New Health Dialogue is pleased to welcome Phillip Longman, a Schwartz Senior Fellow at New America Foundation, to share his expertise on the health IT systems of the Veterans Health Administration.

A visit to almost any VA medical center these days demonstrates how the system has overcome its bad old days to become a model of 21st century health care—if only we don't undo the very changes that got it there. At the VA medical center in Durham, North Carolina, for example, a computer-driven robot fills prescriptions, automatically putting the right pills, in the right number, in the right bottles, with the right labels and barcodes, based on orders doctors enter digitally into the VA's world-class electronic health record software.

Then, two robots I also got to know, affectionately called Tug 1 and Tug 2, cruise the hospital corridors delivering meds to nursing stations. Along with many other benefits, these technologies have reduced wait to have a prescription filled to just 28 minutes and virtually eliminated dispensing errors. Before nurses can dispense the meds, they must scan the bottle, scan themselves and scan the patient so the computer system can make sure it's the right patient, the right time, the right med, and so forth. This is no small deal. Patients in non-VA hospitals experience on average at least one drug error each day they are hospitalized, according to a study by the Institute of Medicine.

As it happens, the idea for the VA's pioneering, automated dispensing system, and much of the software that drives it, came from a VA nurse. While returning a rental car in 1992, the late Sue Kinnick noticed an employee using a handheld device to scan a barcode in the trunk of the car. A light went on. "If they can do this with cars, we can do this with medicine."

As I relate in my book, Best Care Anywhere: Why VA Health Care Is Better Than Yours, there's a similar story behind nearly all the health IT pioneered by the VA. Its programs were originally conceived of and written by VA employees for VA employees, in a non-proprietary code, through a highly collaborative process we would today recognized as "open source" software development. It was a revolution from below, brought off by frontline employees who, beginning in the 1970s, were trying to work around the general dysfunction of the VA's central office.

To those familiar with the increasing commercial dominance of open source software in other realms, it should come as no surprise that the VA's open source code, now fully integrated and known as VistA, is the only health IT system to succeed in gaining widespread doctor buy-in and implementation. Signaling the wider importance of the VA's bottoms up revolution in health IT, VistA is already up and running successfully in many foreign countries, including Norway, Mexico, Egypt, and (soon) Jordan. Both West Virginia and Hawaii are also moving rapidly to install it in their public hospitals and clinics.

Yet here is the danger. Under pressure from the Bush administration and some members of Congress, the VA has been forced in recent years to recentralize and outsource much of it's health IT. The early results are ominous. For example, last August 31, VA hospitals throughout the West, and including Hawaii, Alaska and even the Philippines, lost access to their digitally-driven records and devices for a full day. This occurred when a single server in Sacramento, now hosting all VA computer operations in a region spanning one-third of the globe, went down. In an article entitled "Crisis at the VA," former VA contract employee Roger Maduro gives a devastating account of the potentially life-threatening failure. He also shows how it relates to alarming decision taken by the VA's political appointees both to recentralize management of VA health IT and to begin replacing VistA with commercial software. For further information see also articles written last week by Dana Blankenhorn here and here.

As our country considers how to reform the health care system, we would be wise to learn from the VA experience. Everyone agrees that health IT must be part of the solution, and we must find a way to replicate the levels, integration and innovation achieved at the VA across our whole system.