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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TerryB
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TerryB,
User Rank: Ninja
6/2/2014 | 1:37:21 PM
Not an IT Issue at VA
Like most old government agencies, their problem is bureacracy. Way before this serious story came to light, it was obvious that mgmt is disconnected and internal policies are more important than people. My wife has been a nurse for a very long time, and a very good one. She recently left Prevea to work for VA in the spirit of giving something back, her Dad was a Marine and served in Korea. She was so good that top HR person at Prevea personally asked to see her when she heard my wife was leaving, asked if they could do anything to keep her. She said no because it wasn't about money or wanting to leave Prevea, she wants to help vets. Her job is to travel to home of vets in area and coordinate their care, getting them appointments in clinics when necessary.

After her first year and review time came to evaluate whether her GS grade, the major pay driver in government jobs, should be increased, her immediate supervisor gave her an over the top evaluation, saying she was incredible at her job for a person of any tenure, much less a 1st year employee in the job. She even covered the slack when her partner was in bad car accident and could not work for months.

But whoever this evaluation was sent to up the mgmt chain, she was denied a promotion in GS stating she only met 3 out of 5 criteria they have. I still don't think she even knows what this criteria is. It certainly had nothing to do with satisfaction and feedback from the Veterans, and obviously nothing to do with people who actually manage her local work. How can a system like that possibly work? It's all about manipulating budgets, especially when budgets get connected by metrics in evaluating the higher level managers.

I work in Mfg, so one of our biggest metrics is shipping to our customers on the date we said we would. It connects directly to any bonuses paid out. So there is high motivation to make that number look good. Managers at other business units of our company have been fired for manipulating that data.

The difference to VA is no process seems to be in place, maybe because they hide behind paper processing when they can, to audit the process. That's a mgmt failure at much lower levels than this Shinseki who took the fall. They need to clean house at top manager level in every VA unit implicated in this. Which, by the way, is not in this area where my wife works. She was as shocked as anyone this could even happen. I've seen her extend her workday to make sure any of her Vets who need to see her get to do so. It's not the people actually providing the care who are the problem here.
MedicalQuack
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MedicalQuack,
User Rank: Moderator
6/2/2014 | 10:16:49 AM
Re: Any Coders commenting here?
There's plenty of talent at the VA that knows what they need to do without me:)  Last year both of the head IT folks left as well.  I keep telling all we are a nation of stat rats with math models and software beginning to fail with an over reliance and VA is just the tip of the iceberg.

http://ducknetweb.blogspot.com/2014/05/va-crisis-just-tip-of-iceberg-as-us.html


I have full respect for coders and last thing they need is someone like me telling them on a blog what to do.  In meantime I'm much more concerned about our novice Consumer Financial Protection Chief and his case of Algo Duping right now with building a federal data base on all US consumer credit data.  This problem keeps repeating itself over and over with executives with no data mechanics logic saying stupid things and putting weird data perceptions out there and these executives are duped over and over again, just as was the head of the VA.  Cordray is just like Sebelius suffering from the Sebelius syndrome. 

http://ducknetweb.blogspot.com/2014/05/richard-cordray-yet-one-more-algo-duped.html

 
Alison_Diana
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Alison_Diana,
User Rank: Author
6/2/2014 | 9:16:16 AM
Re: Any Coders commenting here?
You're right, @MedicalQuack: It is very easy to sit at a desk and write an article about what "should" be done. We both agree, as you said, that a lot of the change is cultural. I had hoped that my feeling this is a HUGE, DIFFICULT undertaking would come through. No one in their right mind would ever suggest improving the VA is something that could happen overnight, or even in a year. Writing code is not easy, especially when you're looking to integrate different vendors' systems. That's not something they necessarily want you to do! If it was easy, then healthcare alone would be a much smoother (and less costly) industry.

