The VA waitlist debacle: Don’t blame the VistA EHR system

Without a doubt, the death of American veterans as a result of the VA waitlist debacle is tragic and unacceptable. The Obama administration must move quickly and deliberately to fix the underlying problems and restore faith in the agency.

If these issues were common throughout the VA network of hospitals and clinics, it might make sense to consider dramatic, earth-shaking alternatives like moving veterans to private providers and shuttering the VA. But they are not common. Indeed, as Washington Monthly reporter Phillip Longman has documented, the VA’s challenges are regional, not pervasive.

Still, black hole media coverage of the VA sucks in everything that lingers nearby, including the VistA EHR system. I’m not saying scrutiny is unwarranted. When veterans die prematurely and unnecessarily, the review of root causes should be exhaustive.  But VistA is simply not a root cause and the suggestion of replacement with a commercial system is cynical and opportunistic. No wonder, since most large hospitals and healthcare systems have made their initial health EHR commitments and the DoD and VA are the biggest fish left in the pond.

The challenge is access to VA care, not the quality of the care itself.  Both internal and external analyses point to two root causes: supply and demand, and a corrupted local bureaucracy.

First, the demand for care is much greater than the supply in regions where veterans, particularly baby boomers, have located. The waitlist problem is particularly acute in the south and southwest with Phoenix as the epicenter. Estimates suggest as many as 20 percent of roughly 2 million Iraq and Afghanistan veterans — perhaps 400,000 soldiers — may have post-traumatic stress disorder (PTSD).

Second, the regional VA bureaucracy and administration courted failure by setting unattainable goals. The arbitrary no-more-than-14-day wait for care policy was impossible without enough available physician slots. This led to scheduling departments adopting a “fake or fail” policy and creating dummy wait lists to hide the damning real metrics.

Per both internal audits and external surveys, the culprit is not VistA or it’s scheduling package.  As reported by Modern Healthcare’s Joseph Conn, an extensive (3,772 interviews at VA facilities) internal VA audit showed that among all potential contributing factors, VistA was least to blame.

The lack of open provider slots scored highest with VA staffers as a specific barrier or challenge (with a mean score of 3.0), closely followed by limited clerical staffing (2.8) and the VA target that veterans have an appointment within 14 days of request (2.8) …

… respondents describe a numbers-driven system with unrealistic performance measures as having created a highly stressful work environment that limits the focus on serving the veteran.

Challenges using the scheduling module of the VA VistA electronic health record system … ranked lowest among six choices given by the auditors.

A VA inspector general interim report came to a similar conclusion, finding the problem was not VistA. However, the inspector general did identify interoperability, or rather lack thereof, as a problem for over a decade.

VA staff prints out paper copies of basic patient enrollment information that then has to be reentered into a VistA module for scheduling appointments. That suggests systemic problems with interoperability.

For new veterans coming into the VA system, DoD health records must be printed out and typed back into VistA, which gives rise to a host of questions: Might that slow scheduling down? Why is there no interoperability? Why don’t DoD and VA use a common EHR to ensure continuity, efficiency and quality care for every veteran?

(And will an $11 billion proprietary vendor solution whose major weakness is lack of interoperability solve the problem? But I digress …)

According to a New York Times article, veterans themselves blame the bureaucracy and praise the quality of care they receive once they are through the doors. Indeed, their complaints — repeated canceled appointments, unreturned calls, lengthy waits for appointments and rapid turnover in physicians — all fall under the management heading.

In a typical and representative response one veteran said:

It’s frustrating and infuriating that there are so many dedicated doctors who work for the V.A. but it seems impossible to get to them … They’re serving too many people.

While the HIT industry and media love the smell of scandal, a recent HIStalk comment lays out both the conventional wisdom and the actual facts.

More signs that the VA’s VistA baby will be thrown out with the agency’s dirty bath water …  Evidence is ample that that the real problem was that VistA’s scheduling system was accurate and transparent, and due to the VA’s resource and management challenges, that created a reason for users to avoid using it. In other words, the system gets thrown out because it was doing exactly what it was supposed to do.

