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Mr.
Charles DeCoste
Director, Health Administrative Office, VHA
The following points were made by Mr. DeCoste during the course of the interview in response to questions related to the development of an information technology vision that would best support the concept of "One VA for Customer Service."
One VA Brings Cohesion to Disconnected Initiatives. The concept of "One VA for Customer Service" is absolutely the right thing to do. Striving to achieve the One-VA goal should make more cohesive the many initiatives being pursued by well-intentioned people in different VA business lines to improve customer service. To succeed, we must find a way to prevent a coordinated set of initiatives from being overwhelmed by the pressures of day-to-day operations.
One VA Needs Customer-Based System. To successfully implement the One-VA concept we need a customer-based information system that enables and fosters the transfer of customer data across lines of business. For instance, when some part of VA initially stores data on a veteran, no other VA organization should have to ask the veteran for that same data again. The data in the "master veteran record" needs to follow the veteran wherever he/she goes in VA seeking services. Currently, we capture and store veteran data in different systems and different locations, with little sharing. For example, within VHA, in the Boston area there are four VA hospitals. Each will conduct a means test not knowing that one of the other hospitals has already done it. Yet, every VHA medical center sends its means tests to a central collection system in Atlanta every day.
Strategic Planning Coordination and Data Sharing. If we are to achieve One VA for customer access, we must do better at sharing strategic planning information from the Secretary down. The Secretary’s goals need to be clearly articulated, pushed down, and followed up. Once the plans of all lines of business are better synchronized with the Secretary’s direction and among themselves, their implementation needs to be monitored and evaluated on an ongoing basis. In addition, if we can get VHA and VBA to agree on sharing veteran data, then we will have eliminated a major obstacle on the road to One VA.
Veteran ID Card a Key Access Device. The Veterans Universal Access Identification Card (VIC) currently in use is envisioned to be a "dumb" card that interacts with a "smart" system, rather than being a "smart card." The card carries the more stable data about the veteran. The data more subject to change would be carried in the system. Currently, the card contains:
Keeping the card content simple also aids in reproducing the cards, since veterans tend to lose them.
Efforts should focus on making VIC card information transferable across VA, including the photograph. The picture on the card is not only used for authentication. By putting it in an automated system for retrieval, it can be used to help locate beneficiaries with mental illness who may wander off during a hospital visit. Current efforts to record pictures electronically have been hampered by the inability to transfer the picture electronically to another facility.
In terms of integrating the VIC with the master veteran record (MVR), we should think of the VIC as the key to accessing the MVR, making information readily available, minimizing administrative redundancies, and improving customer service.
The VIC could be used to process automated medical treatment co-payments (currently $2), by debiting benefit payments to the veteran. Today, much more than $2 is spent in administrative costs if the co-payment has to be billed separately. After all, who likes being forced to write checks for $2?
Kiosk Access in VA Hospitals. The concept of kiosk access is to establish web-enabled terminals in convenient locations where veterans can get self-service access to VA data. This could be data relating to the veteran, information about how to acquire VA services, or to electronic forms used to request certain VA services. If we implement kiosks in hospitals and other VA locations, the VIC could be Web-enabled and used as at least one of the means for authenticating the veteran and granting access through the kiosk system to data in VA systems. While the concept has promise, there is not yet the level of consensus among VA management needed to implement it.
Means Testing Improvements. A significant part of the VHA treatment population must by law be "means tested’ in order to confirm eligibility status. The process as it exists today is accomplished by staff at VAMCs who obtain patient information during face to face interviews that is subsequently transferred to the Atlanta HEC for initiation of an income verification process. On average 800,000 means tests are transmitted to the HEC annually with approximately 100,000 of the those needing further verification and confirmation of eligibility status. Dependent upon the exchange of information from the IRS and SSA, the process is exceedingly lengthy (8-18 months for complete determination) and often requires further discussion with the veteran or family members to clarify information inaccurately reported or never obtained. Among the inefficiencies in the process as it now exists is that once income verification is completed, confirmed information is available only to the location which conducted the initial means test interview. Therefore, if a veteran should present to multiple locations seeking care, the same process will be repeated at each site. While a proposal has been conceptually approved to centralize means testing to the Atlanta HEC, and to make the confirmed information available nationally (thereby eliminating the duplication of processes and advancing the creation of "one VA" information systems concept), limited resistance has effectively delayed implementation.
