VA’s Secretary Shulkin wants more private care options for veterans as part of reforms

Released days before our Thanksgiving turkey (or steak, or lasagne), the Department of Veterans Affairs Secretary David Shulkin, in an interview with The Wall Street Journal (paywalled), stated his aims to increase veteran access to private care without having to rely on the VA to approve or coordinate it. This is in the direction of the recently signed bill with $2.1 bn in funding for the Veterans Choice program that targets veterans living in areas without ready access to VA facilities, or who are told they cannot get an appointment within VA within 30 days.

“The direction I’m taking this is to give veterans more choice in their care and be the decision maker for their care, which I fundamentally believe is a concept that has to be implemented,” Shulkin said. He admitted that opening the VA to private care programs will be gradual. Mentioned in the article were commodity, non-urgent services like podiatry and audiology.

For instance, the Veterans Choice program started in 2014 after wait times exploded in multiple regions, delaying care past 30 days for over half a million veterans for years well into 2015. Veterans died after waiting for care or follow up for months, notably at the Phoenix VA, creating a massive and rightfully political problem. 

Dr. Shulkin’s drive for reform and speed of care is also increasing the pace telehealth expansion with programs such as Anywhere to Anywhere which would allow cross-state consults and care that published their Federal proposed rule last month, and the rollout of VA Video Connect [TTA 9 Aug]. Earlier this year, four companies were awarded a total of over $1 bn to provide Home Telehealth over five years, reviving a fading program and updating it to not only smaller in-home tablets, but also to mobile and laptop devices. As noted in our OnePerspective article on telemental health deployment, the VA has the largest program in the US, dating back to the early 2000s.

While some veterans organizations, such as the Veterans of Foreign Wars, have been critical of moves towards integrating private care, this Editor cannot see where the problem truly is. Healthcare Dive, The Hill 

Proposed rule issued for ‘VA Anywhere to Anywhere’ telehealth cross-state care

The Department of Veterans Affairs ‘Anywhere to Anywhere’ program, which would enable VA doctors to treat VA patients across state lines via telehealth and telemedicine, yesterday (2 October) published in the Federal Register the required Federal proposed rule. There is a mandated 30-day comment period (to 1 Nov). In the Federal government, these rules move faster than any legislation. From the rule: “VA has developed a telehealth program as a modern, beneficiary- and family-centered health care delivery model that leverages information and telecommunication technologies to connect beneficiaries with health care providers, irrespective of the State or location within a State where the health care provider or the beneficiary is physically located at the time the health care is provided.” PDF of rule.

VA Home Telehealth has both doctor-to-patient telemedicine and vital signs remote monitoring components. While VA is fully able to waive state licensing requirements if both the physician and the patient are in a VA clinic, because of state telemedicine laws they have not been able to provide the same care for veterans at home. VA also has a care distribution problem, with many veterans living in rural areas, at great distances from VA facilities, or with limited mobility. What this will enable is VA hiring in metro areas primary care and specialist doctors to cover veterans in rural or underserved areas and the expansion of mental health care. It also will facilitate the rollout of the VA Video Connect app for smartphones and video-equipped computers now in use by over 300 VA providers [TTA 9 Aug].

The VETS Act (Veterans E-Health and Telemedicine Support Act of 2017, S. 925) would permanently legislate this, but in the US system this type of Federal rule, in this circumstance, moves faster.  Fierce Healthcare, Healthcare Finance, mHealth Intelligence 

VA EHR award to Cerner contested by CliniComp (updated)

See update below. CliniComp International, a current specialized EHR vendor to some Department of Veterans Affairs locations and to the Department of Defense for clinical documentation since 2009, has filed a bid protest in the US Court of Federal Claims on Friday 18 Aug, saying that VA improperly awarded a contract to Cerner in June [TTA 7 June] without a competitive bidding process.

At the time, VA Secretary David Shulkin moved the award via a “Determination and Findings” (D&F) which provides for a public health exception to the bidding process. Without this, competitive bidding could take six to eight months, as Dr. Shulkin stated to a Congressional committee after the award–or two years, as DoD’s did–and would have further slowed down the already slow adoption process. Even if all goes well, the transition from VistA to Cerner will not begin at earliest until mid-2019 [TTA 14 Aug]. The Cerner MHS Genesis choice was also logical, given the Federal demand for interoperability with DoD. In June, the House Appropriations Committee approved $65 million for the transition, provided that VA provides detailed reports to Congress on the transition process and its interoperability not only with DoD’s but also private healthcare systems.

