Technology is supposed to make the health care process easier and more efficient, but regulatory and administrative requirements mean that health care professionals are spending too much time and effort entering data into electronic health records systems, according to a draft Department of Health and Human Services strategy.
The new EHR strategy, released for public comment Nov. 28, proposes to reduce health care provider burden with EHRs by fixing regulatory requirements.
“Usable, interoperable health IT was one of the first elements of the vision I laid out earlier this year for transforming our health system into one that pays for value,” said HHS Secretary Alex Azar.
“With the significant growth in EHRs comes frustration caused, in many cases, by regulatory and administrative requirements stacked on top of one another. Addressing the challenge of health IT burden and making EHRs useful for patients and providers, as the solutions in this draft report aim to do, will help pave the way for value-based transformation.”
The strategy proposes three goals for improving EHR usage:
- Reduce the effort and time required to record health information in EHRs for clinicians;
- Reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals and health care organizations; and
- Improve the functionality and intuitiveness (ease of use) of EHRs.
“Information technology has automated processes in every industry except health care, where the introduction of EHRs resulted in additional burden on clinicians,” said Don Rucker, national coordinator for health information technology.
“Health IT tools need to be intuitive and functional so that clinicians can focus on their patients and not documentation. This draft strategy identifies ways the government and private sector can alleviate burden. I look forward to input from the public to improve this strategy.”
The strategy proposes a number of actions, including reducing the regulatory burden around patient visits, standardizing data and processes for EHRs, simplifying EHR reporting program requirements and doing an inventory of reporting requirements across federal programs to help reduce the reporting burden on clinicians and providers.
The strategy was led by the HHS Office of the National Coordinator for Health Information Technology, in partnership with the Centers for Medicare and Medicaid Services and developed through consultation with clinicians themselves.
“Over the past year, we hosted listening sessions, received written feedback, and heard from a wide range of clinical stakeholders about the current health IT systems and the requirements specifying documentation, reimbursement and quality reporting that are burdensome and should be re-examined,” said Seema Verma, CMS administrator.
“CMS has demonstrated through bold regulatory action the importance of reducing clinician burden.”
Those interested in commenting on the strategy have until Jan. 28, 2019.
There’s a right way for doctors to integrate technology into patient care
I don’t know if you’ve noticed this, but something has come between you and your doctor. It’s there at every office visit, stealing the doc’s attention and punctuating conversations with awkward silences and the light clicking of a keyboard. Yes, it’s the computer, an omnipresent participant in the modern medical exam.
Electronic health records (EHRs)—and the computers that support them—crept onto the scene about 25 years ago, but they took off after getting a $19-billion boost in 2009 as part of the federal economic stimulus package. Several other countries, especially those with national health care systems, had already adopted EHRs, reaping the benefits of instant access to a patient’s history, prescriptions, and much more. The U.S. was playing catch-up.
Alas, the rollout was excruciating. University of Chicago pediatrician Lolita Alkureishi vividly remembers the 2010 arrival of EHRs at the clinic where she sees patients. “It was like seeing the five stages of grief,” says Alkureishi, who had volunteered to orient colleagues to the system. “People were angry and cursing at the computer. They were sad, lamenting the loss of paper charts. People were trying to bargain with me—saying, ‘Could you just put in the orders for me?’ Some finally accepted it, and some never got to that stage.” Sadly, a number of veteran physicians took the arrival of EHRs as a cue that it was time to retire, recalls Neda Ratanawongsa, associate professor of internal medicine at the University of California, San Francisco.
The shift reshaped the doctor-patient relationship, says Elizabeth Toll, a pediatrician and internist at Brown University: “Prior to that I would have told you I had a job that revolved around people. Immediately thereafter I had a job that revolved around the computer. If you didn’t pay 100 percent attention to the machine, you’d start making mistakes: you’d pick the wrong medicine or the wrong dose or send orders for the wrong test. I would often feel that the patient was slipping into second place.” In fact, a 2017 study showed doctors spent twice as much time on clerical work—much of it after hours—as seeing patients.
