Healthcare // Patient Tools
Commentary
5/31/2014
09:06 AM
Alison Diana
Alison Diana
Commentary
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Shinseki's Successor Should Use Technology To Rehabilitate VA

The Veterans Administration let down the men and women of the Armed Forces. But technology can help the VA in its long road to rehabilitation.

Friday's resignation by Department of Veterans Affairs Secretary Eric Shinseki is only the first of many steps the beleaguered agency must take to fix its treatment of America's military, bolster its tattered reputation, and attract the talented professionals it needs for the future.

The department -- which has about 312,481 full-time employees and a 2014 budget of $153.8 billion -- is bulky and well funded. Neither understaffing nor money lies behind its failures. Instead, culture, a dearth of checks and balances, and a history of unpunished transgressions helped create a department that allowed wait times to last for months or erase veterans from lists entirely, according to published reports. Forty members of the Armed Forces, who waited for 21 months to get care at a VA hospital, may have died as a result of this negligence, a whistleblower charged. As more employees come forward, media and government officials are turning their attention to previously published reports by departments such as the U.S. Government Accountability Office, which in March 2013 found "inconsistent implementation of certain elements of [Veteran's Health Administration's] scheduling policy that impedes VHA from scheduling timely medical appointments."

At that time, the GAO determined the VA was implementing various technologies to improve wait times and service. In light of recent revelations, it's imperative for the VA to use these tools as part of its major overhaul. These are only tools, of course. The VA itself requires much more than technology to once again become worthy of veterans' trust. But by installing technologies for transparency, communication, and visibility, the VA can demonstrate it is moving in the right direction.

  • Waiting Room Apps: A number of healthcare organizations, looking to enhance efficiency and patient satisfaction, use apps to reduce or even eliminate waiting room times. No matter who's providing care, 90% of patients were aggravated by doctors' wait times, according to a 2013 study by reviews website Software Advice. Sitting around in an uncomfortable room watching the news is one thing; being totally unable to see a doctor because your name is removed from a provider's calendar is another. Empowering patients to register themselves and set up appointments via text, patient portals, or other systems eliminates the now very real fear of being overlooked by VA schedulers. Automated reminders reduce missed appointments, keeping veterans healthier, patient satisfaction higher, and making clinics run smoother.
  • Integrate EHRs: Since older veterans also are eligible for Medicare or Medicaid, it's vital the VA's electronic medical records integrate with the government's other large health programs. Encouraging -- or, certainly, not penalizing -- veterans to use alternate healthcare providers when it's more convenient or timelier will help clear some backlog, especially in certain regions where VA resources are harder to access.
  • Telemedicine: Expand the use of telemedicine for areas such as psychiatry, monthly check-ins, and non-emergency care. Of course, there are many cases where veterans must see a physician in person. There are, however, other instances where clinicians provide equally good care via video or phone, saving patients a drive and wait and enhancing the provider's efficiency.
  • Analytics: With data from 151 medical centers and 827 outpatient clinics and having served more than 6 million patients in 2013 alone, the VA should use real-time analytics not only to track diseases and treatments, but to monitor its own performance.
  • Remote patient monitoring for the home: By equipping homes with sensors and alerts and working closely with families and patients, VA organizations help the nation's wounded war heroes return to normal lives. Not only does this improve veterans' quality of life; it also reduces medical expenses.
  • Feedback: Given the shattered relationship between the VA and its constituents, VA administrators or an external agency should conduct frequent audits of wait times and proactively seek feedback from veterans using inexpensive polling applications, whether or not they are registered to a VA provider.

The VA must open up the toolbox and use everything -- from technology to training, from staff changes to new oversight -- to try and regain the trust it lost. When you exist only to serve the men and women who pledged their lives to save this nation (and then let them down time after time), you're lucky to have another chance to atone.

Has meeting regulatory requirements gone from high priority to the only priority for healthcare IT? Read Health IT Priorities: No Breathing Room, an InformationWeek Healthcare digital issue.

Alison Diana has written about technology and business for more than 20 years. She was editor, contributors, at Internet Evolution; editor-in-chief of 21st Century IT; and managing editor, sections, at CRN. She has also written for eWeek, Baseline Magazine, Redmond Channel ... View Full Bio
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don voltz
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don voltz,
User Rank: Author
6/9/2014 | 3:43:01 PM
Re: IT to help the VA
Clearly interoperability continues to plaque EMR's and is a complex, not well understood issue with multiple proprietary systems implemented and a lack of standardization between them.  Lack of interoperability slows innovation in healthcare since it is the road block for cost effective IT solutions in support of care providers.  One of the best ways to address the VA challenges is to scale up care providers bandwidth since it is a zero sum game on the number of care providers available to extend more coverage for patient care.

