of it on the federal government's Medicare tab, while the president says the federal government shouldn't get more involved in making sure children have health insurance. It's not like this cost comes out of nowhere; when healthcare dollars go to MRIs, there's somewhere else they're not going. When we use broad spectrum antibiotics to "cover" someone with a fever we can't yet diagnose, it costs money and increases bacterial resistance.

But if I'm honest, it's not just the system that demands this of me. My own views are full of contradictions: when facing an individual I am ready to go all out, to order everything that might have some benefit.

When thinking about the society, I think that there should probably be some limit to this. But I'm not the one who makes the limits. More often, as an intern in a large teaching hospital, I push the limits.

I say something about this to the ID fellow, and say that even if I had any power at this point, I'm not sure what I would do about this contradiction of wanting limits and abhorring them. We're quiet for a second.

Then I say, "Anyway, we want our IV vancomycin."

"Another resistant organism being created, at exorbitant cost," he says.

"Yep," I say. "Still, we want it."

"Done," he says, clearing it off the approval queue on his computer screen.

Night float: "MD aware"

Last night I was on night float--this time, a one-time thing, to give other night float interns a night off. Today, I'm spaced out and headache-y. Some of the other interns are getting together for dinner and drinks tonight, and I should go, but I feel as if I can't bear to talk to anyone or go anywhere. Instead, I'm sitting in my apartment while Ms. Dr. Hemodynamics is on call. I'm listening to KCRW on the internet, writing this after cooking myself some dinner.

I'm not sure when the concept of night float was invented, but it's become a lot more common with work-hour restrictions for residents. In overnight call systems, when residents literally lived at the hospital (hence the word "resident"), "call" meant not only admitting patients to the hospital but also cross-covering other residents' patients.

Now, the interns and residents on call stop admitting after a certain point in the evening, and a nighttime team takes over both admitting and cross-coverage. In our hospital, the night float interns respond to the problems of patients already in the hospital. The night float residents admit new patients who are coming in overnight.

That means that as an intern, I was answering pages from nurses for some large number of patients--I didn't want to know exactly how many. Something in the range of 50 or 60 or 70, I think, but I never counted; I just answered pages.

Some of these pages seemed simple; this patient wanted medicine for back pain, while that one wanted something to help him sleep. But for me last night, anything but the simplest and heavily chart-documented chronic back pain warranted a visit (was it new? where was it? was it a kidney infection or a spine infection? or just from sitting in a hospital bed for days?). Help with sleeping required at least a chart review (how was the patient's kidney function? liver function? what had they taken in the past? any psychiatric issues?) to try to figure out whether the easiest choices might make them crazy or dangerously sedated.

Then there were the pages that went something like "[Patient name] down to 90/56". A drop in blood pressure can be truly ominous: it can be a sign that someone has a new serious infection, or an acutely failing heart, or new internal bleeding. But the majority of overnight pressure drops last night were probably mostly caused by something simple: sleep.

One of my more alarming pages about low blood pressure last night was solved by turning on the lights and talking to the patient and listening to her heart and lungs with my stethoscope. When that was done, she was at an average blood pressure, and I was convinced by her quick wake-up and easy return to coherence and consciousness that she'd been doing fine all along. The unfortunate effect of this kind of evaluation: when the number on the screen means a nightmare for me, that's the end of sweet dreams for you. On the other hand, it's better than getting a bag of unnecessary IV fluids.

Some reasonable proportion of us, if we had telemetry monitors hooked up to us at home every night, would be setting off alarms all the time. But even when nurses are reasonably sure that this kind of normal situation is why the pressure is low, they need to page the doctor anyway. In the nursing note, they have to make note of abnormal vital signs, and they write something like "BP down to 89/56 during night while pt sleeping. MD aware."

As with my first night on the MICU, I was once again grateful for my hospital's well-educated and experienced nurses. In one case, a renal fellow talked to me about the patient in some detail in the late evening, and then checked back in with me in the morning about how the plan had gone. I explained that we'd stopped the fluids, and why; the fellow was pleased because this is what she'd called to recommend.