Alkureishi decided to investigate the phenomenon, working with internist Wei Wei Lee, assistant dean of students at Chicago’s Pritzker School of Medicine. They led a 2016 meta-analysis of 53 studies examining the impact of EHRs on patient-physician interactions. Six of the studies quantified EHR use and found it consumed, on average, 32 percent of a doctor visit. A 2017 study by Ratanawongsa found that health care providers spent 30.5 percent of a visit dividing their attention between patient and computer, another 4.6 percent silently tapping away and 33.1 percent in focused discussion with the patient.
The meta-analysis identified both good and worrisome behaviors. Conversation was too often synchronized to typing pauses and subject to abrupt shifts, as the doctor worked through screens of required questions. Only about 10 percent of doctors shared the screen with patients, but when they did, patients liked it. One study found that when trauma patients were shown scans of their injuries on a tablet, they felt more involved in their care.
Based on their research, Lee and Alkureishi developed a set of “patient-centered” best practices for EHRs that are now taught to all Pritzker students and included in EHR training for medical staff. Among the tips: review patient records before the visit so you can begin the first “golden minute” with eye contact and conversation; position the computer in a “triangle of trust” where the patient can also see it; narrate data entry aloud so the patient can listen and comment; and disengage with technology when discussing sensitive matters. The authors also encourage using online videos and graphics as what Lee calls “a communication-enhancing tool” for patients. They have shared their ideas widely, including via a brief Doctor’s Channel video.
One reason EHR systems were so disruptive in the U.S. is that they were designed with billing in mind, as opposed to simply patient care, as is the case in countries such as Sweden and the U.K. Newer systems are better, Ratanawongsa says, and integrated with tools for patients. At the same time, some practices are employing “medical scribes” as notetakers or employing a “team care” approach in which a nurse or assistant shares the record-keeping role. Making patients aware of ways to avoid letting technology hijack their visit also helps. If that starts to happen, speak up.
Niam Yaraghi Monday, November 19, 2018
Patients’ medical data constitute a cornerstone of the big data economy. A multi-billion dollar industry operates by collecting, merging, analyzing and packaging patient data and selling it to the highest bidder. Data buyers range from health policy researchers to pharmaceutical companies and marketing corporations. While this industry has been quietly operating and accumulating profits for many years, patient advocacy groups have recently turned their attention to it. They argue that patients should own their medical records and therefore should be entitled to a fair share of the profits created through the sale of their data.
Data stewardship, not ownership
With one exception, every U.S. state either recognizes medical providers as the owners of medical data or do not have any laws to confer specific ownership or property right to medical records. Only New Hampshire explicitly grants ownership of data to patients. Regardless of state law, I believe that we must abandon the discussion of data ownership and instead focus on data stewardship. The ownership of data, whether granted to patients or to providers, will have dangerous unintended consequences.
Patients’ ownership of data implies that they would have a right to change their medical data as they wish. For example, an individual could edit the results of a blood test to show lower levels of cholesterol when applying for a life insurance policy, or refuse the Centers for Disease Control (CDC) access to medical records and undermine the agency’s efforts to predict and manage the outbreak of viral diseases. On the other hand, providers’ ownership of data implies that they can destroy data without notifying patients or refuse to share them with oversight agencies if a malpractice lawsuit is brought against them.
A model of data stewardship alleviates these concerns. Once a party takes the stewardship of data, they have to act according to a set of rules which guarantee the benefits of all other parties. Despite some notable exceptions such as the Apple Health Application in which patients will be in charge of storing and sharing of their medical records, medical providers are designated as de facto stewards of patients’ medical data in the U.S. healthcare system. This aligns with the long term vision of policymakers who authorized billions of dollars to incentives medical providers to adopt Electronic Health Records (EHR) systems so that they could collect, store, and share patients’ medical data in electronic format.
Data management is an expensive and risky business
The major challenge of the data stewardship model is the fair compensation of the steward. It is very expensive to store digital data: The costs of implementing an EHR system at a hospital network can exceed 1 billion dollars. Providers not only have to pay for upfront technology implementation, but also continuously invest in maintaining their systems and ensuring their security. Additionally, they bear the risks of potential privacy breaches which are extremely common in the healthcare sector and have significant financial and organizational consequences for health care providers.
Healthcare providers, or any other agency, will not invest in building and maintaining technology platforms for collecting and maintain medical data unless they have adequate economic incentives to do so. To recoup these costs, medical providers should either charge patients directly for their data management services, or be allowed to monetize such data. A system in which patients are neither willing to pay providers for keeping their data nor willing to allow the providers to monetize their data cannot succeed financially.
