Non-Clinical Topics

Technology Experts Question MISSION Act Electronic Systems

by Stephen Spotswood

May 17, 2019

WASHINGTON—VA is working under a tight deadline to implement the community care provisions of the MISSION Act, the new law that goes into effect this summer and revises and codifies access standards for veterans receiving care from non-VA providers. That preparation includes the creation of new electronic systems to support those efforts.

A glitch in the technology has raised concerns, however.

A recent review of VA’s efforts by the United States Digital Service—a group of top-level technologists employed by the White House to help agencies improve federal systems—found that one of the digital tools is so flawed that the report recommended scrapping it and starting fresh.

The review also set off an alarm that, as VA’s new community care networks go online, veterans may experience life-threatening interruptions in their care.

Much of the data needed to determine a veteran’s eligibility for community care is housed in multiple legacy systems that do not interoperate. The Digital Support Tool being developed by VA would gather that data and deliver it to a physician on a single-dashboard screen. The physician could then determine whether a veteran was eligible for VA-funded care from a community provider.

USDS reviewers expressed concern about the condensed timeline for development of the DST. Development did not begin until late summer 2018, and upcoming deadlines leave little wriggle room if problems are discovered. Initial training and a release to a select set of users was scheduled this month between May 2 and May 22.

“If this crucial first set of testers find serious usability issues or find that the department designed the wrong product altogether, it will be too late to pivot before the production release on May 23,” the report warned.

Also, the data a physician sees on that DST dashboard might not be entirely reliable. Some of the systems being integrated into the DST have known data quality issues, including missing, duplicative or out-of-date data, all of which could prevent veterans from receiving an accurate eligibility determination, the report states.

Interviews conducted by USDS with VA physicians suggested that providers might not be pleased with adding eligibility determination into their exam room workflow.

“These people are out of their minds,” one VA primary care physician is quoted as saying. “We aren’t housekeepers, doorkeepers, garbage men.”

According to the reviewers, “Little research has been done in the field to understand how veterans, physicians, and clinical staff are currently providing and receiving care through the VA before new processes are established.”

Work on Something New?

USDS recommended VA scrap the DST as currently imagined and begin work on something new—a tool that better incorporates the needs and desires of physicians and veterans. The review recommended a simplified system, and one that’s integrated into the My VA dashboard to show a veteran whether or not they were eligible for community care.

VA officials appeared before the House VA committee last month to provide a response to the USDS report. That response was appreciation to USDS for their work, but ultimately the dismissing of their recommendations.

“The Decision Support Tool will improve efficiency for VA providers, making referrals by helping to simplify decisions about community care eligibility. But the tool is not essential for implementing any of the provisions for the MISSION Act,” explained Acting VHA Chief Richard Stone, MD. “VA is planning to deploy the DST by June 6. In the event that any technical challenge occurs, VA will be able to make eligibility decisions using existing and enhanced methods and tools. Veteran care will not be disrupted.”

Stone also refuted the review’s assertion that VA does not understand how veterans and clinicians interact with its system.

“Since 1945, we’ve been buying care in the community. On any given day, we decide to buy care about 50,000 times,” Stone declared. “The decision support tool was designed by our clinicians in the field. I’ve seen the prototype of it. I’ve sat with clinicians in the field. The research [leading to the DST development], although I would refer to it as anecdotal, was all from actively-practicing clinicians.”

As for the recommendation that VA design its DST to be veteran-facing, Stone said, “This is not about providing a Google site and then having [the veteran] make decisions. Those decisions are best made in conjunction with their provider care team.”

Stone did not entirely dismiss the recommendations made by USDS. “[They] brought up some very interesting ideas that could lead us into the future,” he said. “But I think you’re going to see a very traditional approach in the first phase on June 6.”

“Are we going to get it all right?” he added. “No. Are we going to be able to deliver care on June 6? Yes. There will be something that doesn’t go in the right direction and we’ve got to get corrected.”

USDS reviewers are also concerned that, as VA switches over to its new Community Care Networkers, some veterans could experience lapses in care.

In 2013, VA contracted with TriWest and Health Net Federal to create two massive community care provider networks spanning the country. The Health Net contact was allowed to lapse due to poor service and nonpayment to providers and TriWest took up the slack. In preparation for the implementation of the MISSION Act, VA has divided the country into six regions for a new Community Care Network, awarding a different contract for each region.

As contracts are awarded, veterans may move from VA to community care or find that their previous community care providers are now out-of-network, the USDS report cautions. “Poor implementation and administration of the contracts implementing the statute and regulations pose real, life-threatening risks to veterans. They may transition from one provider to another as contracts are awarded, or lose access to their providers as they come in and out of network during these regional transitions.”

The report recommends that VA include language in all network contracts to ensure providers remain in-network, regardless of contracting changes, if a veteran is in the middle of treatment and that any changes in eligible services are communicated openly to the veteran.

According to the report’s authors, when these concerns were communicated to VA officials they were dismissed as easily solvable by “communicating to the veteran that they may have to switch providers.”

The authors considered this kind of generic announcement woefully insufficient. “This is unacceptable and will harm the most vulnerable veteran populations.”



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