"Actually," I said, "the nurse called when the labs came back, and said we should stop the fluids, and I said that sounded like an excellent idea." The fellow laughed, and praised me for listening to the nurse.

I said, "I try to do what the nurses tell me, probably... mmm... 85% of the time." She laughed again: "Sounds about right," she said.

The rest of the 15% is complicated, and it's rarely due to some error on the nurse's part. More often, it has to do with differing priorities. For instance, since the nurse is hearing the patient complain all night, and is sick of answering the call button again and again, the nurse might be more ready to want the patient to get a sedative medication for sleep. Often, this is informed by knowing that a particular medication is given all the time, and knowing that a particular patient is medically stable, and knowing that it's really hard to get good sleep in a hospital.

On the other hand, for people with complex medical problems, a lot of these medications can be frightening for the doctor to prescribe, and if I can avoid prescribing them, I will. The most satisfying visit last night was with one of these patients, who had many medical issues. The patient and the nurse wanted a sedative to help him sleep. The idea was worrying to me, since all I knew about the patient was a list of medical problems, and the drugs I knew best each had some possible bad interaction with at least one of those problems. I was doing some other things, and took a while to come up to evaluate the patient, probably to the annoyance of the nurse and the patient. But by the time I got there, the patient was asleep without my help. (The ideal solution for this situation is for the doctor who is taking care of the patient by day to anticipate this problem and suggest a possible sleep medication for the night float intern to prescribe if necessary--but it's July, and that kind of hand-off is a ways off.)

The most frustrating thing about night float was one of the things that makes night float systems worrying to most people who think about their risks and benefits: hand-offs. I got some less-than-totally-informative descriptions of what was going on with some of the patients I got called about overnight. And on my end, hopefully just because it was my first night, the system I was using to keep track of overnight events turned out to be much-less-than-excellent, and I fear that I may not have handed off all the information I should have.

But looking at the hospital computer system from home, it looks like everyone is OK for now. The people I worried about didn't get the kind of labs drawn that would suggest problems (like arterial blood gasses, which are drawn for people in respiratory distress). A tentative sigh of relief: night float is over, and the day has come.

Wise words: internship starting

Illustration: William Hogarth, Industry and Idleness, Plate V (1747). "The idle apprentice: turn'd away and sent to sea." The British Museum. (Sad: he probably violated rule #8, below.)

Internship starts tomorrow. I'll be starting with the medical ICU, and my first day will include an overnight call night.

Amidst all the emotions associated with the anticipation of such an event, some of the graduating interns came up with tips for us while on rounds, and one of them wrote them up and sent the list out to our email list. Here's an excerpt (the first six are mostly hospital specific):

7. Send each other funny pages--it will keep your spirits up. And make you laugh in the middle of an otherwise serious conversation.
8. Get your coffee on the way to work. Otherwise you'll never get it, and nobody wants that.
9. If you're thinking about writing an order, just write it. Don't make a box on your to-do list to write an order.
10. If you don't know the answer, don't lie and make it up.
11. Don't forget to pee. They trigger patients for more urine output than some interns have. And drink a lot of water.
12. We know you're scared to death. Under no circumstances (unless you are [name of graduating intern]) should you memorize ACLS protocols.
13. And from [name], a graduating senior: "Nobody ever died of note-penia. Just take care of your patients. The note will come."

Fear really is the mindkiller

ACLS training today. That's Advanced Cardiac Life Support--it's where you learn how to shout "Clear!" and deliver a shock; or, "One milligram of epinephrine!" Just like TV. (Except, you shouldn't shout.)

I passed the written part of the exam with 100% of the questions correct (not a super hard test, and my result was shared by many present, but still, it was satisfying). Then we went downstairs to do what the American Heart Association calls "Megacodes" which inspired some of us earlier in the day to keep saying "Megacode!" at random times during breaks. (Well, mainly me, actually. But I'm sure that others wanted to.) The megacode involved standing with a mannequin and a bag-mask and a defibrillator; while an instructor ran us through a basic simulation of cardiac or respiratory emergencies.