Thanks for sharing some of the details of why there are so many challenges facing the VA. What do you think can be done to improve the system? I don't think anyone disagrees that there are major problems here, when so many folk are coming forward to show veterans had been shelved without appointments, wait-listed for months, and some execs received bonuses for allegedly falsifying records. How would you start this process? What resources would you want?
Alison_Diana
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Alison_Diana,
User Rank: Author
6/2/2014 | 9:10:53 AM
Re: Can the VA Automate Successfully
You are absolutely right, @SeniorMoment. As we saw with Healthcare.gov (and many other examples, too long to list), the government's entire approach to purchasing, managing, and implementing complex solutions is broken. I'm not sure what the reasons are and don't want to get into a big political debate, since this isn't the forum (and from what I can tell, this problem extends across multiple parties' leadership). But the end result is that taxpayers spend a lot of money needlessly; our systems are years (or perhaps decades) behind, and - in the case of the VA - heroes are dying.
SeniorMoment
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SeniorMoment,
User Rank: Apprentice
6/2/2014 | 6:15:39 AM
Re: Any Coders commenting here?
I concur that the core problem at VA, based on the experiences I had with my parents, is cultural.  The VA does not function as a whole organization but as an amalgam of its component facilities which even have different eligiblility standards which I woudl have thought woudl be a violation of equal access regardless of state and equal due process of law.  Management has to feel like they are part of a team with the actual health care providers and veterans at the core of their world--not internal management philosophy disputes and office politics that go on in every bureaucracy, including business ones. I have never observed that existing in VA, whch most nurses for example regard as an employer of last resort, just above a rural county hospital.  Unless it has changed the annual turnover in doctors is unaccetable high.  I once paid for a veteran's prescription because he was new to town and although he had only asked for a ride to the VA,  I didn't want him to spend hours waiting to establish local eligibility and see a doctor all to fill a $10 for 90 day prescription because I had waited that long myself with my mother.

It takes doctors more than one visit to understand all but the simplest patient's problems and past treatment attempts, and each new doctor comes with a new set of medical opinions too.  I once saw 4 lipid specialist.  It turned ut the first 3 were students.  I told the 4th one what the others had said, and he replies (as it turned out they were his students) didn't they learn anything at all from me.  I felt just a VA patient then.

From a long past article from Information Week, 90% of the computer programing is done by 10% of the programmers.  I personally wrote over a quater million lines of code over a decade, so computer programming is only hard for people to whom it does not come naturally.  For me it was much easier than learning Spanish, Zoology, or English Literature was in college.

The real problem with computer programming comes when it is done by people who know only computer programming and not actually how the business or agency processes work by having physically done the work or closely supervised or watched it unobtrusively. I once threatened to kill a multi-year project unless they delivered part of their proposed system within a year.  They did and learned the hard way I was right that they approached the problem poorly all because the Team Leader way back then did not want to learn how to write a single interface page in CICS and insisted on doign everything in Natural which magnified the total number of programming modules needed.  Of course by now CICS probably does not exist and Natural having come from Software AG probably doesn't have such tiny program size requirements on today's faster computers and storage devices.

When Windows NT was written it was done by a small team of good programmers working over a reasonable number of months, and now the development tools are greatly improved, yet advancements are much slower and no less error prone.  In fact the recent Heartbleed smart phone security vulnerability was introduced by accident to a computer program that did not have it, yet 2 or 3 levels of review did not catch it because everyone was treating old code as unlikely to have changed any except where intended revision was made.

If you want to know what is hard in programming, it is finding a logic or non-obvious syntax error, so it is really important the first run at the code is great.

 
MedicalQuack
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MedicalQuack,
User Rank: Moderator
6/1/2014 | 12:04:50 PM
Any Coders commenting here?
I love these types of articles that say "what so and so should do"..we see it all over the web.  First off there's the disability rankings that are done for VA Vets with LHI, a subsidiary of United Healthcare for tose who will be receiving those benefits and enrolled in the VA, United has quite a few military contracts with the VA and DOD.  There's a a front runner to the system before they even get into the VA system that adds more time..anyone aware of that?  That uses another EMR system that LHI has and then those records need to get put into the VA ViSta system.  Has anyone seen ViSta? I have and it's actually very good. 