With the amount of stimulus funds that has been invested in a national implementation of EMRs, I think the issue of interoperability needs to be implemented in a shorter time frame.  From the ONC 13 page document on their 10 year vision, it is clear that this needs to be accomplished, 

"To ensure that individuals and care providers send, receive, find, and use a basic set of essential health information across the care continuum over the next three years, we need to migrate policy and funding levers to create the business and clinical imperative for interoperability and electronic health information exchange," 

But why wait ten years when we can do this today with healthcare 2.0 vendors like Zoeticx. They provide the ability to view patient medical information from different EMRs from one type of media. This type of technology will cut down potential errors, while at the same time, giving back precious time to care providers so they can take care of additional patients. (I can prove this to you through a simple WebEx demo if you have time next week.  I would be happy to volunteer to help arrange a demo through web ex. We believe a healthcare Ninja must always be well armed.) ☺  

EMR vendors have a conflict of interest with widespread access and use of their systems by physicians and other hospital systems where there is no license agreement in place or business relationship with their product.  Patient's past medical data, collected by EMR's, is absolutely required for physicians and other healthcare providers to care for patients in a safe, efficient and cost conscious way. 

This discussion on interoperability has been focused on HIE (Healthcare Information Exchange) where duplicated patient medical data records add to the overall complexity. On the other hand, leading EMR vendors advocate for a rip-and-replace effort, as you cites in your response as 'too costly to oust the incumbent'. Why do healthcare institutes have to rip-and-replace its deployed EMR, or create additional database layers in order to achieve interoperability? Or do they really offer interoperability, or yet another roadblock to a true interoperability solution. Would one entertain solutions focusing on patient medical information (not data) sharing (not exchange)? Why not leverage data from the existing deployed EMR solutions (its strength in data) to dynamic patient medical information?

I think we should step back and look at what would be feasible and practical for healthcare and care providers. 
  1. Achieving interoperability by adopting standard patient medical data format (ONC) in the EMR: This 'train' has left the station. As EMRs are deployed in most US healthcare facilities, to roll out the next generation of EMRs using a new patient medical format standard is mostly equivalent to a rip-and-replace of an EMR system, which would lead to another wave of service disruption and severely impact care providers' bandwidth.
  2. Achieving interoperability by data duplication (HIE approach): Basically, it is about duplicating patient medical records and presented in an additional new data base layer adopting a new standard format. This approach does leverage existing EMR deployments, but it is costly and not sure to really address care providers' needs. It does address a number of needs such as patient medical data analysis, but faces the challenges of operating on potential stale data due to its batch mode synchronization approach. 
  3. Providing access to patient medical record as single source of truth: This approach leaves the patient medical data at its source, puts an emphasis on a middleware infrastructure to provide an 'information highway' for patient medical data. It focuses on multiple data sources, mapping patient medical data into information on a near-time approach. This approach leverages deployed EMRs, avoids a rip-and-replace, and addresses care providers' collaboration needs. Coupled with an open architecture, this approach would be ideal for inspiring innovation in healthcare, addressing care providers efficiencies by extending their bandwidth. 

Would you like to witness a scenario where a physician can retrieve patient medical information from both hospitals and clinics (different EMRs / different vendors) on the same media, have the ability to collaborate on patient care (patient care continuum) and using the most up-to-date data from its sources (point of data collection)? Would it be good if I could consult with you on a patient medical condition similar to a web-ex session where there is no miscommunication? 

To sum up, the challenge is not about realizing and agreeing on the problem. It is interoperability, but how to solve the problem without any disruption of service, contain the cost, and protect healthcare institutes investment on EMRs. The recent ONC announcement acknowledges the challenges and outlines the steps to address the challenges. It is the 10-year road map with another major disruption. As I pointed out previously, such a solution exists today and is available now. We can't just wait for another 10-years with billions re-investing in another form of EMR deployments. Let's leverage it and get healthcare IT moving forward!
Alison_Diana
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Alison_Diana,
User Rank: Author
6/6/2014 | 9:31:30 AM
Re: IT to help the VA
Oh yes, @Pedro. Unfortunately, this will NOT get resolved overnight -- or even in a year. Whoever takes over this position should have brilliant leadership capabilities; extensive knowledge of healthcare, perhaps from the ground up (with a medical background as well as being a veteran, him/herself), and the abiilty to see the big picture and clear-cut goals. This leader must have the resources and backing they need without outside lobbying or political battling, although it's doubtful s/he will get that liberty! I'd suggest they conduct visible pilots across several sites, sharing the results to demonstrate a new transparency. Those employees found guilty of gaming the system to get bonuses should be fired, if union rules allow; if not, they must be demoted and retrained, moved to positions with little to no authority that have nothing to do with patients. 
Alison_Diana
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Alison_Diana,
User Rank: Author
6/6/2014 | 9:27:50 AM
Re: IT to help the VA
You are right, Dr. Voltz, that for vendors it typically is in their best interest not to promote interoperability. It's like the olden days of earlier enterprise systems, where proprietary solutions battled for tenure: Once they had a foothold, it appeared too costly, too career-damaging to oust the incumbent, the reasoning was. That did change, of course, but it took time and lots of very expensive failures. With the ONC's announcement yesterday of its 10-year plan and focus on interoperability, I wonder whether that will change. Given the challenge of change, I think a decade is optimistic, particularly as this is a political office and roles (and funding) change, there will be privacy concerns, and we all know there'll be a ton of lobbying by multiple factions.