I was the first to volunteer to be a team leader, and it was brutal: I couldn't remember whether the pathway we were on led to adenosine or atropine. The sonic similarities of the two drug names caused me to merge these two drugs, which are not at all used for the same things. In the larger sense, I did the right thing in that I knew I was in doubt and asked my team members--who said, no, it's not adenosine. And though I was then able to say, "OK, right, atropine 0.5 mg IV"--still, I was miserable at the end.

The schedule isn't actually out yet, but I have reason to think I'll be starting in the ICU next Saturday. If it's true, that means I'll be on the code team starting within the first three days of internship. As long as my resident answers the code page as fast as I do, I'll be fine: I'll take orders, bag-mask, do compressions. We'll sprint down staircases in our scrubs, and as long as my resident is running right there beside me, I feel more or less ready. Excited, even.

But if the resident is in the bathroom? Doesn't hear the code page? Is dealing with some other emergency? It's unlikely, but I fear being, for even a minute or two, the only MD in the room. Because we are the ones with prescribing capability, we end up being the people who call for drugs. And therefore, the MDs generally become the team leaders. Even, it seems, when my ACLS instructors who work as respiratory therapists or nurses are also on the team. (I wanted to ask, "Seriously, you started working as a respiratory therapist when I was two years old, and I'm one of the oldest interns in the place, and I'm the one who's supposed to run the code?" But it didn't seem like the right time or place for that conversation; I'll save it for a night in the ICU when there is time and quiet.) Thankfully, asking for help is encouraged. As long as there are other people there--and if the code cart and the drugs that freak me out are also there, that means that someone else will also be there--I will be OK.

Still, mixing up the drugs when I was suddenly on the spot and feeling nervous was scary. That in turn made me upset and worried enough that I started having a hard time concentrating on the next cases and on what the instructor was telling us after I was done. I actually said to myself: "I will not fear. Fear is the mindkiller" in my internal Kyle Maclachlan voiceover voice, and with that, I was able to force myself back to the present, to the work in front of me.

Also I went around and talked to a couple of people to see if I could find a way to do some simulator sessions before internship starts. I want to pound on some mannequins, and see if that helps.

"Found Down": HMS/HSDM Commencement speech

"Each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?"
Photo: rescue staging area after Hurricane Katrina.


...More to write about graduation soon (it was yesterday, June 7). First, here's the speech I gave at the commencement ceremony of the Harvard Medical School and Harvard School of Dental Medicine.

I’m going to start with a story. It starts when a man falls down on the sidewalk. He might be drunk, or he might not. He might be unconscious because he fell, or he might have fallen because he became unconscious. Hopefully sooner than later, someone realizes that he has fallen down.

The call to 911 comes from the first person to realize this and to care. Next comes the ambulance crew, and even the cars that get out of the way when the siren goes on. As the story continues, there are triage nurses and doctors, x-ray technicians and respiratory therapists. Maybe the man found down has a strange rash, goes to cardiac cath, or needs a CT scan; maybe he has blood in one of his eyes, or a shattered bone. There will be more to the story, but this is its essence: a person falls, and in small and large ways, a huge network of people begins to pick him up again.

Today, we step into a new role within this network. But we have already been part of this group of people: those who go to the man found down, and try to help him up.

We can’t be too romantic about this story. Almost as soon as the man’s story begins, promises and demands of money start moving through the wires underneath the sidewalk onto which he fell, perhaps even before he has been picked up off of it. But today is not about that part of the story. Today is about what we do because of who we are, and not just who we are paid to be.

Each of us will encounter different versions of this story in our work. A child is frightened of her father. A veteran is overwhelmed with anxiety inside an MRI machine. And a family is just down the hall, waiting to hear the news of an operation, and someone must tell them that the operation went badly. Hundreds and maybe thousands of stories like this are unfolding at this moment, right outside this tent, in the hospital and clinic buildings all around us. And each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?

We’ll have to answer this question day after day. I once heard an ICU nurse in an urban hospital say, “All of our patients have the same chief complaint: found down.” July’s novelty and excitement will be followed by February’s bleak repetition. Just about any hospital has many people found down for reasons that are easy to diagnose, but can seem impossible to solve.