Sharing profits Imposes Extra Costs, privacy risk
Sharing of profits with patients has many challenges. First, although patient data constitute the raw material necessary for data mining, it has very limited value before processing. It is the aggregation, merging, and analyses of such data that creates value. For example, the hospitalization history of a patient on its own provides limited information. However, when such data are merged with the patient’s family history and compared to similar data of a large group of patients, one can infer the chance of re-admission for the patient, which will be of significant medical and financial value. In other words, the value of patient data emerges only after significant processing. This makes it very difficult to assess the fair value of any single patient’s data.
Second, even if one could successfully assess the fair value of patients’ data, distributing the fair share of profits to patients would require a sophisticated tracking and accounting system far more complicated than that of the Internal Revenue Service (IRS). The cost of implementing this system will significantly eat into profits and further reduce the amount that patients receive. More importantly, such a system would be a significant threat to patients’ privacy because it will require identification of patients in order to make financial transactions with them.
A New Model For DATA Sharing
An overwhelming majority of patients are willing to share their medical data with patients, doctors, researchers and even pharmaceutical companies. That is why in almost all of the health information exchange organizations in the U.S., most patients consent to sharing of their medical records. The indirect benefits that patients receive from sharing of their records, such as access to newly developed life-saving drugs or targeted marketing, could easily surpass the small financial benefits that they could receive from the sale of their data. The benefits of disclosing health information are not necessarily medical or economic: Once individuals are given the choice, pure altruistic motives will be strong enough for a majority of them to freely disclose their information.
There is potential for private businesses to build platforms that enhance the value of patient data and share the additional profits directly with patients. A good example is a platform for sharing patient data for research on Alzheimer’s disease. It is the nation’s most expensive disease, affecting over 5 million Americans each year, and yet still has no cure. Despite notable efforts, such as the Alzheimer’s Associations’ Trialmatch program, it is very difficult to find qualified patients to enroll in clinical trials.
A system in which interested individuals could share their detailed and identified medical records with Alzheimer’s researchers and pharmaceutical companies would both benefit society and save lives. The system could analyze data and alert patients if they qualify for a clinical trial, which would reduce the time and cost required to complete the trial. It could also diagnose the patient’s disease early or even find a treatment. Moreover, such system could easily financially reward patients for their data which are otherwise difficult to access. Policymakers should consider the long-term benefits of patients and refrain from imposing expensive regulations that could potentially slow down research and development activities in the healthcare sector.
The plan sets up a clash with Democrats, who say the administration is thwarting congressional intent and will starve the VA health system to pay for private care.
Last June, President Donald Trump signed a landmark law on veterans’ health care after months of tense negotiations. At the ceremony in the Rose Garden, Trump said the bill would deliver on his campaign promise to let veterans see private doctors instead of using the Department of Veterans Affairs’ government-run health service: “I’m going to sign legislation that will make veterans’ choice permanent,” he said.
Standing behind him, the leaders of major veterans groups looked around uncomfortably. What Trump called “choice” these veterans groups called “privatization,” and they’d been warning for years that it would cost taxpayers more money and deliver worse care for veterans. The veterans groups had endorsed the bill, but Trump’s description of it was not what they thought they were there to support.
The moment left no doubt that the Trump administration is determined to use the new law to expand the private sector’s role in veterans’ health care. The administration is working on a plan to shift millions more veterans to private doctors and is aiming to unveil the proposal during Trump’s State of Union address in January, according to four people briefed on the proposal. The people spoke on the condition of anonymity because they weren’t authorized to disclose information about the administration’s plans.
The cost of expanding private care is hard to predict, but VA officials have told Congress and veterans groups that it will range from $13.9 billion to $32.1 billion over five years, the four people said. Since the administration opposes lifting overall government spending, Democrats say the increased cost of private care will come at the expense of the VA’s own health system. Some lawmakers said the administration’s plan defies the purpose of the law they passed.
Trump’s first VA secretary said he was forced out by ideologues determined to privatize the department, which he called, in a New York Times op-ed, “a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.” The new secretary has repeatedly denied that privatization is the administration’s goal. But the fact is that Trump is doing exactly what he said he would do: The share of VA care delivered in the private sector has grown to 36 percent from 22 percent in 2014, and the administration is weighing policy changes that would move up to 55 percent of veterans to private providers, according to the people briefed on the deliberations.