Well the employees at the VA found a bug on the schedules so time drag out some code modules and fix it as well as an over all audit of the audit trails to find out who, where, time stamp of those gaming the system.  I used to hate that as a former developer when I missed something like that too as it's code bug that needs to be fixed and in this case they gamed it instead of reporting it, happens all the time with software development and there's no way around finding every bug as that's the software world.


The VA is fractured and does us a lot of different technologies too, you can look at Picis if you want, anesthesia software used throughout, another subsidiary company of United Healthcare.  Integration, easier said than done, folks coding is freaking hard..if it were that simple the DOD and VA would have had that done by now.  I'm sure they have a burial ground of sandbox applications they have worked with over the years to test integration too, as they don't just do nothing but integrating two massive systems is not easy.  Actually using a middleware app such as Zoeticx is becoming a better solution and cost sustainable as well so not only the VA but others are looking at middleware as integrator.

Actually the "real" problem with the VA is a big culture change needed all over as we have become a nation of "stat rats" and you can see it failed here with being out of touch with the real world and if you look around and read the news you are starting to see more models fail as we need both but we need balance on how technology is used so to say they just need to use technology and line up a a list of things to do doesn't mean a lot as it's monster project by all means.  I understand non coders and the general public don't understand the complexities for the most part and I keep telling everyone "the short order computer code kitchen burned down years ago and there was no fire sale"...

http://ducknetweb.blogspot.com/2014/05/va-crisis-just-tip-of-iceberg-as-us.html

We have had a few years of the Sebelius Syndrome we have all had to live through with her searching for the "algo fairies" she thought was the cure and wanted to "hurry up health IT" as well...so again it's balance and not leaving the human out as that's what happened here with the stat rat effect, sadly.  I'm in tech and I would not stick my nose out there and tell the VA what to do as you can't be a Monday morning quarter back and you have to really be there.  Again the perception of non code folks and folks who create code and software will always differ, I had that when I wrote my medical records program and once I sat down a couple of MDs and showed them how complex coding changes are, we a got along great as they saw the difficulty and structures i had to work with at as well from my side, so no algo fairies rushing in for a fix.

 

JimS826
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JimS826,
User Rank: Apprentice
6/1/2014 | 8:54:17 AM
Re: Can the VA Automate Successfully
The 'people served' have to Pay For It, Decades now and wars from of ignoring the many issues so they don't have to!!!

Travesty For Us Veterans': Especially if another Conservative Executive Administration oversee's, we already have them in Congress and State Houses talking but doing nothing but obstruction!

Finally a Non-Political VA Secretary That Was Addressing Long Ignored, and Newly Ignored Combat Theater Veterans, Issues By Those They Served and Through Their Representatives, With Help From the Full Executive Branch and Accomplishing For the Surviving Veterans of Those Issues!!

As Veterans, and especially us looooong time Veterans Activist and Advocates: WE ARE PIS*ED ! ! !
and what we are pis*ed about is that senior VA mangers are setting Shinseki up to take the blame for their own back-stabbing, incompetency and bullsh*t {thanks to llbear for this}

Patriotism Posers!! Sen. Sanders to bring back veterans bill GOP previously blocked - Put Up or Shut Up!!!!!!!

Conservatives got what they've long sought, and attempted to do prior, since he was nominated and confirmed as VA Secretary!

The General was like most of us Veterans, though we really know better but when them served are a wavin them patriotic symbols there's just a maybe they really mean it, others like those served, like their representatives, quickly lay all blame on the VA, no demand they sacrifice, especially conservative led Vet orgs., who think that Politics and Greed wiil be kept out of the many area's of the VA agency and the total focus within would be to fulfill the countries contract in caring for the very few who served them. Most do, especially the unpaid many many volunteers, but it only takes a few employee's, especially looking to help the conservative ideology, when under democratic executive administrations especially, in wanting to privatize for corporate profit off the people's treasury and added fee's legislated for same.