To respond to this sometimes relentless suffering, we’ll have to push back against huge impersonal systems, even when those systems beat us back again and again. And we’ll sometimes have to forgive terrible human frailty even as that frailty pushes us to our limits of forgiveness. And so nearly all of us will succumb to frustration and even cynicism from time to time. This is nothing to be ashamed of, as long as we don’t wallow in it, and as long as we don’t mistake bitterness for truth. We are graduating from medical school, not saint school.

Nonetheless, we can hope to meet the basic moral standard of looking towards suffering instead of away from it. In clinics and hospitals, in our personal lives, and in research and policy, we’ll constantly face this moral challenge. Even the best of us will often fail it. But that should not stop us from continuing to try.

When we do reach this standard, we have one final important task: to avoid congratulating ourselves too vigorously for our own forms of benevolence. Sentimentality about our special virtue as doctors can be as dangerous as cynicism, because it causes us to forget that we are joining something much larger.

Our medical training means that we will bring our expertise, our intellectual curiosity, our readiness to work hard. We can be justifiably proud of ourselves for what we have already accomplished, and we know for sure that the people in the audience today are already proud of us.

But today we also join others—paramedics, nurses, social workers—and dentists—and many others who spend their lives responding to suffering. In the few blocks around us, there are thousands of people like this. And even more importantly, there are many other people who are not healthcare workers, but just caring people who also see suffering and find ways to respond. I came to medical school because of people like this—people who responded to the crisis of the AIDS epidemic in San Francisco, people who taught me about courage in the face of disaster.

In small or large ways, most of us have probably come to sit here today partly because of people like this, people who taught us how to behave in the face of suffering: teachers, friends, family. They have usually taught us by example, often because they cared for us when we were suffering. Some of those people are here today. They have seen us fall; in one way or another, they have found us down and helped us up, sometimes many times. As we graduate, we honor their acts of faith in us. Today we mark a moment in which their gifts to us have come to fruition. Now, we will join them in helping those who are found down.

Fleeced.

After many loud denials and proclamations against it, I have reversed my position: I have purchased a class fleece.

But before we come to why I finally committed this dastardly act, it's worth explaining the broader phenomenon of medical fleece. I'm not sure exactly how it happened. But I'm pretty sure it started happening about two years ago: every health-related group started getting fleece jackets and vests with their logos and team names embroidered on the left chest.

This is not unique to healthcare. In fact, I think the first local fleece explosion came from the Harvard Business School students. They've been walking around town for the last several years with HBS fleeces, each with their section name on them, full of mysterious significance. The HBS logo, initials and class year are accompanied by a big proclamation of "Section A" or "Section C", and so on, generic and externally meaningless, only serving to alert fellow HBS students to the room of people to whom the fleece-wearer was randomly assigned. In fact, it is their sheer meaninglessness which is their meaning. The fleece above all is an expression of group membership, and what is more in-group than a piece of arbitrary jargon? I'm sure that computer companies and consulting firms have been handing out team fleeces for even longer, and for the same reason. (I feel like I've seen fleeces that say stuff like "HDC Implementation Task Team" or similarly obscure nonsense, but who can remember that kind of thing?)

Last year or the year before, I'm not sure which, doctors-in-training in the Boston area joined the fleece craze. They started getting fleeces with their hospital logos and the name of their department: "Internal Medicine" or "Surgery." Soon after, nurses and attending physicians started getting more specific kinds of team fleeces: "Obstetrics L &D"; "MICU"; "Emergency". (This has the effect of one-upping the housestaff fleece. Because it says you work on a particular floor, doing a particular job, it also says that you are not a trainee.) These fleeces began replacing the white coat as a way to walk around the hospital and look like you belong there. For medical residents, they also were a proclamation of your team. If you were a meddie, you walked about in your team fleece that said "medicine" loud and proud.

