Office of Public and Intergovernmental Affairs

Remarks by Deputy Secretary Sloan Gibson

Armed Forces Communications & Electronics Association Inaugural Health Summit
Washington, D.C.
July 31, 2015

Last summer — at the peak of VA’s access crisis — Dr. Harvey Fineberg came to see me. He’d just stepped down after 12 years as president of the Institute of Medicine.

I told Dr. Fineberg that because of the crisis, VA could accomplish more in two-to-three years than we otherwise could have done in two-to-three decades.

Dr. Fineberg corrected me immediately — he said, “VA can accomplish things now it never could have accomplished!”

He’s right — we’ve never had an opportunity like this.

So I want to talk about change, about transformation on a large scale, and about technology — that critical enabler for consistently delivering high quality healthcare outcomes.

Think what it would take to overhaul a massive healthcare system in the private sector — transforming business processes, reallocating resources, and implementing organization-wide cultural change.

Now, imagine doing all that in the Federal Government — in the second largest agency in government.

Let me tell you some things about VA you may not know.

We have 9 lines of business.

Eleven million Veterans are registered, enrolled, or use at least one VA benefit or service.

We provided 4 million Veterans and survivors compensation for disability totaling $58 billion last year and assisted another 100,000 disabled Veterans with vocational rehabilitation and employment benefits.

We provide Post-9/11 GI Bill benefits to 1.4 million Veterans and family members.

We have the lowest foreclosure rate in the industry on the 2.2 million home loans guaranteed by VA — a $100 billion portfolio.

VA is the Nation’s 10th largest insurance enterprise — $1.3 trillion in coverage.

Our National Cemetery Administration (NCA) oversees 132 National Cemeteries. For the past decade, the American Customer Satisfaction Index — ACSI — has ranked NCA the top customer-service organization in the Nation, public or private.

We have more than 340,000 employees — a third of them Veterans — and a budget of $169 billion.

And I haven’t even gotten to healthcare.

VA’s the largest integrated healthcare system in America — over nine million Veterans enrolled.

We employ 23,000 doctors, and our 91,000 nurses make VA the largest employer of nurses in the country.

These professionals deliver everything from primary care to complex specialized procedures like organ transplants and neurosurgery.

Most Veterans are satisfied with VA healthcare. ACSI has reported since 2004 that Veterans receiving VA healthcare give us higher satisfaction ratings than patients receiving care in private hospitals — inpatient and outpatient.

Last year, the Joint Commission recognized 24 VA medical centers as “top performers.”

We compare favorably to and outperform private-sector counterparts in many categories of patient outcomes. We exceed private hospitals in prescribing Beta-Blockers after a heart attack, controlling high blood pressure, and conducting colorectal cancer screening. Veterans have a lower risk of dying of heart failure in their VA hospital than in the private-sector. And VA hospitals match or are better than the best private hospitals for patient safety and preventing hospital-acquired infections.

I could cite other examples of VA leadership in important areas. But as long as even one Veteran waits too long for care or benefits, we still have room to improve.

And one of the most tangible opportunities we have to make truly transformational, revolutionary change is in the realm of health information technology.

VA’s ability to advance functionality in healthcare delivery to the levels necessary to serve Veterans is encumbered by many examples of legacy IT systems on which we continue to rely.

To complicate matters, the more we layer functionality over legacy systems to meet immediate needs, the more we compound our technology debt.

Let me show you graphically what technology debt looks like. This is the technological structure in which our Veterans Benefits Management System operates — to which we had to adapt it. What you see here is the outcome of a failure to migrate out of legacy systems. It’s about not managing to an IT architecture future.

Here’s another example. VistA has been the flagship electronic health record for the entire industry. The Chief Information Officer of one of the most highly regarded healthcare systems in the United States said that VistA’s “still out front in average implementation of an electronic health record” in what matters most to VA – caring for Veterans and research. Results reporting, facility interoperability, physician entry standardization, and facilitating distant healthcare are staples.

But we’re our own worst enemy. Facility by facility, more than 120 different VistA versions have evolved since its inception. We became facility-centric rather than Veteran-centric.

That means a Veteran registered at Charles George VAMC in North Carolina can’t transition seamlessly to treatment at Orlando’s new VAMC.

That means that a Veteran vacationing on the west coast can’t fill a prescription ordered on the east coast.

It means that the first thing the new Secretary saw a year ago when he visited Phoenix — the epicenter of the access crisis — is the scheduling platform our employees were enduring (VistA – multiple Clinic Booking).

Now, our new VistA scheduling enhancement on the right (VSE GUI) is a lot better than what we had, but it’s still not leading edge. It represented a 15 to 20 year leap in technology, but we’re still about a decade behind. And that small, really simple change vastly improves not just the employee’s experience, but the Veteran experience.

Notwithstanding these challenges, VA is both committed to and progressing rapidly in bringing cutting-edge healthcare applications to Veterans so we can improve the Veteran experience.

We’re here to talk about healthcare, but our Veterans Benefits Administration (VBA) and Veterans Benefits Management System (VBMS) is a logical place to begin — since eligibility determinations are the first step to providing Veterans care and benefits.