VA spokesman Curt Cashour wouldn’t comment on those figures. He said the new policies are still under development but “will ensure that VA delivers veterans the best and most timely care possible with maximum continuity — whether it’s at VA or in the community.”
As a candidate, Trump spoke often about improving veterans’ care, and as president, he has returned often to that rhetoric. At his post-midterm press conference, he said, “I’ve done more for the vets than any president has done, certainly in many, many decades, with choice and with other things.” But he has plunged the VA leadership into turmoil and stirred anxiety over privatization, which many veterans oppose. And just this week, he was criticized for not participating in any public events on Veterans Day.
The White House declined to comment.
Democrats are eager to use their new House majority to stymie the Trump administration’s plans for the VA. “I am deeply concerned about efforts to profiteer off of veterans by undermining VA-administered care and expanding VA’s reliance on private care,” Rep. Mark Takano, a California Democrat who’s hoping to chair the House veterans committee, said in a statement. “It will be extremely important for the new Congress to conduct effective and frequent oversight of VA leadership so that this legislation is implemented properly.”
Despite the VA’s scandal-tainted reputation, studies have shown that the quality of VA health services compares favorably to private providers, and other research suggests private doctors are generally not prepared to handle veterans’ complex needs. Yet the politics of health care reform have made the VA a target for conservatives; they have attacked it as the epitome of bloated bureaucracy and held it out as living proof of the dangers of “socialized medicine.”
The VA has been purchasing private care to supplement its health system since 1945, and there’s broad consensus that doing so makes economic and medical sense in many instances. But in recent years, conservatives such as the Koch brothers have made it a political priority to shift more veterans to private doctors, under the banner of choice.
In 2014, after a scandal over long waits for appointments at the Phoenix VA, Congress created a new program, called Choice, to send veterans to private doctors if they would have to wait more than 30 days for a VA appointment or lived more than 40 miles from a VA facility. By the start of the Trump administration, the Choice program was running out of money and suffering from payment and scheduling problems.
Lawmakers got to work on overhauling the program and consolidating the VA’s various channels for buying private care. Sen. Jerry Moran, R-Kan., wanted to establish across-the-board guidelines, known as “access standards,” for when veterans could see private doctors. When the Senate veterans committee took up the proposed amendment, all the members, Republican and Democrat, voted against it, except Moran.
“The overwhelming majority of veterans in this country, despite a lot of bad media, as I think you understand, believe the VA provides quite good-quality care for them,” Sen. Bernie Sanders, I-Vt., said to Moran before the vote. “I feel a drip-by-drip effort — not by you, but just an overall drip-by-drip effort — to end up moving toward the privatization of the VA.”
Despite the committee’s 13-1 rejection, Moran’s proposal found a key ally in the White House: Darin Selnick, who used to work at a group backed by the billionaire brothers Charles and David Koch called Concerned Veterans for America and had signed onto an infamous proposal to dismantle the VA health system.
Officials in the VA, then led by Secretary David Shulkin, warned in meetings with lawmakers that what Selnick and Moran were seeking to do would explode the government’s costs by $60 billion to $80 billion a year, forcing the VA to cannibalize its own health centers to pay for private care, four people involved in the talks said.
“If you get the access standards wrong, it can have disastrous effects,” Shulkin said in an interview. “Whether intentionally or not, you could end up diluting the ability to maintain a strong VA. If access standards are too broad, the impact on the budget could end up being so significant that it would essentially become a system that’s spending out of control.”
But a bill to overhaul the Choice program couldn’t move forward without the White House’s support. So lawmakers struck a deal, according to four people involved in the negotiations. They adopted the access standards from Moran’s failed amendment, but added the word “designated.” That word meant the VA secretary would have the authority to decide, or “designate,” which access standards would make veterans eligible for private care and which were merely guidelines.
VA officials reassured Democrats that Shulkin would designate only three access standards, limiting the circumstances when veterans would automatically get referred to the private sector, the people said. Moran and Selnick, meanwhile, successfully got access standards into the bill. According to the people involved in the negotiations, both sides walked away thinking they would have their way later on, in the implementation.
