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High-quality care is a near-universal goal of medical care systems and there is a growing consensus that performance quality should be measured and perhaps used as part of the basis for payment for services. Identification of valid performance measures and reliable means for measuring them are critical if such efforts are to improve patient outcomes. The Veterans Health Administration (VHA) is, in many ways, ideally set up to both implement and evaluate quality improvement programs. The VHA system is the largest integrated delivery system in the US and has one of the most comprehensive electronic health record systems currently available. Over the last 20 years, the VHA has developed and steadily expanded the VistA system and its user interface the Computerized Patient Record System (CPRS). CPRS now includes an electronic medical record, a computerized physician order entry system, medical image viewing, diagnostic test results, and electronic pharmaceutical management among other features. The VistA system, in many ways, serves as a model of how a comprehensive electronic medical record system not only can assist providers by providing easy access to relevant patient data but can be used to study patient-care patterns and implement quality-improvement programs. For example, the VHA has incorporated alerts and automated reminders at the point of medical decision-making (when orders are written) in an attempt to improve patient care. The VHA has been a leader in efforts to incorporate performance measures into a comprehensive qualityimprovement program and the program has been reported to be very successful. For example, in 2004 a RAND Corporation study measured the quality of medical care using a chart-based quality instrument consisting of 348 indicators. The study found that the VHA had substantially better quality of care than did a national sample [1]. Similarly, a 2009 Congressional Budget Office report [2] found that ‘‘the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines— particularly those that the VHA has emphasized in its internal performance measurement system.’’ Two performance measures that have been incorporated into the VHA quality-improvement program are (1) the percent of patients with a positive fecal occult blood test who have a colonoscopy within 60 days, and (2) the percent of patients with an interval of 30 days or less from the time a consultation is requested until the patient is seen in consultation. These performance measures are well-intentioned and would seem to be intuitively valid as they are based on the reasonable premise that more efficient identification and work-up of potentially serious symptoms or signs would lead to better patient outcomes. Logic would tell us that at some level this premise is true since at the extreme, an infinite delay in the workup of a potentially serious sign or symptom would undoubtedly lead to a bad outcome in some patients. The uncertainty of such performance measures is in the details: how long a delay is too long and what is the spectrum of bad outcomes that could arise from a delay in evaluation? The study by Fischer et al. [3] in this issue of Digestive Diseases and D. J. Ahnen (&) Denver Department of Veterans Affairs Medical Center, Denver, CO, USA e-mail: dennis.ahnen@ucdenver.edu

Colorectal Cancer: What to Do When Logic and Good Intentions Are Not Enough