Veterans Affairs has a proud tradition of innovation, leading in the 90’s with the groundbreaking Electronic Health Record, VistA, demonstrating that EHRs can be built and challenging the Private Sector to do better. Today, VA is once again poised to lead healthcare providers, solving one of the toughest “white whales” eluding the industry – clinically effective continuity of medical care for patients spanning health care institutions. What we have been calling “interoperability”.
Veterans Health Administration, has, until quite recently, been the nation’s largest closed healthcare provider system. It has relied on proprietary, internally developed and maintained software tools to deliver clinical services and operations. VHA operating culture seems committed to individual facility empowerment in pursuit of innovation in quality service delivery. This well-intentioned direction has, unfortunately, resulted in weak central governance and some well publicized breakdowns in service and institutional integrity. Restoring confidence in medical quality, prompt service and disciplined governance have become priorities as the White House has pledged to fulfill the nation’s commitment to Veterans.
Congress has been challenging VA to provide continuity in patient care for Vets transitioning from Department of Defense healthcare to VHA as wounded service men and women are discharged from active service. Oversight committees have been pushing for updated services and improvements in patient experience.
Pressures have been building from all directions to support and sustain change initiatives at the VA.
Now the exciting part. VHA has been mandated to improve patient’s access, convenience and quality by becoming a more “open” healthcare system, enabling Veterans to choose providers from the private sector. Initial implementation has been predictably cautious, heavily controlled and, frankly, designed more to preserve VHA utilization and volumes than to put Vets in control of their healthcare provider choices. But the times are changing. This initiative can and must mature to meet Veteran’s needs in every community. Private sector heath care services can be allowed to join the VHA provider network. Veterans will have more freedom to choose where care is received for convenience and quality, not just for access and availability.
VHA will be expected to assure that Veterans receive high quality care, at reasonable costs, from private sector provider participants and VHA providers in a seamless manner. This will challenge VHA to require robust data reporting; compliance with VHA clinical practices and standards of care; and collaborate to offer Choice to Veterans in ways that can be easily understood and accessed. Private sector providers are likely to be highly motivated to contract with VHA to participate in this program. It offers much needed patient volume, revenue and a compelling service message that will be hard to resist.
Next – change to commercial systems. DoD healthcare operations selected a new hospital and healthcare systems’ clinical software solution, CERNER, as the common basis for military medical operations going forward. In 2017, VA committed to join DoD healthcare by selecting CERNER to replace VistA at VHA hospitals and clinics. Additionally, VA has elected to “join” DoD healthcare systems’ instances of CERNER, rather than building their own, unique versions from scratch. Not only should these decisions accelerate VA hospital conversions and reduce costs, they should also greatly simplify challenges to achieving continuity of patient care between the two systems.
One hopes that DoD and VA together will base clinical content provisioning and ongoing maintenance on the best credible external clinical standards and content available. This is not as easy as it is obvious. There are many “sources of correct, best medical practice” competing for primacy. Furthermore, clinical content is rapidly evolving as medical science advances on so many fronts concurrently. DoD and VA can do enormous good by creating an effective medical content and practice service, monitoring medical advances, curating, implementing and publishing standards as an open resource for all healthcare providers.
So, VHA is actively transitioning from a closed provider network to an open one. Private sector partners should be expected to contractually commit to compliance with a broad framework of clinical practice, data driven governance, and coordination of service offerings/patient experience delivery as a requirement of participation. VHA hospitals are joining DoD healthcare on a commercial platform already in wide use in the private sector. Commercial clinical solution suppliers are actively seeking to support sound clinical interoperability between private sector health service providers and each other. Capabilities to achieve interoperability across all software products are improving.
The experience of working with DoD to share clinical content and tool configurations provides VHA with an opportunity to build real world, pragmatic templates and guidance that can be used to establish similar working relationships with private sector Veteran’s Choice partners. This second initiative will require bridging the challenges of interoperability across differing commercial software products. However, starting the journey with established standards for working across institutional boundaries provides a foundation for taking this tough step.
In summary, VHA, challenged to become an “open” provider network, “interoperate” with DoD and update tools from proprietary to commercial products, is poised to lead healthcare service advancement once again. No other healthcare system commands the scale, breadth of services, social mandate and clout to drive collaboration, coordination and compliance needed to deliver this long-imagined level of patient care. Making seamless medical care happen for our Veterans can make it happen for everyone.