All true. Except VistA will not be thrown out.  We don’t have the luxury of spending billions of dollars and the better part of decade to replace a system that already provides the best care anywhere. The right answer for the EHR industrial complex is the wrong answer for veterans and taxpayers.

New VA leadership must revamp the local and/or regional bureaucracy to make it transparent and open. Congress must increase funding for VA health care services and increase the number of available physician slots. And VistA must endure as part of the solution, as it is not part of the problem.

Edmund Billings is chief medical officer, Medsphere Systems Corporation.

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  • ninguem

    Posterior-covering at the VA continues.

    • Eric Strong

      I don’t understand how this article is “posterior-covering”? The author is simply pointing out the root cause of the problem (e.g. supply-demand mismatch with health care providers, and arbitrary unobtainable goals set by administrators). He’s not saying the problem doesn’t exist.

      • ninguem

        After all the years of being told how great the VA is

        After all the years of being derided as some tinfoil hat crazy for pointing out problems with the VA.

        Now that the story is out, and cannot be covered up any more, your credibility is zero with me.

  • buzzkillerjsmith

    Another excellent analysis by a dispassionate observer who examined all the evidence closely and came to the inevitable conclusion that the VA’s EHR is truly wonderful.

    Oh wait, this guy’s company developed the VA’s EHR.

    • Dr. Drake Ramoray

      Hey some tech companies sponsored studies that EHR’s will streamline care and reduce medical errors. They apparently convinced a lot of people of that. Lots of people drank the Kool-Aid once, I’m sure many will do so again.

      • Eric Strong

        I don’t understand what you would advocate in place of an EHR for the Veterans Health Association? We serve millions Americans, who are spread across hundreds of medical centers, and who historically are more likely to migrate between different geographic regions. We have hundreds of extended care facilities (i..e nursing homes). We also frequently transfer patients between facilities to match patient needs with sites best able to meet them. Would you suggest each individual medical center maintain paper charts, and then rely on an army of people in each medical records department to fax records back and forth when needed?

        It’s fine for some providers to shun EHRs if they work in private community practices, but for large health care systems, it’s impossible to provide 21st century-level care without them.

        And to BuzzKillerJSmith, try reading the article. The author isn’t saying the EHR is “truly wonderful”, but rather that it isn’t the root cause of the scheduling problems. (And he’s right, it isn’t)

        • Dr. Drake Ramoray

          I think that healthcare could naturally move to an EMR system, and I have thing against EMR per se, I just don’t like what the government and big companies have made them. Similarly I’m not against smart phones, or any technology for that matter. However I would be willing to wage money that the CMSphone would be a horrible product.

          As for the primary article I didn’t respond directly to the author because I never really even considered the EMR as the scheduling flaw in the VA system. I actually found it a little odd that the author felt he needed to defend it. From the get go it has been about “secret lists” I never for a second thought that any of the scandal was a result of the EMR.

          • Eric Strong

            Lying about clinic wait times is not akin to Medicare fraud. No one lied about providing care that was not actually provided. And there was no direct payoff for the secret waitlist in a way that justifies the claim of embezzlement. Here’s what appears to have happened:

            1. VA Central Office issued mandates regarding maximum acceptable wait times for Veterans to be seen by a doctor. These wait times, for some VAs, were impossible to achieve due to an insufficient number of providers.

            2. Failure for a specific VA to achieve the goal wait time looks bad to the Central Office, and brings increased scrutiny to the process at the local VA.

            3. The increased scrutiny from this failure may or may not have some unmeasureable (though almost certainly very small) impact on the overall career trajectory of the local VA’s administration.

            4. Even if there is no direct financial impact, local administrators don’t want to look bad to their superiors in Washington, so they direct clinic staff to create the secret waitlist system.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Just curious, how did they all come up with the same idea for hiding wait times? And if there was only minimal impact on their career, why didn’t they just get on a plane to Washington and raised hell with the Central Office on behalf of their patients?