In the course of about four years under Allison Hickey’s leadership, VBA has effected the biggest organizational change in its history, a massive transformation. I challenge anyone to match their progress in speed or quality, in either the public or private sector.

You’re familiar with VA’s claims backlog — so you know the kinds of challenges Allison faced.

Central to VBA’s transformation has been the agile, incremental development of their Veterans Benefit Management System, or VBMS — the web-based, electronics claims processing solution.

Backlogged claims peaked at 611,000 in March 2013. Since the peak, there’s been an 81 percent reduction in backlogged claims — it’s at the lowest it’s been since we started keeping track back in 2007. Claims inventory is the lowest since 2008, and productivity has risen by 67 percent since 2009.

In 2013, they completed a record-breaking 1.17 million claims. In 2014, they beat that with another record year of 1.32 million claims. And they accomplished all that while increasing claim-level accuracy from 83 percent in 2011 to 91 percent today and bringing the issue-level accuracy to 96 percent.

In addition to reducing the claims backlog dramatically, VBA’s going fully digital — a by-product of VBMS. They’ve gone from touching 5,000 tons of paper each year to processing virtually all disability claims electronically. Because the majority of the claims inventory is digitized, they can start converting regional offices to fully electronic processes — faster, more productive, more accessible information and better quality determinations. And paperless claims process means we’re positioned to adopt a national workload strategy that’s boundary free — increased production capacity, increased consistency, and minimized wait times.

VBMS is an example of best-in-class innovation, design, and deployment of IT systems. Agile software development delivers VMBS upgrades every three months — responsive to unique requirements as they emerge. That’s an example of what technology means to transformational efforts.

With DoD’s announcement of the Cerner-Leidos-Accenture team for their electronic health record contract, I should say a few things about interoperability. Interoperability is not new between VA and DoD.

Few know that we already exchange millions of pieces of health information with DoD over our Bidirectional Health Information Exchange — some 7.4 million exchanges last quarter, which is a million more than the quarter before that.

Few realize that our e-Benefits platform is a joint VA-DoD web portal where Servicemembers, Veterans, and families can find, access, research, and manage benefits — and that includes electronic claims submissions. Blue Button already provides Veterans on line access to their health records and the ability to share those records with other doctors.

Beyond e-Benefits, the DoD-VA Joint Legacy Viewer (JLV) represents groundbreaking agency-to-agency interoperability. JLV combines and shares data and gives both Veterans Health Administration (VHA) clinicians and VBA rating specialists a composite view of Veterans’ treatment history.

We launched JLV in October 2014. Less than a year later, there are nearly 13,000 VA or DoD users. We’ll see a quantum leap in that number when DoD expands JLV in October.

Now, JLV is a great tool. You query it — and it goes out and gets the information you asked for. But it’s nothing like the Enterprise Health Management Platform (eHMP) we’re launching to replace JLV next March.

Here’s an example of what eHMP can do. Care teams can cache all the data for their day’s entire slate of appointments. That means for each patient, the team can see all quality care data — data from across the VA system, data from DoD systems, and any data community providers have shared.

Right now, if a Veteran needs orthopedic surgery, it takes a manual system-by-system search to collect the data necessary to determine whether the patient can sustain the rigors of surgery.

With eHMP, the care team can search patient data with the even the vaguest queries — like CAD — Coronary Artery Disease. With that general search, providers will see every instance of CAD-related care in the patient’s history.

You can see if the Veteran was treated with CAD meds. You can see if the Veteran had a heart attack eight years ago. You can quickly find every instance of cholesterol management.

Even with JLV, you just can’t achieve that speed, granularity and precision.

eHMP is the kind of transformational technology I’m talking about — expanding our capacity to see the whole person rather than addressing a single symptom in isolation.

By the way, the Vista Scheduling enhancement starts fielding this fall and eHMP begins a phased roll out early next year.

Here’s some more innovations changing how we provide care to Veterans. We’re aggressively using technology to expand Veteran access.

Our Distance Hearing Aid Fitting App links into Bluetooth, so an audiologist in a distant clinic can remotely make hearing aid adjustments for Veterans in their home — or anywhere there’s WiFi.

Remember the Veteran I mentioned on the west coast with the east coast prescription?

Telehealth is one of our most significant transformational initiatives to provide convenient, accessible, Veteran-centric care. Since 2002, VA telehealth has provided care to over 2.1 million Veterans. Today, nearly one-third of Veterans receive care virtually through channels such as tele-health, eConsults, and secure messaging.

Home-based telemental health applications give Veterans flexible access to mental health services. It reduces cancelled appointments and no-shows and improves clinical outcomes. And for Veterans without access to a personal computer and high-speed internet, we’re providing mobile devices like iPads and netbooks with high-speed cellular broadband to expand the home-based service. We’re using these same technologies to extend services to spinal cord injury, speech, and audiology patients.

Our Perceptive Reach application will use open-source tools and existing VA data to identify Veterans at risk and securely notify support staff who can deliver outreach.

That same application may be modified to identify other health risks.

