VA Roundtable

Written by JEFF MCKAUGHAN

THE SAME GOALS AND MISSIONS BUT WITH SLIGHTLY DIFFERENT PERSPECTIVES.

Ask four witnesses to the same traffic accident and you are likely to get four similar but differing accounts. Much is based on the location of the witnesses, their perspectives and their own interpretations of events. With that concept in mind, MMT thought it would be interesting to ask the same questions to four different Department of Veterans Affairs facility directors. The individual facilities are from different parts of the country and of differing sizes.

VA BACKGROUND

The Department of Veterans Affairs was established on March 15, 1989, succeeding the Veterans Administration and is now the second largest of the 15 cabinet departments and operates nationwide programs for health care, financial assistance and burial benefits.

VA’s fiscal year 2005 spending was $71.2 billion—$31.5 billion for health care, $37.1 billion for benefits, and $148 million for the national cemetery system. The 2007 budget will be around $88 billion.

On September 30, 2005, there were an estimated 24.4 million living veterans, with 24.3 million of them in the U.S. and Puerto Rico. There were an estimated 37.2 million dependents (spouses and dependent children) of living veterans in the U.S. and Puerto Rico. There were over 542,300 survivors of deceased veterans receiving VA survivor benefits. Thus, more than 62 million people, or 21 percent of the total estimated resident population of the U.S. and Puerto Rico, (301.2 million) were recipients, or potential recipients, of veterans’ benefits from the federal government.

From 54 hospitals in 1930, VA’s health care system now includes 154 medical centers, with at least one in each state, Puerto Rico and the District of Columbia. VA operates more than 1,300 sites of care, including 875 ambulatory care and community- based outpatient clinics, 136 nursing homes, 43 residential rehabilitation treatment programs, 206 Veterans Centers and 88 comprehensive home-care programs.

VA manages the largest medical education and health professions training program in the United States. VA facilities are affiliated with 107 medical schools, 55 dental schools and more than 1,200 other schools across the country. Each year, about 83,000 health professionals are trained in VA medical centers. More than half of the physicians practicing in the United States had some of their professional education in the VA health care system.

For this interview we spoke with Elizabeth Joyce Freeman, director, VA Palo Alto Health Care System, Palo Alto, Calif.; Michael D. Adelman, MD, medical center director, Erie VA Medical Center, Erie, Pa.; Peter P. Henry, CHE, director, VA Black Hills Health Care System, Fort Meade, S.D, and Patricia O. Pittman, VAMC director, Memphis, Tenn.

Q: Could we start with just a little background on each of your facilities?

Freeman, Palo Alto: The VA Palo Alto Health Care System [VAPAHCS] is located 35 miles south of San Francisco and has approximately 85,000 veterans enrolled for care in its three inpatient divisions and six community-based outpatient clinics. It is a teaching hospital, providing a full range of patient care services, with state-of-the-art technology, as well as education and research. We have 885 operating beds, including three nursing homes and a 100-bed homeless domiciliary and is home to a variety of regional treatment centers, including a Polytrauma Rehabilitation Center, Spinal Cord Injury Center, a Comprehensive Rehabilitation Center, a Traumatic Brain Injury Center, the Western Blind Rehabilitation Center, a Geriatric Research, Educational and Clinical Center, a homeless veterans rehabilitation program, and the National Center for PTSD.

We are affiliated with the Stanford University School of Medicine and train more than 1,300 university residents, interns, and students each year and have 80 affiliation agreements to train health care professionals in disciplines to include: anesthesia, audiology and speech pathology, chaplain, dental, health care administration, health services research and development, medicine, nursing, nutrition and food, optometry, pathology and laboratory, pharmacy, physical medicine and rehabilitation, podiatry, psychology, social work and blind rehabilitation.

Adelman, Erie: The VA Medical Center [VAMC] is a primary care, general medical and surgical facility. We are a teaching hospital, providing a full range of primary care services, with state-of-theart technology. Comprehensive health care is provided through primary care, specialty care, and long-term care in areas of medicine, surgery, behavioral health, physical medicine and rehabilitation, dentistry, geriatrics and extended care. We are located in the far northwest corner of Pennsylvania serving over 20,000 veterans each year and have an annual budget is $70 million with over 500 employees.

Erie VAMC has community-based outpatient clinics in Ashtabula, Ohio; and Meadville, Smethport, Warren and Oil City, Pa. In total, we serve veterans in Ashtabula County, Ohio; Chautauqua County, N.Y.; Crawford, Erie, Elk, Forest, McKean, Venango and Warren Counties in Pa.

