VA looks to apply innovation to better care and service for veterans

The U.S. Department of Veterans Affairs launched a new innovation center to solve big problems.

va-header-logoThere are few areas as emblematic of a nation’s values than how it treats the veterans of its wars. As improved battlefield care keeps more soldiers alive from injuries that would have been lethal in past wars, more grievously injured veterans survive to come home to the United States.

Upon return, however, the newest veterans face many of the challenges that previous generations have encountered, ranging from re-entering the civilian workforce to rehabilitating broken bodies and treating traumatic brain injuries. As they come home, they are encumbered by more than scars and memories. Their war records are missing. When they apply for benefits, they’re added to a growing backlog of claims at the Department of Veterans Affairs (VA). And even as the raw number of claims grows to nearly 900,000, the average time to process them is also rising. According to Aaron Glanz of the Center for Investigative Reporting, veterans now wait an average of 272 days for their claims to be processed, with some dying in the interim.

The growth in the VA backblog should be seen in context with a decade of war in Afghanistan and Iraq, improved outreach and more open standards for post-tramautic stress syndrome, Agent Orange exposure in Vietnam and “Gulf War” illness, allowing more veterans who were previously unable to make a claim to file.

While new teams and technologies are being deployed to help with the backlog, a recent report (PDF) from the Office of the Inspector General of the Veterans Administration found that new software deployed around the country that was designed to help reduce the backlog was actually adding to it. While high error rates, disorganization and mishandled claims may be traced to issues with training and implementation of the new systems, the transition from paper-based records to a digital system is proving to be difficult and deeply painful to veterans and families applying for benefits. As Andrew McAfee bluntly put it more than two years ago, these kinds of bureaucratic issues aren’t just a problem to be fixed: “they’re a moral stain on the country.”

Given that context, the launch of a new VA innovation center today takes on a different meaning. The scale and gravity of the problems that the VA faces demand true innovation: new ideas, technology or methodologies that challenge and improve upon existing processes and systems, improving the lives of people or the function of the society that they live within.

“When we set out in 2010 to knowingly adopt the ‘I word’, we did so with the full knowledge that there had to be something there,” said Jonah J. Czerwinski, senior advisor to VA Secretary Eric Shinseki and director of the VA Innovation Initiative, in a recent interview. “We chose to define value around four measurable attributes that mean something to taxpayers, veterans, Congressional delegations and staff: access, quality, cost control and customer satisfaction. The hard part was making it real. We focused for the first year on creating a foundation for what we knew had to justify its own existence, including identifying problem areas.”

The new VA Center for Innovation (VACI) is the descendent of the VA’s Innovation Initiative (VAi2), which was launched in 2010. Along with the VACI, the VA announced that it would adopt an innovation fellows program, following the successful example set by the White House, Department of Health and Human Services and the Consumer Financial Protection Bureau, and bring in an “entrepreneur-in-residence.” The new VACI will back 13 new projects from an industry competition, including improvements to prosthetics, automated sterilization, the Blue Button and cochlear implants. The VA also released a report on the VACI’s progress to date.

“We’re delving into new ways of providing audiology at great distances,” said Czerwinski, “delivering video into the home cheaply, with on-demand care, and the first wearable automatic kidney. Skeptics can judge any innovation endeavor by different measures. The question is whether at the end of the cycle if it’s still relevant.”

The rest of my interview with Czerwinski follows, slightly edited for clarity and content.

Why launch an “innovation center?”

Jonah J. Czerwinski: When we started VAi2, our intent was delving into the projects the secretary charged us with achieving. The secretary has big goals: eliminate homelessness, eliminate backlog, increase access to care.

It’s not enough for an organization to create a VC fund. It’s the way in which we structure ourselves and find compelling new ways of solving problems. We had more ways to do that. The reason why we have a center for innovation is not because we need to start innovating — we have been innovating for decades, at local levels. We’ve been disaggregated in different way. We may accomplish objectives but the organization as a whole may not benefit.

We have a cultural mission with the center that’s a little more subtle. It’s not just about funding different areas. It’s about changing from a culture where people are incented to manage problems in perpetuity to one in which people are incented to solve problems. It’s not enough to reduce backlog by a percentage point or the number of re-admissions with an infection. How do you reward someone for eliminating something wholesale?

We want our workforce to be part of that objective, to be part of coming up with those ideas. The innovation competition started in 2009 led to 75 ideas to solve problems. We have projects in almost every state now.

How will innovation help with the claims backlog?

Jonah J. Czerwinski: It’s complicated. Tech, laws, people factors, process factors, preferences by parts of interest groups all combine to make this hard. We hear different answers, depending upon the state. The variation is frustrating because it seems unfair. There are process improvements that you can’t solve from a central office. It can’t be solved simply by creating a new claims process. We can’t hire people to do this for us. It is inherently a governmental duty.

We’ve started to wrestle with automation, end-to-end. We have a Fast Track Initiative, where we’re asking how would you take a process, starting with a veteran, and end up with a decision. The insurance industry does this. We’ve hired a company to create the first end-to-end claims process as a prototype. It works enough that it created a new definition for what’s in the realm of the possible. It’s created permission to start revisiting the rules. There’s going to be a better way to automate the claims process.

What’s changed for veterans because of the “Blue Button?”

Jonah J. Czerwinski: There’s a use case where veterans receive care from both the VA and private sector hospitals. That happens about half the time. A non-VA hospital doesn’t have VISTA, our EHR [electronic health record.] If a patient goes there for care, like for an ER visit during a weekend because of congestive heart failure, doctors don’t have the information that we know about the patient at the VA. We can provide it for them without interoperability issues. That’s one direction. It’s also a way to create transparency in quality of care, if the hospital has visibility in your healthcare status.

In terms of continuity of care, when that veteran comes back to a VA hospital, the techs don’t have visibility into what happened at the other hospital. A veteran can download clinical information and bring that back. We now have a level of care between the public and private sector you never had before.

This post has been updated with additional links and a link to a U.S. News story.

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