CliniComp objected to all that, saying in the protest that VA had enough time for an open bidding procedure, that the failure to do so was “predicated on a lack of advance planning,” and that awarding it to Cerner without it was “unreasonable”. “As shown by the nine counts set forth below, the VA’s decision to award a sole-source contract to Cerner is arbitrary, capricious, an abuse of discretion and violates the CICA and Federal Acquisition Regulations,” according to the suit.

According to Healthcare IT News, “CliniComp said it filed an agency-level protest to contest the sole source award shortly after the announcement, according to the complaint. But the VA Deputy Assistant Secretary for Acquisition denied the protest on Aug. 7. In doing so, the VA violated the Competition in Contracting Act of 1978, the company claims.”

This is not CliniComp’s first bid protest. Before one dismisses the bid protest as sour grapes picked by a minor vendor, this Editor discovered via Law360 that CliniComp was successful in a VA bid protest in August 2014. In this case, VA had a $4.5 million contract for computer systems at several intensive care units for saving patient waveform biometrics. The VA’s award to Picis in October 2013 was overturned because the Court of Federal Claims found that in clarifying the CliniComp bid, VA never had official discussions with CliniComp, only informal requests for clarifications. The court found that the two bids were not evaluated the same way–and that likely both were acceptable, with CliniComp’s bid preferable because it was lower. (More on CliniComp and its 30-year history here)

Update. Arthur Allen in POLITICO Morning e-Health also did his homework and found the same Law360 article on CliniComp’s 2014 bid protest win, adding the following:

  • DoD and VA officials have complained that CliniComp’s software is not compatible with legacy systems. However, some IT experts have noted that neither DoD nor VA can provide platforms which can be interoperable with Cerner. (Circular firing squad?)
  • Oral arguments are set for 2 October, if necessary, after motions are filed next month. Cerner joined in the defense against the protest as of Monday. 

Will the brakes be put on Cerner’s work while the protest wends its weary way through the Federal Claims Court? The bid protest is high-profile embarrassing for VA, though the D&F is completely legal. Stay tuned. Also Modern Healthcare, KCUR, Healthcare Dive

VA unveils several ‘anywhere’ new telehealth services for veterans

The new Veterans Affairs Secretary, David Shulkin, has wasted no time since his appointment in introducing several technology and mobile-based services at the VA, all of which are long overdue in this Editor’s estimation:

  • Anywhere to Anywhere VA Health Care will authorize telehealth consults and cross-state care for veterans no matter their location and regardless of local telehealth restrictions. VA is already the largest provider of telemedicine services (called VA Telehealth) in 50 specialties to 700,000 veterans annually. This new regulation will enable VA to hire primary care and specialist doctors in metro areas to cover veterans in rural or underserved areas. 
  • Rolling out nationally over the next year is the VA Video Connect app where veterans can use their smartphones or home computers with video connections to consult with VA providers. At present 300 VA providers at 67 hospitals are using it.
  • The Veteran Appointment Request (VAR) app will also roll out from its test. It will enable veterans to use their smartphone, tablet or computer to schedule or modify appointments at VA facilities nationwide.

Dr. Shulkin advocated these programs while undersecretary, especially ‘Anywhere to Anywhere’, which required advice from the Justice Department. VA’s technology is also being supported by the American Office of Innovation to improve care transitions between the Defense Department and VA. 

President Trump participated in the announcement with Dr. Shulkin and sat in on between Albert Amescua, a 26-year Coast Guard veteran at a VA clinic in Grants Pass, Ore., and Brook Woods, a VA internist in Cleveland. VA announcement with videos, POLITICO Morning eHealth, HealthcareITNews

Iron Bow partners with Vivify Health for $258 million VA telehealth contract

One mystery solved! Iron Bow Technologies announced that its telehealth delivery partner for their award of $258 million in the Veterans Affairs Home Telehealth program is Plano, Texas-based Vivify Health. As noted in our original article [TTA 6 Feb] on the much-delayed VA remote patient monitoring award, Iron Bow was an existing contractor in other VA Telehealth services, Clinical Video Telehealth (video conferencing) and Store-and-Forward (clinical imaging review), but did not have vital signs RPM capability. The addition of Vivify with its mobile and tablet-based solutions and integrated peripherals adds that capability.

Vivify structures its main telehealth solutions based on escalating patient ‘risk’: 1) healthy and ‘at risk’ (may have early stage disease), 2) rising risk (has complex chronic disease) and 3) high risk (for hospitalization). The approaches are scaled up from engagement on BYOD mobile and web for (1), to vital signs monitoring and telemedicine clinician visits via mobile and tablet (2), to the highest level of an integrated kit with tablet and integrated peripherals (3). These further divide into five ‘pathways’ which are more product-oriented.