Long Past Time, Decades and War Of, Those We've Served Stand Up and Take Blame For Lack of Sacrifice From:

PTSD, Agent Orange, Chemical Exposures, Gulf War Syndrome, Homelessness, National Cemeteries, Veterans Courts getting help for instead of just throwing a Vet into jail or prison, to Name But Only a Few, Including Issues From These Two Present Long Occupations, Totally Ignored Now Being Addressed by This VA and the Executive Branch Cabinet Helping the Long Under Funded Peoples Responsibility, the VA! Thankfully the only Government Branch, this Executive and it's Cabinet, doing anything for not only Veterans but Military and their Families will continue working with the VA to fulfill what the peoples representatives, Federal and States, aren't as those served like that!

"Why in 2009 were we still using paper?" VA Assistant Secretary Tommy Sowers "When we came in, there was no plan to change that; we've been operating on a six month wait for over a decade." 27 March 2013

It isn't a VA 'scandal', it's the Country served and through their Representatives 'SCANDAL', decades long and wars from as they ignore the issues so they need not pay for! Wars over no need to wave them patriotic, patriotism posers, flags! Nothing more to see or need to do here, move along!

That spending, like most of the budget is still mostly borrowed, especially in the last decade plus and two wars of choice, with two tax cuts as they started especially for the wealthy with costs for the wars rubber stamped off the books with no bid private contracts and and all borrowed, as this VA started addressing long ignored issues of previous decades and wars from, since Korea and even WWII issues, with interest and problems created by the people and their reps taking from those budgets to fix. Instead of the flag wavin country building and just maintaining and advancing the Agency that should have always been, thus costing less to operate and with quality!!

Long Time Example of just one Long Ignored Military, and wars, Veterans' issue:

Conservatives Pro-Business right-wing Think Tank American Enterprise Institutes own Sally Satel, Still Selling Care for PTSD Veterans is Waste of Money! Nemesis of us Vietnam Veterans who fought for recognition of for the brothers and sisters suffering with and not only as to Vietnam and war PTS but the Civilian personal from their traumatic life experiences as well! She, and some others, have made very lucrative livings writing and speaking in denial of, giving reason to country and politicians serving them to ignore, and thus have the blood of hundreds of thousands of not only military, military veterans but civilians who suffer the ravages from extreme trauma's, on just one long of many ignored issues by those served issue so they need not pay for care!

USN All Shore '67-'71 GMG3 Vietnam In Country '70-'71 - Independent***

SeniorMoment
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SeniorMoment,
User Rank: Apprentice
5/31/2014 | 10:48:08 AM
Can the VA Automate Successfully
The VA has even proven itself incomptent to do a relatively simply task of converting data from one database, the Defense Department's system for discharged service personnel, and its own system to eliminate mountains of tree use for paper.  The only computer software I woud trust the VA with is off the shelf software already being used by another health care organization.   The only allowed difference until internal to the VA technical and adminstrative competency can be absolutely proven is that every patient will have the same health insurance information.  It is fair to assume such programs have a place to enter the name of the business, which in this case is the USA Veterans Adminstration.

Information Week about 25-30 years ago printed an article that said the federal government had contracted out so much system development work that it no longer had in its agencies enough technical competence to even specify data system needs, and this even proved true with the Affordable Care Act enrollment system, one of the highest federal priorities, so it is apparently little has really changed.

To circumvent purchasing rules and legal requirements for competitive bidding of all purchases that dragged on with appeals past the generational life expectancy of the equipment to be purchases, federal agencies started writing software development contracts that required only an evaluation of Requests for Proposals that included delivery of all the computer hardware necessary to run the software.  To cost justify such decisions the agencies had to reduce their own information systems staff, and that was a huge mistake that has haunted the federal government ever since.
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