            And one more thing, do you by any chance know the ratio between total payroll for administrators (of all types) and clinicians at the VA? or even just the one where you work…

          • Dr. Drake Ramoray

            They received performance bonuses for meeting targets that were not achieved. That’s fraud. Not very different than the government auditing people meaningful use claims.

  • May Wright

    Why not require all politicians, including Congresscritters and their families, to use the VA system in lieu of any other? After all, if it’s a True Fact(tm-thingy) that it provides “the best care anywhere”, surely they’d be overjoyed with such a move!

    • ninguem

      You might be a racist for suggesting such a thing.

  • QQQ

    From CNN ” Since 2009, Congress has given Secretary Eric Shinseki
    every penny he has said he needed to fund the VA fully, resulting in an
    astonishing 50% increase in the agency’s overall budget at a time when
    budgets everywhere else across the federal government have been
    squeezed, strained and slashed. Congress even exempted the VA from
    sequestration, a win that not even the Pentagon managed to score while
    still engaged in a war overseas.

    Congress also agreed to take the
    extraordinary step of giving the VA the annual funding it needs to cover
    veterans’ health care a year in advance so that the agency’s hospitals
    and clinics never run out of money. It is the reason the VA’s health
    care system continued to operate without interruption during last fall’s
    government shutdown, even as parks, federal buildings and congressional
    offices were forced to close or curtail operations for weeks.”

    • EmilyAnon

      I think the obvious problem is there’s no oversight for all that money pouring into the VA. So the fraudsters who run the individual hospitals can give themselves unearned raises and exorbitant bonuses with impunity. And probably reap even more goodies for turning a blind eye while their buddy suppliers overcharge. The ease of big ticket swindling of the government is just too tempting to resist.

      • Eric Strong

        Good heavens – doesn’t anyone attempt to read something factual before posting on here?

        VA hospital administrators cannot give themselves raises or bonuses. It is impossible. Period. As a federal employee, their salaries are fixed by the VA central office in Washington. And for the record, their salaries pale in comparison to their non-VA counterparts.

        The director of my Palo Alto VA Health Care System (which operates 1 tertiary care hospital, 2 long-term nursing facilities, and about 10 large clinics spread across half the state of CA) made $179,700 in 2013. (This is a matter of public record, and can be Googled). While this is certainly not pocket change for most Americans, consider the following annual total compensations for CEOs with similar jobs responsibilities (salary + bonus):

        CEO of Kaiser: 13 million (including 5 million dollars in bonuses!)
        CEO of Univ of Pittsburgh: 6 million
        CEO of Banner Health: 3.8 million
        CEO of NYU: 3.5 million
        CEO of Cleveland Clinic: 2.5 million
        CEO of Mayo: 2 million
        CEO of Stanford: 1.9 million
        CEO of UCLA: 1.5 million
        CEO of UCSF: 1.4 million
        CEO of MD Anderson: 1.4 million

        So who exactly has the problem with lack of oversight?

        • EmilyAnon

          Well, somebody got these bonuses.

          “VA Reviewing Bonuses After Awarding $400M in 2011″

          http://www.military.com/daily-news/2012/06/07/va-reviewing-bonuses-after-awarding-400m-in-2011.html

          • Eric Strong

            3.4 million distributed to 231 senior executives (including medical center directors) = $15,000 per person, on average. A lot relative to most Americans, but much much less than bonuses for comparable jobs in the private sector.

            With the remaining 397 million dollars in bonuses divided up among the Veterans Health Administration’s 280,000 employees, that’s a very reasonable $1400 per person.

