The Veterans Health Administration (VHA) is the largest integrated health care system in the U.S., providing care at 1,240 health care facilities, including 170 medical centers and 1,061 outpatient sites of care, serving 9 million enrolled veterans every year.
The VHA is advancing forward in a number of areas to leverage health IT to change the way patients experience medical care and to improve health outcomes. The VA was one of the earliest pioneers of electronic health records (EHRs), as the agency began its shift from a paper-based to a computer-based records system in the 1980s, although research into an electronic system began a decade earlier. Also in the early 1980s, the VA made its software available without restriction in the public domain to other government and private sector organizations, which offers the use of VistA as the standard-bearer for EHR implementation around the world.
Francine Sandrow, M.D., chief health information officer (CHIO) at the Corporal Michael J. Crescenz Veteran's Affairs Medical Center in Philadelphia, is involved in a number of VHA clinical informatics initiatives. Sandrow is a board-certified emergency medicine physician, and she also is boarded in clinical informatics. In her CHIO role, she works to help facilities realize their potential to help patient populations through the application of technology. Sandrow will be speaking on a panel about digitizing patient engagement at the upcoming Florida Health IT Summit, being held at the Hilton St. Petersburg Bayfront July 24-25.
Currently, Sandrow is involved with the VA’s work to standardize instances of the VA’s EHR, known as VistA, in preparation for the roll out of a new Cerner EHR platform, scheduled to be deployed at three sites in Washington state by 2020. The VA signed a contract with Cerner in May, and the entire deployment could take 10 years to complete. “We are working to standardize our tools and our workflows. When they deploy the Cerner EHR, if the workflows are similar across the VA, it will take less work for the deployment at each facility,” she says.
While the Cerner EHR deployment grabs the headlines, the VA healthcare system is moving forward with many innovative IT initiatives, both at the national and local level. Just this past June, President Donald Trump signed the Veterans Affairs’ Mission Act into law, which will provide more than $50 billion in federal investments to the VA’s healthcare system. Major provisions of that law included an expansion of telehealth services to veterans (passed by Congress as the Veterans in E-Health and Telemedicine Support Act of 2017, or VETS Act). These provisions allow a licensed healthcare professional of the VA to practice his or her profession using telemedicine at any location in any state.
“This gives the VA an incredible opportunity, as it’s allowing a veteran to have telehealth visits with any VA provider, regardless of where the patient is or where the provider is,” Sandrow says, noting that state licensing laws and policies have been a major barrier to the practice of telehealth. “Congress basically obliterated that barrier for the VA and our Office of Connected Care has developed applications to allow telehealth to be provided pretty seamlessly. I think that the VA model is actually going to be one that’s going to be looked at by community providers. It’s amazing that we now we have a network throughout the country of all these providers who can see patients anywhere.”
Sandrow notes that there are significant advantages to working in the VA healthcare system to advance health IT initiatives.
“I think I’ve had opportunities here because of the size of the organization, opportunities that you just don’t get in your typical community hospital or even academic institution,” she says. “One of the things that I think people don’t realize is that the VA is the single-largest graduate medical education provider in the country. Most of our major VA centers have academic affiliates and we have agreements where research is done across the two institutions. In Philadelphia, our academic affiliate is the University of Pennsylvania. Our research department is fairly large, and we have a lot of grants that are coming in, and that leads to unique opportunities for us.”
Sandrow points to a project she was involved in that was a collaboration between the VA and IBM Watson Health. “For that project, I was able to work with our human factors engineering team, and that project focused on identifying patients who were at-risk for post-traumatic stress disorder, but who had not actually been diagnosed with it. Through this project, they were identifying patients at-risk by simply feeding their charts into the engine of Watson. I think working within the VA, whatever your interest is in, as long as its improving veteran care, you have opportunities to grow. It’s exciting.”