Henry, Black Hills: The VA Black Hills Healthcare System [BHHCS] was established in May of 1996 by the integration of the Fort Meade and Hot Springs medical centers—about 90 miles apart. Prior to that time each medical center functioned independently. The integration established a single management team over both campuses in addition to the staffed community-based outpatient clinic [CBOC] at Rapid City, S.D.

Fast forward to today and we have the two campuses in addition to twelve CBOCs and/or rural health clinics that provide access to veterans in a large, sparsely populated geographic area of western South Dakota, eastern Wyoming, northwestern Nebraska and southeastern Montana. This area has approximately 38,000 veterans, approximately half of whom receive services from us.

We have a staff of 1,000 employees and an operating budget of $110 million. The BHHCS, which is part of Veterans Integrated Service Network 23, provides primary and secondary medical and surgical services and tertiary mental health care. In addition, the Fort Meade campus has a large nursing home care unit and the Hot Springs campus has a small NHCU, and Hot Springs has a domiciliary residential rehabilitation treatment program and a dialysis program.

We had 200,000 outpatient visits in FY06. Tertiary care patients are primarily referred to VAMCs in Minneapolis, Minn., or Omaha, Neb. The VA also has several sharing agreements with Indian Health Service, Department of Defense and the South Dakota National Guard.

Pittman, Memphis: Located on a 33-acre campus, the Memphis Veterans Affairs Medical Center is a fully accredited 254-bed tertiary care facility, ranked at number 24 in the VA system of 163 medical centers. We have one main campus located at 1030 Jefferson Avenue, and two off-site, VA-staffed primary care clinics and four community-based clinics.

The medical center’s main campus offers acute medical and surgical care, as well as intermediate care, and a full range of primary, specialty and subspecialty care including psychiatry, neurology, spinal cord injury, rehabilitation, oncology, dentistry and special services designated for women’s care. The medical center’s primary affiliation is with the University of Tennessee, Memphis, colleges of medicine, dentistry, nursing, pharmacy and allied health, with additional affiliations for associated health professions with colleges and universities throughout the country. It supports hundreds of active research projects with a total funding averaging $16 million annually.

The Memphis campus houses a state-of-the-art, five-story patient bed tower that was dedicated in June 2000. The medical center is now in the final phase of a 3-phase seismic corrections building project, due to complete by 2007. This was a historic project for Memphis and the medical center. It is the only retrofitted building in the Downtown area, and all work, including removal of the top nine stories of the existing patient care building, was done without any change in patient care. Patients were still cared for in inpatient beds, surgery proceeded, etc.

Some 435,000 outpatient visits were recorded last year among the 44,500 veterans that are in enrolled for care.

Q: Digitizing health records is a major priority for health care providers. Where are you in the process, from a technological perspective, in capturing and using digital health records?

Adelman, Erie: The vast majority of information is available electronically. This includes the actual radiology images, ECG’s, photos taken during endoscopy, progress notes, consult results, photos taken to document a condition, and the vast majority of consents.

Outside medical records are scanned and available in the electronic medical record [EMR]. Acknowledgement of receipt of discharge instructions by patients is electronic in the emergency room but not when patients are discharged from an inpatient or nursing home bed. The actual pulmonary function test is not yet available in the EMR but will be incorporated this fiscal year.

Freeman, Palo Alto: VAPAHCS’ 30 ICU beds have fully implemented a paperless ICU. In addition to the VA’s Computerized Patient Record System, VAPAHCS has an ICU dedicated computer information system. This system continuously acquires electronic data from the monitors and ventilators—every minute—and the nurses enter into the system additional patient information, for example, nursing assessments, events, drugs given by and IV drip, etc. In addition, every computer workstation at each ICU bed is equipped with a wireless bar code reader that is used by the nurses to administer the correct drugs and doses to the correct patient.
 
All this digitized data flows to our wireless laptops that are used by the physicians during ICU rounds—three times a day—and throughout the day. Displayed on these laptops are VA’s patient record—and the ability to electronically order therapy for the patients—the ICU record, with up-to-the-minute data on the patient’s condition, and all the radiology exams that the patient has had, like chest X-rays, CT scans, MRI, etc.

Pittman, Memphis: The VA is a leader nationwide in computerized medical records, documented in various media articles. The Memphis VA surpasses all community medical centers in this technology. In addition, we also have a full picture archiving computerized system in radiology, making patient X-rays available at any location in the medical center where there is a computer workstation.

Henry, Black Hills: The VA has a superb electronic medical record [EMR] where all progress notes, physician orders, lab results, Xray reports etc are entered directly into the patient’s electronic record. The EMR ensures a legible record is available and reduces any errors because someone could not read a provider’s handwriting.
 