Other External Interfaces Important to VA. The Social Security Administration (SSA) provides data to VA on the veteran’s earned income while the IRS provides data on his/her unearned income. Acquiring current income data to determine basic eligibility and the treatment priority level for the veteran can take months into the new calendar year given the filing deadline (i.e., April 15) and the subsequent determination of a return’s validity by the IRS. Meanwhile, the veteran is denied either benefits or priorities he/she deserves, or is provided more medical benefits than he/she merits.
Another example of effective interagency cooperation was realized when VA arranged for the Treasury Department to include a VA Explanation of Benefits (EOB) with the benefit check it mails to the veteran. Previously, VA mailed the EOB separately, causing confusion for the veteran and a lot of unnecessary postage cost. Synchronization eliminated substantial queries by the veteran wondering when the check (referenced in the EOB) would arrive. There is potential for this somewhat mutually beneficial cooperation between VA and other agencies, but it is hard to accomplish without managing it intensively until it happens. We need to actively pursue improvements (i.e. electronic information exchange) in streamlining wherever possible to expedite processes.
Improved VHA/DoD Interface. It would improve service to capture the individual’s DoD records prior to his/her discharge. Today, a veteran’s DoD medical records are available only upon special request. VA would like to know the conditions for which the veteran was treated while on active duty. Having this information at hand will accelerate the process of qualifying the veteran for health care and disability benefits.
VA has derived some benefit from matching VA electronic files to those of DoD. For example, the DoD DEERS database in Monterey maintains information on all DoD beneficiaries. Those veterans’ dependents eligible for CHAMPUS are not eligible for CHAMPVA. In matching the VA CHAMPVA file to the DEERS CHAMPUS file, VA reduced the number of eligibles for CHAMPVA from 250,000 to 89,000. Clearly, there are benefits to be derived from better interfaces to, or integration with, DoD systems.
DoD paper-based medical records are sent to the DoD Military Records Center in St. Louis after the individual’s discharge. Today, DoD transfers paper records to VA when VA requests them. No automatic transfer to VA occurs pre- or post-discharge. Imaging these records, before or after VA receives them, would facilitate a much faster retrieval and transfer of the records to the requestor. This is hindered by the federal records retention law, acceptability of an imaged record as official, and the cost to convert an enormous number of records from paper. The Health Administration Center in Denver has established an electronic records management system. Although VA and DoD share hospital facilities in some areas (e.g., Albuquerque, Anchorage), there is limited collaboration on management of patient records inside the hospital.
Potential for More Self-Service. The IS-1 handbook ought to be made available directly and electronically to veterans. However, before too long in the Veteran’s inquiry on eligibility, he/she would need to talk with an expert. Although some people have suggested that hospital appointments could become a self-service component, there is reluctance within VHA to pursuing this idea.
Primary Care Facility Enrollment to Improve Health Care and Balance Resources. There is a significant effort underway to enroll VA beneficiaries at the VA medical center that is to be their official primary care facility. By October 1, 1998, veterans have to be enrolled to receive services. The enrollment process will start on October 1, 1997 and be a rolling enrollment for twelve months. The prior-year user population will be prioritized based on their service level (priority 1 – 7). Each month one-twelfth of last year’s users will be automatically enrolled to a primary facility for basic health care. Walk-ins will be added as they come to a VHA facility.
The enrollment is part of the move to the primary care approach, which will not only improve health care for the individual patient, but enable VHA to more equitably allocate funds to medical centers and determine fair inter-hospital funds transfers. The facility responsible for the care of an enrolled beneficiary would have to reimburse another facility if the veteran obtains services there instead (because, for instance, he/she may be vacationing there). The need for establishing an enrollment system should bring with it a requirement for establishing patient information transfer capabilities that readily identify beneficiary enrollment information.