Cost is, of course, a factor, with VA a very demanding client in this regard as individual VISN (region) budgets are tight. Medtronic, the incumbent, has not only been using the venerable Cardiocom Commander Flex hub, but also provides VA with Interactive Voice Monitoring (IVR) which is an inexpensive patient management solution. (Ed. note: having worked with IVR in the past, it can work well if used with primarily lower-risk patients, is structured/implemented properly and integrated with live clinical check-ins.) Vivify’s system is all new–and not inexpensive, especially at the high-risk level. From their website, Vivify uses BYOD for the lower levels and the integrated kit for the highest and poorer outcome patients. This Editor notes they offer a voice telephony care solution which presumably is IVR. This gives them a welcome flexibility in price, but also a complexity which will be a training issue with VA care coordinators.

Other factors affect mobile-based solutions. Many at risk at-home veterans are older and thus don’t have smartphones or tablets. Reliable broadband connectivity is also an issue. Many don’t have Wi-Fi, which is a prerequisite for tablet use, and may live in areas with poor cellular reception.

The other work and labor-intensive parts for Vivify and Iron Bow are to integrate their reporting platform into VA’s complex and secure systems, which also involves a highly structured updating process: CPRS (computerized patient record systems), the VistA EHR and whatever replaces it (Epic is being trialed in Boise, Idaho–scroll down to ‘Big Decisions’ and Dr Shulkin).

Founded in 2009, Vivify has compiled an impressive track record with CHRISTUS Health (TX), RWJ Health (NJ), Trinity Health (MI), Centura Health (CO) and other large systems plus home care. It has also been conservative in its venture funding, with $23.4 million to date and its last big round from LabCorp and others in 2014 (CrunchBase).

Release. Hat tip to Vivify’s Bill Paschall via LinkedIn.  P.S. Stay tuned for an announcement of 1Vision’s partner. 

Editor’s clarification: The VA Home Telehealth contract is structured as a one-year base period, followed by four one-year optional periods, for five years total. The awarded amount over the five-year period is $258 million for Iron Bow/Vivify. It is the same amount/term for each of the three other awarded companies, totaling just over $1 billion for the five-year program. This is comparable to the 2011 five-year program value of $1.3 billion divided over six awardees. Thanks to Josie Smoot of Iron Bow Technologies’ press office.

Can expanding telehealth help VA solve veteran access crisis?

The Department of Veterans Affairs (VA) has been both one of the largest US users of telehealth in various forms–and widely criticized for practices including veteran patient wait lists for care, a lack of accountability, a scheduling system full of problems, an ancient EHR (VistA), and an inability to meet interoperability and modernization goals set over years. Telehealth is, in fact, one of VA’s bright spots with store-and-forward imaging, clinical video telemedicine and home telehealth.

At the American Telemedicine Association ATA 2016 meeting Monday, Under Secretary for Health and VA Chief Executive Dr. David Shulkin noted that the crisis has pushed VA into other options for achieving the goals set for the end of year: every VA medical center provides same day primary care services and same day mental health services. One area of focus is telemental health. Dr Shulkin announced in his plenary speech the opening of five new Mental Health Telehealth Clinical Resource Centers this summer, located in Charleston, Salt Lake City, Pittsburgh, and a consortium of facilities in Boise, Seattle, and Portland, Oregon. West Haven, Connecticut is already open as a specialty hub focused on the most severe and complex mental health issues, such as chronic depression and bipolar disorder. Other VA telemedicine initiatives include kiosks and text messaging to help with medication adherence and chronic condition management. (We’ve reported on their partnering with nhssimple to develop ANNIE, a sister of NHS’ Flo in text messaging to encourage patients in their health monitoring, TTA 2 Dec 15.)

VA delivered 2.1 million episodes of telehealth care last year (FY 2015), in 45 specialty areas of care, including 400,000 telemental health visits. They also reduced bed days by 56 percent, reduced readmissions by 32 percent, and decreased total psychiatric admissions by 35 percent, maintaining high user satisfaction scores at 89 percent.

Dr Shulkin also noted that four generations of veterans are served by VA–WWII, Korea, Vietnam and Desert Shield through current Iraq/Afghanistan–and all four have different delivery requirements. He closed with what is, for VA which has been very proud of their ‘home grown’ solutions from the time of Dr Adam Darkins in the early 2000s on, something unusual: “We’re looking to learn, we’re looking to work with all of you who are innovating to help take better care of veterans.” (Next on tap: the award of the next five-year round of home telehealth providers, which is presently down to two Grizzled Pioneers, Medtronic (Cardiocom) and Viterion.) MobihealthnewsVA press release

Mississippi to get VA telemed pilot amid controversy

Mississippi has led the way in telemedicine projects in southern USA for some time with the University of Mississippi Medical Center’s various successful projects [grow_thumb image=”http://telecareaware.com/wp-content/uploads/2015/10/Dept-of-VA-logo.jpg” thumb_width=”150″ /]attracting well deserved funding. Now the US Secretary of Veteran’s Affairs has announced that a new pilot programme to use telemedicine to reduce wait times for new patients at VA hospitals will take place in Mississippi.