Middleware would seem to be the most cost-effective approach since it wouldn't require ripping and replacing, something few healthcare organizations rightfully would be loathe to do after spending perhaps millions in software, hardware, staff, training, and more. In hindsight, interoperability should have been part of the equation from Day One -- but it wasn't, so now the industry and vendors must address it in order to move forward. 

So many people believe healthcare is in an age of disruption and some organizations definitely seem to be trying to break the mold. Other than a desire to improve patient care, cut costs, and be viewed as a leader, do you think there should be additional financial incentives for those willing to experiment with tech (not just the VA. As you say, this is a more extensive issue.)? And if so, what sort of parameters should there be? Or is trial and error part of the cost of doing business, something healthcare orgs should be willing to pilot whether they succeed or fail? 
PedroGonzales
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PedroGonzales,
User Rank: Ninja
6/5/2014 | 4:26:55 PM
Re: IT to help the VA
I think all the points you have indicated are the correct strategies to find various ways to fix the current problem the VA has.  But, I wonder whether whether the next person in charge will define clear goals and be accountable to how they are accomplishing the suggestions you have made.  Also, lets take into account that such and other changes will take years to acomplish.  People have to understand that as well. 
don voltz
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don voltz,
User Rank: Author
6/5/2014 | 12:47:04 PM
Re: IT to help the VA
Clearly there are issues in the VA that have been recently highlighted. They do not stop there, however. As pointed out by MedicalQuack, development of software is hard. Developing software using the typical waterfall methodology presents its own issues, especially in healthcare where requirements, processes, and workflows are not completely understood, standardized and regulatory issues continue to change with new initiatives including the latest Affordable Care Act and all the IT requirements that go along with it.
 
One needs to ask the question, can a single platform effectively address the needs of healthcare practitioners, offices, clinics, hospitals, health systems and governmental agencies? The current model of EHR development, deployment and implementation is clearly moving in this direction. With the continual expansion of EHR functionality to add new requirements, we make these systems more complex, add inter-dependencies, setting ourselves up for potential catastrophic failure of systems we are becoming more dependent upon. As each EHR vendor continues development and is in competition with other providers, we need to address the big question of why interoperability is good for their business model. The short answer is it is not and will only be added to comply with federal regulations and mandates. One has to wonder if this will be the concept of interoperability many of us have in mind from the provider as well as the patient consumer. Is there another solution?
 
At the core, all EHR's are databases, albeit, built on platforms and database technology from the 1960's, MUMPS. My concern is many of these have been developed and consist of millions of lines of code making re-factoring and expansion a difficult, if even possible solution. I agree with MedicalQuack in the concept of a middleware platform to interact with the data and allow for expanding these systems to meet local, regional, federal and evolving requirements. In exploring the Zoeticx platform and their recent announcement of an API allowing others to build applications and services on top of a platform, we open up development far beyond the EHR vendors (Zoeticx's New API Allows for Faster Medical App Development). Much as iOS brought innovative ideas as well as major flops to the marketplace, a middleware platform connecting disparate EHR systems while maintaining security and integrity of the data being stored by these systems and the development of customized applications to address the needs of providers, clinics, hospitals, health systems, and governmental agencies. This moves the development from the waterfall process to a more agile one where ideas can be tested and the market can respond to the solution without having to rip and replace expensive EHR systems for a niche market within healthcare. 
 
We have amassed a significant collection of healthcare IT failures and are likely to uncover many more. As with the art of medicine, we need to develop a system for healthcare IT that can be treated and managed with novel and creative solutions.
 
