Robert Kolodner, M.D., didn't write the book on the process of computerizing large, integrated healthcare networks, but he did edit one.
Kolodner is the deputy chief information officer for the Department of Veteran Affairs, and the book he edited -- Computerizing Large Integrated Healthcare Networks: The VA Success -- was published last year by Springer-Berlag New York.
Just because the title connotes a triumph in the effort to computerize the VA doesn't mean the success came easily. In fact, Kolodner and other pro-technology physicians in the late 1970s were seen as subversives. And the book, which is addressed to senior healthcare administrators, chief executive officers and physician managers, makes building a clinical technology system seem like a Sisyphean task.
"Healthcare informaticians, like astronomers who build stronger telescopes to see more stars, know that the price of progress is repeated realization that completing one task merely reveals the next," Kenric W. Hammond, the staff psychiatrist at VA Puget Sound Health Care System in Tacoma, Wash., writes in Chapter 13.
But Kolodner, 49, isn't worrying about finding the ideal. His goal is to ensure physicians have the information necessary to make the best clinical decisions.
As a medical student at Yale University in the early 1970s, Kolodner used a minicomputer to put together clinical data gathered through questionnaires filled out by other students. He had no computer-related degree, but he did learn programming skills "as a hobby," he says. "It was just pushing some numbers and data around."
It wasn't until Kolodner began his last year of residency at Washington University in St. Louis that, with the help of a librarian who served as sort of an information mentor, he began to comprehend how computers could be used as a clinical tool.
For starters, Kolodner thought computers could solve the problem of getting information from medical journals.
"There were clearly times my colleagues were seeing patients for certain conditions where there was a recent article relevant to them, yet they were unaware of the existence of these recent articles," he says. "The computer (would be) a tool for closing that information gap."
When Kolodner in 1978 joined the VA in Atlanta, he hooked up with a group of Georgia Technological University researchers who had received a National Library of Medicine grant to study the use of computers in healthcare.
"They helped me to understand the importance of data banks of experience so that not only the literature but also the rich repository of experience could be resources for helping clinicians to make better decisions and achieve better patient outcomes," Kolodner says. "The challenge became knowing what was happening to the patient. To do that, we needed a healthcare information system."
At that time, the VA's computer systems were bulky mainframes located in five data processing offices, so they weren't much use as clinical tools.
Kolodner, offering his services as a programmer, hooked up with Joseph T. (Ted) O'Neill and Martin Johnson, who in 1977 had begun developing a site-based computer system using minicomputers. O'Neill and Johnson, of the Department of Medicine and Surgery in the VA's Washington central office, were the founders of the VA's "Underground Railroad," a nickname inspired by the need to work in secret because of the VA's resistance to their plan. The agency's Office of Data Management & Telecommunications declared all work on site-based computing to cease, and O'Neill was dismissed for his participation, according to the VA book.
It wasn't until 1982 that the VA, with a little arm-twisting from Congress, decided to implement O'Neill and Johnson's system, calling it the Decentralized Hospital Computer Program. By the early 1990s, the system had been expanded to allow patient records to be transferred via computer to any of the VA's 173 medical centers.
DHCP now is being updated with a new system called Veterans Health Information Systems and Technology Architecture, which will be based on an open, client-server system, a common system today. VISTA, which a VA spokesman estimates will cost in the hundreds of millions of dollars, will begin running sometime this year.
Kolodner acknowledges that the VA used DHCP for too long, as it was basically an expanded, cobbled-together system of individual machines, rather than a truly seamless network. But, he says, the current VA administration is dedicated to updating technology, as evidenced by the creation of two new information posts in 1995.
R. David Albinson, a non-M.D. who once handled technology for Tenet Healthcare's predecessor, National Medical Enterprises, was named CIO, and Kolodner, who had advanced to the position of director of the VA's Medical Information Resource Management Office at that time, filled the new position of deputy CIO.
Among the projects Kolodner is working on is a plan to create a joint patient-record system between the VA and the Department of Defense to assure the smooth transfer of records of active personnel when they step down from the military.
Kolodner says he doesn't think he was hired as deputy CIO because he is a physician, although "it doesn't hurt." He says the VA's doctors are as concerned as those in other medical organizations about making sure their voices are heard when it comes to technology.
And even though the VA now has its own guidebook to technology, it doesn't mean the former rebel Kolodner expects everything will go by the book.