This pilot programme comes in the wake of the highly criticised wait times reported for new patients at VA hospitals in 2014. A CNN report based on internal VA documents claimed that thousands of veterans had to wait more than three months to see a specialist.

(more…)

Veterans Affairs boosts telehealth, HIT in proposed 2016/2017 budgets

The US Department of Veterans Affairs (VA), in its proposed 2016 budget released earlier this week, is increasing support for telehealth/mHealth along with programs that use these services–rural health and mental health. Telehealth’s VA budget from FY 2014 increased from $986 million to just below $1.1 billion in the current year. In FY 2016 (beginning 1 Oct), the VA is allocating $1.22 billion of a $56 billion budget, and in 2017 advance appropriations, $1.37 billion–a year-to-year increase of 11 percent and 12 percent respectively .

VA has the largest telehealth program in the US, divided into three main functional areas: (more…)

Reforms, restructuring at Veterans Affairs announced (US)

A new Secretary, but the same old process? New Secretary of Veterans Affairs (VA) Robert McDonald is quickly finding out that cleaning house at a government agency is not quite as straightforward as at Procter & Gamble, where he had been CEO. Since being confirmed by the Senate in late July, he has had to fight the fires of multiple scandals, beginning with the Phoenix VA ‘secret’ veterans care wait list leading to uncovering disastrous delays in care at VA regions across the nation. As of this week, and convincingly timed around Veterans Day, McDonald announced a reorganization of the VA to the Washington Post–a restructuring of the VA around the creation of:

  • A new customer service organization across the entire VA, headed by a “chief customer service officer” reporting to McDonald
  • A standardized regional framework meant to streamline partnering and coordination
  • Realignment of internal business processes into a shared services models to improve efficiency, reduce cost and increase productivity
  • Collaboration with partners to create a national network of Community Veteran Advisory Councils

Heads are rolling, but slowly. There are pending disciplinary actions affecting at least 35 employees and perhaps as many as 1,000 employees upcoming. (more…)

VA, DoD aren’t collaborating on EHR: GAO

Your ‘Dog Bites Man’ item for the weekend (no, it’s not in reverse!) is that the Government Accountability Office (GAO) has determined that Veterans Affairs (VA) and the Department of Defense (DoD) have not yet proved that their current two-system path, having rejected a single EHR, actually will be workable. In February 2013, both agencies abandoned a joint system after $1 billion in spend, and $4 billion in fixes/upgrades to their separate VistA and AHLTA systems. [TTA 15 Dec] By the two agencies going their separate ways, the GAO is mystified on what is going on with interoperability. The answer: not much. And as mentioned in our 15 December article, there was a 31 January deadline for an interoperability plan (or single system) to be implemented by 2016, mandated by the 2014 National Defense Authorization Act (NDAA). Obviously, this deadline has come and gone. FierceEMR article, GAO recommendation (full text PDF)

One way to overcome the interoperability problem and too much in the EHR? Get rid of those pesky backlogged patient records! The Daily Caller uncovered a VA whistleblower’s complaint to the VA’s Inspector General and their office of special counsel, plus Congress, that VA officials in Los Angeles intentionally canceled backlogged patient exam requests going back more than one year–and that the delay on exams went back 6-9 months. The deletions started in 2009. There is a wrongful dismissal (of said whistleblower) suit and other joy. Article, audio (02:21) Updates 3-4 March:  according to Under Secretary for Health Robert Petzel, the Daily Caller report was ‘scurrilous’. He stated that about 300 records were closed but not deleted after administrative review, generally for old imaging requests, and there was no effort to delete records to boost performance.  According to FierceHealthIT, the backlog is about 400,000. Also Military Times. According to EHR Intelligence, both DoD and the VA agree with the GAO recommendations; GAO will update its findings once the agencies have taken action. Also iHealthBeat.