Other hospital fashion changes started earlier, and I think they're related. Housestaff long ago started wearing scrubs around the hospital, even in situations where they clearly don't really need them, as did many other kind of healthcare workers. Scrubs have become a hospital worker uniform. Doctors and radiology techs can all wear the same pajamas.

It's not like hospitals have ditched hierarchy. So we should probably wonder why scrubs appeal to so many different healthcare workers regardless of status.

The first reason is utilitarian. The hospital gives them to you and then takes them back and washes them; you don't have to iron anything; and they're comfy.

But scrubs also signify more than sheer laziness. For those who wear them when they don't have to, scrubs signify a kind of industrial worker of healthcare, too busy saving lives to put on pressed shirts and ties. There's a kind of reverse glamour to scrubs. Scrubs originally come from the operating room, and they're designed for people who are ready at any moment to get themselves splattered with blood. Now people in the hospital who have nothing to do with surgery or fluid-splattering of any kind wear scrubs, as if to signify that they are part of the larger project of fluids splattering about, even if they personally are not going to get splattered.

I think scrubs and fleeces are part of the same set of social changes. Obviously no one intends to get their $100 Patagonia logo-embroidered fleece jacket splattered with body fluids. And yet it's common for fleece-wearers to be wearing scrubs underneath the fleece, walking down the empty lonely corridors in what is an outfit of pajamas, a jacket made out of material that feels like an infant's blanket, and round shoes without laces. In other words, medical fashion and toddler fashion have nearly met up. This is about comfy coziness, and definitely not about fighting through spurting arteries.

Housestaff and other healthcare workers sometimes wear their fleeces over other outfits, too. It's common to see medical housestaff wearing clogs, khakis, a shirt and tie, and their fleece, with their ID flapping around on a lanyard over the fleece. This is where the social functions of the scrubs and the fleece are headed in the same non-toddler direction. These are elements of a postindustrial factory-floor look. The fleece takes the role of the corporate identity (the hospital and department, without specifying the profession), rather than the white coat taking the role of the professional identity (the doctor, from a particular hospital).

As long as they avoid those nutty teddy-bear print scrubs that so many nurses have unfortunately become afflicted with (talk about toddler fashion!), the outfits of nurses and doctors start looking more and more alike: scrubs, fleeces, clogs. (Folks like radiology techs, respiratory therapists, and physical therapists can all potentially get in on the act too, although they've been slower to get the whole outfit together.) The scrubs and the fleece become about team membership, just like a white coat is about team membership. But it's in the hospital team sense rather than the professional team sense. I'm not sure that this provides any less distance from patients, but it's a different kind of distance. It says, "We're part of the hospital" rather than "I am a doctor."

So, why am I getting a medical school class fleece? Partly because my partner J says, "I got some of that college stuff when I graduated and later I was grateful"; partly because I want another warm zip-up sweatery thing for spring and fall. And then there's the problem that I'm just dying for a team fleece, even as I know it's a little ridiculous. I'm secretly as eager to be part of the world of medical fleeces as I once was to be a paramedic and wear a special paramedic uniform and drive around in a red truck with sirens.

At first, I had proclaimed against the fleece because it had our school's coat of arms. Also, it was crazy expensive. But proceeds beyond the retail price of an unadorned fleece jacket go to some kind of class party, which is fine. And at the end of the day, I have to admit that I'm actually proud to be graduating from medical school. I went from not remembering how to multiply fractions when I decided I was going to try to take chemistry, to getting a medical degree from a coat-of-arms kind of place. If the medical school fleece is some kind of aggressive status symbol, I at least feel as if I more or less earned it.

And what I earned is under the coat of arms: "MD 2007". The business school students can have their "Section A" and wear their fleeces like they're headed out to the team-building ropes course, I say smugly to myself; my fleece says "MD 2007" and I'm ready for the MICU. Their fleeces are practice for the consulting firms and investment banks which will give them their next fleeces; our fleeces are pre-hospital fleeces.

I'll get the actual hospital fleece soon enough. But for now, the medical school class fleece is a kind of hospital fashion/professional fashion hybrid. It's a white coat statement with a hospital floor sentiment. And right now, that's exactly who I am. That's the right fleece for me.