In a separate collaboration, this week, the VA announced it was extending its partnership with IBM Watson Health to apply artificial intelligence to help interpret cancer data in the treatment of veteran patients. First announced two years ago as part of the National Cancer Moonshot initiative, VA oncologists have now used IBM Watson for Genomics technology to support precision oncology care for more than 2,700 veterans with cancer, according to a press release.
VA treats 3.5 percent of the nation's cancer patients—the largest group of cancer patients within any one healthcare group. VA established a central “hub” in Durham, North Carolina where a group of oncologists and pathologists receive tumor samples from patients nationwide and sequence the tumor DNA. They then use AI to help interpret the genomic data, identifying relevant mutations and potential therapeutic options that target those mutations. More than one-third of the patients who have benefited from VA's precision oncology program are veterans from rural areas where it has traditionally been difficult to deliver cutting-edge medical breakthroughs, according to the VA.
Driving Innovation on Many Fronts
Sandrow also notes that the sheer size of the VHA can be a barrier to clinicians and IT leaders sharing best practices. To address this issue, the VHA initiated a Shark Tank-style competition to identify best practices to improve veterans’ health care. According to the VHA website, this past January, 10 winning ideas were selected from among 19 finalists for the first Shark Tank competition. Champions for each of the 10 practices completed a six-month facilitated replication at one or more VA facilities, adapting and implementing their programs, leading to gold status practices being replicated at over 40 sites.
“Many of these projects are going on to be funded, developed and deployed throughout the country. I think we have a lot of ground-breaking processes that we’re working on and that you’re seeing being reflected in the community hospitals,” Sandrow says.
Sandrow also points to the VHA’s Life-Sustaining Treatment Decisions Initiative (LSTDI) as another industry-leading effort. LSTDI is a national VHA quality improvement project led by the National Center for Ethics in Health Care (NCEHC) with the aim of promoting personalized, patient-driven care for veterans with serious illness by eliciting, documenting, and honoring their values, goals, and preferences. The initiative involves a new national policy to standardize practices related to discussing and documenting goals of care and life-sustaining treatment decisions, and the tools, resources, education, and monitoring to support clinicians and facilities in making practice changes.
VA is the first health care system in the world to develop and implement practices and related tools across the health care system, setting a new standard for discussing and documenting treatment decisions with high-risk patients, according to the VA.
“When people reach the end of life, whether it’s a natural end of life or they have developed a terminal condition, there are decisions that have to be made, and medicine, as a whole, does a very poor job of handling those discussions,” Sandrow says. “The VHA has developed an entire program to not only document patients’ preferences, but to provide patients, through our palliative care providers, support and assistance at that difficult time in the patient’s life. When you are treating a patient, you’re also treating their family, and the end of life is one of hardest times for the family as well.”
VA healthcare leaders are also focused on advancing population health management efforts, particularly to improve preventive care measures. Through a partnership with Walgreens, veterans can receive immunizations, such as flu vaccines, at any Walgreens location and the immunization records are electronically shared with the VA and then connected to the patient’s VA medical record. Both Walgreens and VA are participants in the Sequoia Project’s eHealth Exchange, a health data sharing network, which enables veterans’ medical records to be integrated. According to Sandrow, this data sharing effort enables the immunization records from Walgreens to be reconciled with VA providers’ clinical reminders, enabling them to more effectively provide patient-centered care.
“Another area that we’re working on right now is that we are working to identify high-risk populations,” Sandrow says. “We have a tool that identifies, via a CAN (care assessment need) score, that estimates the probability that a patient is going to have a significant hospitalization or death within the next 365 days. We can use that score to find people who are being underserved. If you have someone who has a really high CAN score, but has a low cost to the VA, then we may be missing opportunities.”
She continues, “Because our EHR addresses all aspects of that patient’s care—primary care, inpatient, mental health—we have an advantage, I think, over many of the community organizations. What we’re trying to do now is to bring together the data that we have and the risk factors that we can identify to improve care, across the board, to our patients.”