The negotiations on the bill repeatedly put Shulkin at odds with other Trump officials, creating confusion about the administration’s position. After Trump fired Shulkin, at the end of March 2018, some VA officials warned that without his moderating influence, the Trump administration would use the bill to dramatically expand private care. “It’s dangerous now, it’s like a loaded weapon — they’re going to take access standards and run with it,” a former official involved in the negotiations said. “But everybody wanted to get a bill.”
With a looming deadline to act before the Choice program ran out of money, the compromise bill, now known as the VA Mission Act, gained the support of traditional veterans groups as well as conservative groups like Concerned Veterans for America. The nonpartisan Congressional Budget Office analyzed the bill’s cost on the assumption that it wouldn’t significantly increase the rate of veterans going to private doctors.
The Mission Act passed the House over the objection of Democrats who said it failed to address how the VA would pay for it, meaning the private care would come at the expense of the VA’s own hospitals. In the Senate, proponents waved off that concern. “We can work through this. This is a lot easier to work through than getting this bill to prime time,” ranking member Jon Tester, D-Mont., said at a press conference. “This is a minor issue.”
But soon after the Mission Act became law, the White House made clear that it opposed increasing the VA’s funding in order to pay for it — exactly as House Democrats had warned. “This funding can and should be provided within the existing non-Defense discretionary spending cap, and the administration opposes efforts to increase or adjust the cap,” Office of Management and Budget director Mick Mulvaney and then-acting VA secretary Peter O’Rourke said in a July letter to Congress.
Rick Weidman, the policy director for Vietnam Veterans of America, said Trump was breaking his campaign promises to veterans by refusing to fund the law he signed. “He got all the plaudits, then said we’re not going to pay for it,” Weidman said.
The same people who were pushing for more private care during the legislative negotiations are now the people leading the Trump administration’s implementation of the Mission Act. Selnick briefly returned to Concerned Veterans for America before becoming an adviser to the new VA secretary. Selnick was replaced in the White House by Drew Trojanowski, a former aide to the late Sen. John McCain, R-Ariz., who worked closely with Moran on the access standards proposal.
“Darin Selnick is a veterans health care policy expert who helped write the Mission Act,” Cashour, the VA spokesman, said. “There is no one more qualified to advise on the law’s implementation.”
It isn’t surprising, then, that Selnick’s interpretation of the bill has gained the upper hand: The VA is planning to “designate” all the access standards as making veterans eligible for private care, according to veterans groups and congressional staff briefed on the plan. Congressional aides said that would expand the use of the private sector much more than they expected.
“The fact that Congress put ‘designated’ in there, there was an assumption some would be designated and some would not be,” a staffer involved in the negotiations said. “Why else would you have the word?”
The Shadow Rulers of the VA
How Marvel Entertainment chairman Ike Perlmutter and two other Mar-a-Lago cronies are secretly shaping the Trump administration’s veterans policies.
Selnick did not respond to a message seeking comment.
Concerned Veterans for America’s director, Dan Caldwell, defended the administration’s interpretation. “It doesn’t make sense to create a set of standards and only use some of them,” he said. “The VA has been moving for years, even before the Mission Act, toward a model of using more community care. Attempting to keep more veterans in the VA’s brick-and-mortar health care system would be a huge mistake.”
The three Trump associates who’ve secretly steered the VA from Mar-a-Lago have also supported spinning off VA medical services to private providers. In a September 2017 email, the trio’s chief, Marvel Entertainment chairman Ike Perlmutter, proposed inviting private health executives to help the VA divvy up services that should be outsourced to private facilities. The new VA secretary, Robert Wilkie, said he never discussed privatization with the Mar-a-Lago trio and he’s not aware of any ongoing contact with them.
The VA official who’s currently running the Mission Act implementation, Assistant Secretary for Enterprise Integration Melissa Glynn, came from the same consulting firm as another member of the Mar-a-Lago trio, lawyer Marc Sherman. Sherman didn’t initially put forward Glynn’s name, but he did recommend her for the job, according to a person with direct knowledge of the matter. Glynn and a representative for Sherman declined to comment.
The Mission Act gives the VA until March to finalize the new access standards. Wilkie has not yet advanced a proposal to the White House and has rejected several drafts, three people familiar with the process said.