There are very few things that are not entered directly into the record and these few items are scanned into VistA Imaging so they are viewable electronically. The scanned items include consults to specialists in the community, lab/X-ray reports performed outside the VA and copies of medical records from the patient’s private—non-VA—provider. All medications that are given to the patient in the hospital are bar coded and documented electronically to ensure the right medication is given to the right patient at the right time. This has significantly reduced medication errors.

When patients go from one VA facility to another, each site is easily able to view the electronic records from all VA facilities in a matter of seconds. This availability of information has greatly improved access to information on patients that travel around the country. Because the VA has an extensive electronic record, patients are able to access their information through My HealtheVet. At this point, they can order refills on their medications through the program and soon will be able to view their medical record and make copies of notes, lab/X-ray reports, etc. to take to their private providers. The VA is recognized as a world leader in the electronic medical record and this success has been noted by national magazines and organizations.

Q: How has telemedicine affected your hospital? In what areas is it most utilized and where would you like to see it increased?

Pittman, Memphis: We have a vigorous program for monitoring blood pressure, pulse, blood sugar in the home with results transmitted via modem to the physician here as part of the care coordination program. Traditional telemedicine exists in mental health and spinal cord injury. We plan to increase telemedicine with the community-based outpatient clinics and in dermatology.

Freeman, Palo Alto: Telemedicine offers a unique solution for patients who live far away and who have chronic health issues that require frequent monitoring and management. VAPAHCS has established telemedicine programs that focus on diabetes, chronic heart failure, and chronic obstructive pulmonary disease. Using special monitors, veterans send their blood sugar results, weight or blood pressure readings to a secure website that is monitored daily by nurses. When appropriate, nurses alert providers and doctors review the information without the patient having to visit. If need be, the provider can adjust treatment without the patient having to travel to VA.

In the future, VAPAHCS hopes also to expand its current treatment of patients with PTSD, depression and spinal cord injury through telemedicine by making this technology even more widespread.

Henry, Black Hills: We use telemedicine extensively at the Black Hills Health Care System; it has been very beneficial in providing access to specialists we do not have on staff. Telemedicine is currently being used in: cardiology, endocrinology, infectious disease, orthopedics and plastic surgery.

We also use telemedicine for taking pictures of the eye on diabetic patients, which are reviewed by an ophthalmologist in Minneapolis to determine if the patient has diabetic retinopathy. We soon will be using telemedicine for dermatology. The aforementioned uses of telemedicine are between both the Fort Meade and Hot Springs campus and a tertiary medical center, most frequently the VAMC Minneapolis.

Mental health has utilized telemedicine to provide PTSD treatments— either individual or group—to veterans on the Rosebud Reservation and in the near future to veterans on the Standing Rock and Cheyenne River Reservations. It has also been utilized by a psychiatric-trained physician’s assistant at the Rapid City Clinic with patients at the Pierre CBOC.

Obviously in a geographically remote area telemedicine can save a veteran—and his/her family—significant travel costs and travel time. We anticipate the telemedicine program to continue to expand.

Adelman, Erie: Telemedicine has allowed us to provide some specialized services to area veterans. Specifically in the delivery of behavioral health in our community-based outpatient clinics, and follow-up for veterans involved with sleep studies from the Pittsburgh VA Healthcare System. The use of telemedicine affords the patient the opportunity to eliminate the need to travel long distances for specialized services.

Q: Has it been difficult in recruiting and retaining the skilled health care professionals that you need to maintain your medical care standards?

Henry, Black Hills: For years the BHHCS has enjoyed the benefits of having a loyal, stable workforce. In the next five years, 50 percent of our employees will be eligible for retirement. We have just started to experience an increase in the number of retirements.

The recent publications by Time magazine and others which showcase the accomplishments of the VA have helped in attracting employees to our medical centers. For the most part we have been very successful in attracting quality employees, however, the difficulty are those ‘one of a kind’ positions that are scarce and difficult to recruit—we address this further as one of our challenges.

Overall we have been very successful in recruiting and retaining the type of employee that enhances the care we offer veterans. This is confirmed by a number of patient and employee satisfaction surveys that are accomplished on a periodic basis. The BHHCS consistently scores as one of the best in the VISN in both areas, and frequently is in the top 10 nationwide. We promote an atmosphere of open communications, empowerment and a grass roots quality improvement program called “Improving Our Work Is Our Work.” We also insure employees are timely and properly rewarded for their accomplishments.

Pittman, Memphis: It’s been difficult recruiting physicians in specialty care such as orthopedics, neurosurgery, plastic surgery and anesthesiology due to pay. The recently approved Physician Pay Bill has helped to reduce the gap in some of these specialties. Ancillary specialties in the therapies—physical therapy, occupational, respiratory—have been difficult to recruit to the level we would like. And of course, in a city with 15 major hospitals there is always the nursing shortage to confront.