We’re facilitating patient encounters with advances in secure, encrypted messaging between Veterans and their providers — Primary Care Teams, Specialty Care Teams, Mental Health providers, and pharmacists.

Right now, we have about one-and-half million Veterans using secure messaging — completing 900,000 secure messaging encounters every month.

Our Veteran Appointment Request app — developed, piloted, and soon to be deployed — will let Veterans request primary care and mental health appointments on their mobile devices, expanding control over their own scheduling.

Our Summary of Care app gives Veterans snapshots of their medical information — on demand — so they can monitor their own health over time.

And our Annie messaging service can use cell phones to help Veterans follow their personal care plans. Think about this: caregivers and Veterans in remote settings can monitor their own vital signs, like blood pressure and oxygen saturation.

If you want to see the range of mobile applications, visit our mobile app store at www.Mobile.VA.Gov/appstore. And if you have an idea for a mobile app for Veterans, caregivers, or VA, you’ll find everything you need to contribute at the same site.

So in spite of our technology challenges, we’re changing.

We’re changing VA’s business model and starting to manage to requirements rather than to a budget number.

We’re laser focused on technology innovations that can have a meaningful impact on the quality of Veterans’ experience.

And we’re prioritizing the greatest opportunities for transformational change.

We’re marshalling all the intellectual grit we can muster — a growing team of world-class IT experts changing how industry imagines healthcare.

They’re people like our new Under Secretary of Health, Dr. David Shulkin, formerly President of Morristown Medical Center, Goryeb Children’s Hospital, and Atlantic Rehabilitation Institute.

They’re people like Ms. LaVerne Council, our new Assistant Secretary for IT and Chief Information Officer. LaVerne was the Chief Information Officer for Johnson & Johnson and, before that, for Dell.

The best and brightest are populating our Digital Services Team that’s designing the software to change how we manage Spinal Cord Injury treatment plans, to accelerate Veterans’ claims and appeals processes, and to establish a single, unified digital experience for Veterans: Albert Wong who came to us from Google Chrome; Ellen Ratajak, former IT Director at Amazon.com who built their distribution network; Alex Gaynor, who directed the Python Open Source Foundation; Marina Martin, our Chief Technology Officer and former senior advisor to our Nation’s Chief Technology Officer Todd Park. Marina’s one of President Obama’s “stealth startup” recruits you read about this month in Fast Company.

They’re just a few of more than 340,000 people who are singularly committed to helping us transform — for Veterans.

They’re people like Dr. Peter Almenoff — Professor of Biomedical/Health Informatics and Internal Medicine at the University of Missouri, Kansas City, School of Medicine. Peter directs our Operational Analytics and Reporting office. He manages and continually updates and improves our web-based care quality and patient safety scorecard — Strategic Analytics for Improvement and Learning. SAIL, for short.

Let me tell you about SAIL.

SAIL measures, evaluates, and benchmarks quality and efficiency at medical centers. It’s our roadmap for delivering progressively better health-care outcomes by assessing quality, patient safety, patient satisfaction, and access — among 22 other criteria.

Most health-care industry report cards are updated annually — telling you today where they were two years ago. SAIL reports quarterly at every facility — medical centers can track and improve performance.

Over the last year, 61 percent of VA medical centers improved performance using SAIL.

SAIL’s Statistical Process Control charts monitor patient outcomes and care processes to identify changes and where processes need attention. We use these charts to monitor patient outcomes, hospital complications, and scheduling irregularities.

Our Scheduling Accuracy Dashboard combines data to flag scheduling inefficiencies so medical centers can refine scheduling processes and improve over time, increasing capacity.

How good is SAIL? The chief marketing officer of one of the largest healthcare organizations in America said that if the world knew what VA’s doing with SAIL, they’d beat a path to our door. If he had SAIL in his organization, he’d implement it tomorrow.

I’ll close by repeating what I proposed at the outset. Health information technology is the critical enabler for consistently delivering high quality healthcare outcomes.

And what you find embedded in the best health technology platforms like SAIL are the metrics and functions that translate large quantities of clinical data into actionable information. That’s information that can drive measureable improvements in the most important criteria like mortality rates, patient safety, and hospital-acquired infections.

On the topic of hospital-acquired infections and in closing, let me quote from a January New York Times piece by Tina Rosenberg:

Hospital-acquired infection is one of the country’s leading causes of death, killing 75,000 people per year—more than car accidents and breast cancer combined. . . . hospitals have only started to take prevention seriously in the last decade, most in the last five years. . . . One hospital group, however, has done more than all others. It’s not the Mayo Clinic’s hospitals, nor the Cleveland Clinic’s, nor Kaiser Permanente, nor Sutter, nor Geisinger. . . . all hospital chains known for their quality, but another big name leaves them in the dust: the V.A. . . . VA shows how much faster we could go. . . . VA’s achievement is even more remarkable because its patients are older and sicker than patients in other hospitals.

We’ve never had an opportunity like this. So we are moving fast, accomplishing things now we never could have accomplished otherwise.

Thanks very much for inviting me be a part of this important and timely inaugural healthcare summit.

I’d be happy to take questions.

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