Donald M Voltz, MD
Anesthesiologist
Alison_Diana
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Alison_Diana,
User Rank: Author
6/5/2014 | 9:53:42 AM
Re: IT to help the VA
Being forced to search through three EMRs is a big waste of your time, doctor. When you add up the time spent doing that for patient after patient, that adds up to many hours per week or month. A lot of hospitals face that issue because they choose a best-of-breed approach to EMRs, using one for the main hospital, one for the ER, one for radiology, etc. From conversations I've had with CIOs, CMOs, etc., I'm seeing a shift toward standardization on one EMR across an organization, although this may well cause problems for hospitals' departments if that EMR doesn't resolve the needs of the ER, radiology, surgery, etc.

One thing the ONC now plans to address is integration. Now, I'm not certain how the government intends to do this or if this is the best approach, but the ONC certainly has a big stick to help hospitals and doctors address this time-consuming issue and, hopefully, help physicians like you do what you want with your time. What has your IT department done to try to help you with this issue, Dr. Nearman?
Alison_Diana
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Alison_Diana,
User Rank: Author
6/5/2014 | 9:35:28 AM
Re: Not an IT Issue at VA
Once again you bring up some great points, @AmandaInMotion, and it's one reason I'm so glad I wrote this piece: I wanted to spark a conversation about this horrendous situation because it made me so upset about the treatment of these vets. We may not solve the problems in this forum, but it's a great place to discuss some options, alternatives, and I'm definitely learning new insights.

The fact that lobbyists are involved in the VA is ridiculous, IMHO. Politics has absolutely no place in a medical setting and doctors, nurses, and other medical professionals are the only people who should be deciding which treatments, which equipment, and which vendors are involved at VA hospitals, clinics, rehabs, etc. Lobbyists, politicians, aides, and anyone else from DC shouldn't be there -- unless they're a veteran in need of care. From what I've read, some of the VA's problems stem from the involvement of lobbyists; others stem from the unions' demand for more jobs and its baulking at allowing vets to seek treatment at non-VA facilities, even when vets have Medicare or other insurance. With the non-VA focus on "population health" and "patient engagement," there's a real opportunity for the VA -- with its captive population -- to be a leader, not a laggard. The VA has tons of information on its patients, plenty to create a system of PERSONALIZED care yet it appears to have done the opposite and treated at least some veterans as indistinguishable pawns by not providing them with appointments, and allegedly causing at least some deaths due to that lack of timely care. In other words, the exact opposite of what the government's requiring of healthcare providers that accept Medicare/caid.

There are far more medical devices now implanted in patients so there will be more recalls. That said, there's been a lack of oversight on these devices which have been found to be easily hacked. This is one area I believe the government needs to get more heavily involved in to ensure patient safety, not only from the device components but from external threats from hackers and bad code. 
ICU_DOC
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ICU_DOC,
User Rank: Apprentice
6/4/2014 | 9:32:29 PM
IT to help the VA
I agree with Barbara that better technology is key. One way we can spend more time on the needs of patients is if EMRs were integrated and not silos of disparate data. Doctors like me waste a great deal of time working with systems that are not compatible. A patient's lab data could be stored in one database while data from a surgery in another EMR database and a file of past prescriptions still somewhere else. 
 
By the time I search three different databases, I could have been attending to a patient to help ensure the best possible outcome. Barbara is correct in looking to solutions that go beyond the same old EMRs. Technology like that being offered by visionary EMR leaders like Zoeticx will help make a difference. 
 
Hospitals need to move forward with these types of new solutions and ways of doing business that helps hospitals do more with less.
 
Howard Nearman, MD
ICU Physician

 
AmandaInMotion
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AmandaInMotion,
User Rank: Apprentice
6/3/2014 | 11:03:23 AM
Re: Not an IT Issue at VA
Let's just hope that whatever new "technology" the VA pushes doesn't turn out to be like this: (http://tinyurl.com/mmnphhk). Apparently there have been more medical device recalls in the past decade than ever before.

I fear that the structure of government healthcare - that is, where lobbying corporations have more sway than veterans themselves - means that giant government contracts will be granted to medical device companies who may be pushing out faulty products.

The problem, it seems to me, is the institution of socialized medicine itself. Bureaucracy making health decisions for individuals instead of individuals making them seems to breed these kinds of consequences.

Thanks for the informational article, Alison.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/2/2014 | 3:57:51 PM
Re: Not an IT Issue at VA
There are some absolutely wonderful, dedicated people working at the VA and it sounds as though your wife is one of them. Thank you so much for all she does to help the brave men and women who served our nation. The people actually working in the hospitals themselves are to be commended. From what i've read, it's the beaurocrats behind the scenes who need to be replaced and to use the kinds of tools i detailed in order to avoid some of the very things you described here. 

It's appaling to hear that great employees don't get raises when, elsewhere, we read about paper pushers who get undeserved bonuses for lying about wait times. There's obviously something wrong with the system and somehow we owe it to our vets (and the many great employees within the VA) to do something about it.
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