        • Jenny Jackman

          This goes back to the issue of being unable to recruit staff because of lack f comparable compensation to the civilian sector. I can’t speak for the doctors, but in my area, the compensation for nurses is significantly lower. Nobody who could get a better job in the private sector will apply to the VA, and the ones who do take jobs temporarily leave as soon as a better job opens up. The nursing turnover is pretty phenomenal.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t think they are making out like bandits. I was wondering about the totals, not individual pay, so I get a sense of how much is being spent on administration and how much is being spent on actual care delivery at the VA. I think this is a fair question if the reason for the wait is a shortage of physicians…. maybe they should hire more docs and less clerks….

    • Eric Strong

      The VA wants to hire more docs and nurses all of the time – particularly in parts of the country with a particularly bad mismatch of supply and demand (i.e. Phoenix). The positions are open and the money is there. For example, at times in recent years when we’ve had hiring freezes because of Congressional gridlock over the budget, the hiring of physicians has been exempt. The VA just has problems with recruitment, largely because of things like the waitlist scandal which lead to the public (and potential employees) assuming that VA care is bad, and thus their facilities are bad places to work. This is then reinforced by talking heads on TV news (many of whom have probably never stepped foot within a VA). So even if compensation at a VA is reasonable (which it is for non-procedural MD fields; I can’t speak about nursing and other providers), it’s hard to convince MDs to work at one.

      • Dr. Drake Ramoray

        “….. it’s hard to convince MDs to work at one.”
        I didn’t learn that the VA was a bad place to work from talking heads, TV, or the VA scandal, I learned it by training at an institution that had a VA.

        Perhaps the best way to recruit physicians to work for the VA is to not let us rotate through them as medical students and residents.

        • Eric Strong

          What VA did you rotate through as a student? And which VA do your current patients go to? As with any large health care system, there are good hospitals and bad hospitals. But the best VA hospitals are top tier institutions. To give some specifics, I did med school at NYU, where I rotated (among other places) at both Tisch and North Shore (on Long Island). At the time I was in training, both were rating in the top 10 hospitals in the country by a handful of lists (granted, these rating systems are complete garbage, but they are driven largely by public perception). Then I did residency at Stanford, where I rotated through the Palo Alto VA. There was literally no aspect of the patient care provided by Tisch or North Shore which matched that at the Palo Alto VA – with the exception that North Shore’s food (both patient food and cafeteria) was excellent. There is no circumstance in which I would prefer to receive my care at either of those “top” hospitals rather than where I am now. If you, or anyone else on here ever happens to be in the Bay Area, I seriously would be happy to arrange a tour in an attempt to change your mind.

  • http://twitter.com/skram Mark Silverberg
  • T H

    No, the problem is not the EHR. My not-for-profit hospital uses open-source Vista as its EHR. It has its problems, but for the most part it works pretty well.

    The problems are
    1. 2 weeks was clearly a fatuous goal. Anyone who thought that was possible is caught in the smoke plumes coming from Colorado.
    2. The entrenched beaurocrats cut Shinseki off from real information.
    3. DoD and VA have little to do with each other: there is a serious turf battle and there is no real reason for them to cooperate.
    4. VA providers give good medical care – I’m one of their patients as well as being a doc. I have no complaints about the medical care.
    5. Their senior administrators listen to very few people. “Not my idea = bad idea” pervades the system.

    My suggestions:
    1. Clear, ATTAINABLE goals.
    2. Fire those who were responsible for the clearly deceptive reports.
    3. Censure those who ‘went along.’
    4. Stop the bonuses.
    5. All federal workers above GS-10 and elected officials, including Congress, the Executive, and Judicial get rolled into the VA system.

  • Eric Strong

    It’s hard for me to debate an anonymous poster who cites ancient hearsay from equally anonymous classmates about unnamed VA hospitals as evidence that my place of employment is terrible. But seriously, my offer to give anyone a tour of our facility will stand indefinitely.

  • T H

    “the problem with Vista” :: I hope you mean “the problem with the VA”

    And yes, I agree: that’s why I made the suggestions I did – if those who are creating the problems and the fraud must be part of the system, then they will be less likely to create problems.