Adelman, Erie: We have experienced difficulty in recruiting hospitalists for inpatient care services. The Erie community itself is experiencing difficulty in recruiting and retaining sub-specialty physicians such as orthopedic surgeons, urologists, radiologists, and oncologists, thus this impacts our ability to provide these services in the local area.

Freeman, Palo Alto: Yes, particularly due to pay compression. For example, VAPAHCS can offer RNs a competitive salary upon entering the VA, but is not able to compete with civilian sector pay scales as they advance.

This is also true of many senior facility level leadership positions in both clinical and administrative services. The rewards for individuals to accept increased supervisory responsibility is not matched in the salaries for these positions. VAPAHCS is also facing challenges in recruiting and retaining lower-salaried employees in areas such as environmental management, nutrition and food service, clerks and business office staff. Due to the extraordinarily high cost of housing in the Bay area, these challenges are even more acute for VAPAHCS versus other parts of the country.

Q: What are the biggest challenges you will face in the next 12 months?

Adelman, Erie: Recruitment of sub-specialty physicians to provide more continuity of care for patients receiving care at the Erie VAMC. In terms of the electronic record, there will be several enhancements in the upcoming year. Retinal photography performed in our outpatient clinics will be incorporated into the EMR. In addition, the use of bar code technology will be extended with applications related to laboratory specimen collection and the blood transfusion process.

Henry, Black Hills: As with any large health care organization we certainly have our challenges. I consider three to be the most significant.

The two campuses that comprise the BHHCS both have long histories—the Hot Springs campus was one of 10 original Old Soldiers Homes; the Fort Meade campus originally a cavalry post. Both are located on sprawling campuses with aging buildings. While the patient care buildings have been renovated and are very appropriate for a health care setting, simply by their age and configuration, they have their limitations in trying to provide 21st century care. In addition, veteran population projections reflect a decrease in future years. Therefore, the challenge in the next 12 months is to initiate an effective strategic planning process that prepares us for the future.

The BHHCS has approximately 200 patients a year that require tertiary care that we cannot provide. When we are unable to refer them to a VA facility, a growing number are referred locally at VA expense. The challenge for us is to find a methodology that enables the VA to better utilize local health care resources while maintaining fiscal integrity.

The BHHCS has generally been able to recruit and retain a highly qualified nursing staff. We have had success in recruiting primary care physicians, psychiatrists and general surgeons. Our greatest challenge is in recruiting specialty care physicians, such as urologists—and since they are one of a kind with us, recruitment for vacancies sometimes takes many months. We occasionally experience difficulty recruiting pharmacists, respiratory therapists, laboratory technologists or radiographic technicians. Recent changes in federal law have enabled us to be more competitive in terms of salary, which assists in both recruitment and retention. The challenge is to utilize all tools at our disposal to insure we recruit and retain the best possible staff.

Freeman, Palo Alto: A big challenge is to continue meeting access and timeliness goals, particularly in the specialty clinics—dental, dermatology, orthopedics, etc.—and mental health. As one of the sites with a National Center for PTSD, VAPAHCS staff are acutely aware of the upcoming need for specialized counseling, as more troops are returning from second and third deployments. VAPAHCS is preparing for the increase and examining ways to serve this newest generation of veterans. For example, VAPAHCS provides counseling in the evenings and on weekends, so young men and women can continue to work and care for families. VAPAHCS is also making significant changes to its internet presence to make its services more visible and accessible.

As one of four Polytrauma Rehabilitation Centers in VA, VAPAHCS staff are acutely aware of the importance and needs of the families of our injured service men and women returning. VAPAHCS opened a 21-suite Fisher House in April, which was a huge benefit for families. VAPAHCS therapists have also learned how to incorporate and train family members in the patient’s rehabilitation.

Additionally, we are seeing new types of injuries on our traumatic brain injury unit. IEDs and rocket-propelled grenades leave service members with devastating brain injuries alone or in combination with blindness, complex orthopedic injuries, auditory and mental health concerns. Because brain injury influences all other areas of rehabilitation, service members receive care for their brain injury prior to, or in conjunction with, rehabilitation for their additional injuries. VAPAHCS’ goal is to provide the best care through a multidisciplinary staff that includes physical medicine physicians, nursing staff, rehabilitation-certified nurses, neuropsychologists, physical therapists, occupational therapists, recreational therapists, speech pathologists and social workers.

Pittman, Memphis: Addressing infrastructure needs in the remainder of the 1.1 million square foot facility following the completion of the 10-year seismic project. We also have to [have] succession planning in place for retirement of an aged workforce. Lastly, we need to ensure that we meet the needs of the new veterans—Iraq and Afghanistan. ♦

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