Mental health apps for veterans (US)

The US Department of Veterans Affairs (VA) has signed a 12 month contract with Chicago-based Prevail Health Solutions to further develop the Vets Prevail online supportive behavioral health program in 2014. In development for five years in various pilots, it has corporate support from Goldman Sachs Gives, the Robin Hood Foundation. the Bristol-Myers Squibb Foundation and PepsiCo. Vets Prevail is an online program using Cognitive Behavioral Therapy (CBT)-based e-learning lessons and peer-to-peer support, also routing into select established Veterans Health Administration resources. Mobihealthnews profiles the 10 apps Prevail is using plus others that the VA has developed such as PTSD Coach, smoking cessation app Stay Quit Coach and Care4Caregiver.

VA distributing iPads to Family Caregivers (US)

Back in May 2012 we noted a Veterans Affairs (VA) program for 2013 that would distribute 1,000 iPads to primary caregivers of seriously wounded veterans to facilitate care delivery and data transfer. Then called ‘Clinic-In-Hand’, it is now officially debuting as the Family Caregiver Pilot for caregivers of seriously injured post-9/11 veterans already enrolled in VA’s Family Caregiver Program. The intent is now more clearly focused on reducing caregiver stress, via  pre-loaded apps to share health information, coach patients through chronic pain and PTSD and serve up tools such as reminders and a health journal. A second, the Veteran Appointment Request Web App Pilot, facilitates appointment setting via mobile or desktop PCs for a separate test group of 600 veterans and was launched at the Washington, D.C. VA Medical Center and VA Palo Alto (California) Health Care System. According to EHR Intelligence, if successful it will be rolled out to all patients at these two VA centers with a system rollout in the future–complicated by the fact that every VA center has a different scheduling system. Meanwhile, VA’s VistA and the DOD’s AHLTA still don’t talk to each other. VA integrates mHealth into daily care, gives iPads to vets (EHR Intelligence); VA Mobile Health release (for additional details go to the left hand drop-down menu). Hat tip to Contributing Editor Charles Lowe.

Mobile, flexible–but not joint–military healthcare (US)

If two areas of the government have made a great deal of progress in telehealth and mobile health, it is the Department of Defense (DOD) and Veterans Affairs (VA) which jointly are the leading users (and developers) of telehealth. Your Editor has often mentioned the US Army’s Telemedicine and Advanced Technology Research Center (TATRC) as a leader. Of their current 15 mHealth projects, one of the largest is MobileCare. Working jointly with the University of Miami’s William Lehman Injury Research Center at Ryder Trauma Center (where it is being piloted) and University of Central Florida, MobileCare is a smartphone interface for patient documentation into EHRs using intuitive data entry and voice recognition; mobile learning and point-of-care information; and telemedicine (audio/video consults). Miami’s staff designed the user interface, learning content and programmed interfaces, while an IT team at the University of Central Florida is assisting with mobile development.  Mobile Healthcare Is Solving Major Problems for Military Doctors and Nurses (FedTech)

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2013/03/Flexible-Electronics-on-Plastic-425×303.jpg” thumb_width=”175″ /]The Army Research Laboratory (ARL) located at the Flexible Display Center at Arizona State University is pioneering flexible, thin, low-power plastic displays, about 1/16 inch thick, for use in battlefield devices. These are designed to be worn on every soldier’s sleeve, on the side of an armored vehicle or used in monitors that need no ruggedizing–produced using commercial methods and thus (relatively) inexpensively. The potential for medical devices, smartphones and tablets is substantial if translated quickly to commercial use. Imagine Samsung’s flexible smartphone at CES 2013, the much-heralded iWatch/iPhone combo and even the cutely colorful and crowdfunded EMBRACE+ bracelet smartphone notifier on steroids. Future Soldiers Will Have Flexible Electronics Everywhere (Armed with Science)

Thus it is doubly disappointing when DOD and the VA, who declared their fine intents to develop an integrated EHR (iEHR–another acronym) to be implemented by 2017, have declared to Congress that the project has come to a screeching halt after 1 billion in taxpayer dollars. DOD might use the VA’s Vista EHR–or not. As the Magic 8 Ball says, ‘hazy, try again’. DOD, VA Face Questions Over Halting of Joint EHR Project (iHealthBeat)

VA losing CIO, CTO (US)

The US Department of Veterans Affairs (VA) has two critical vacancies, just announced: CIO Roger Baker and CTO Peter Levin are both leaving the agency after three years. Their resignations come in the midst of major initiatives: Levin’s ‘Blue Button’ PHR (personal health record), mobile telehealth technologies for suicide prevention and oncology; Baker’s adoption of mobile devices and streamlined claims processes. The VA is also coping with the thousands of Iraq and Afghanistan veterans flooding into the system requiring high levels of care, as well as aging  veterans of the Korean, Vietnam and Gulf (I) Wars. No word in this article on what will come next from either Baker or Levin, or the VA, which is unusual. Healthcare IT News