Wilkie has described the Mission Act as increasing veterans’ access to the private sector, but not with the goal of privatizing the VA. “It opens the aperture for a veteran who seeks health care on his own terms, which means that if VA cannot provide the care that veteran needs, and in a timely manner, that veteran will have the opportunity to seek care in the private sector,” Wilkie said in a recent NPR interview. “We’re not replacing. This is not privatization.”
Yet the access standards that Wilkie is considering could dramatically expand the VA’s use of private care, according to recent VA briefings to Congress and veterans groups. The numbers are hard to predict because more veterans might switch to using VA benefits instead of Medicare or private insurance if the VA would pay for them to see private doctors with no copay, and private doctors might bill the VA for more services because they’re paid by volume (whereas VA doctors are salaried). A 2016 commission on VA health care founded that if veterans could see private doctors without first getting a referral from the VA — because, for example, the VA failed to meet certain access standards — costs could increase by $96 billion to $179 billion a year.
“Any effort to automatically send veterans into the community, based upon arbitrary standards alone, would run counter to congressional intent and dramatically increase costs,” Tester said in a statement. “Notably, this comes at a time when the president has ordered all agencies, including the VA, to submit plans for significant budget reductions.”
The House veterans committee is planning an oversight hearing before the end of the year focusing on how the administration is implementing the Mission Act, according to the panel’s outgoing Republican chairman, Phil Roe of Tennessee. In a statement, Roe said the committee will “evaluate whether provisions are being enacted per congressional intent.”
By David J. Shulkin
David J. Shulkin in his office in Washington in 2017 when he was the secretary of the Department of Veterans Affairs. Credit Gabriella Demczuk for The New York Times
It has been my greatest professional honor to serve our country’s more than 20 million veterans. Almost three years ago, I left my private sector job running hospitals and came to Washington to repay my gratitude to the men and women who put their lives on the line for our country.
I believe strongly in the mission of the Department of Veterans Affairs, and nothing about my political experience in Washington could ever change that. I also believe that maintaining a strong V.A. is an essential piece of the puzzle that is the United States’ national security system: We can only expect our sons and daughters to risk their lives and fight for our freedom if we can keep our promise to care for them when they return home broken, injured or traumatized. There is no excuse for not holding up our end of the bargain. The mission set forth by President Abraham Lincoln to care for those who have “borne the battle” is a sacred duty that I will remain committed to always.
During my tenure at the department, we have accomplished a tremendous amount. We passed critical legislation that improved the appeals process for veterans seeking disability benefits, enacted a new G.I. Bill and helped ensure that we employ the right people to work at the department. We have expanded access to health care by reducing wait times, increasing productivity and working more closely with the private sector. We have put in place more and better mental health services for those suffering from the invisible wounds of war. We are now processing more disability claims and appeals than ever before and, for the first time, allowing veterans to see the status of their appeals by simply logging on to their accounts. Unemployment among veterans is near its lowest level in years, at 3.5 percent, and the percent of veterans who have regained trust in V.A. services has risen to 70 percent, from 46 percent four years ago.
It seems that these successes within the department have intensified the ambitions of people who want to put V.A. health care in the hands of the private sector. I believe differences in philosophy deserve robust debate, and solutions should be determined based on the merits of the arguments. The advocates within the administration for privatizing V.A. health services, however, reject this approach. They saw me as an obstacle to privatization who had to be removed. That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.
Until the past few months, veteran issues were dealt with in a largely bipartisan way. (My 100-0 Senate confirmation was perhaps the best evidence that the V.A. has been the exception to Washington’s political polarization.) Unfortunately, the department has become entangled in a brutal power struggle, with some political appointees choosing to promote their agendas instead of what’s best for veterans. These individuals, who seek to privatize veteran health care as an alternative to government-run V.A. care, unfortunately fail to engage in realistic plans regarding who will care for the more than 9 million veterans who rely on the department for life-sustaining care.
The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war. Working with community providers to adequately ensure that veterans’ needs are met is a good practice. But privatization leading to the dismantling of the department’s extensive health care system is a terrible idea. The department’s understanding of service-related health problems, its groundbreaking research and its special ability to work with military veterans cannot be easily replicated in the private sector.
I have fought to stand up for this great department and all that it embodies. In recent months, though, the environment in Washington has turned so toxic, chaotic, disrespectful and subversive that it became impossible for me to accomplish the important work that our veterans need and deserve. I can assure you that I will continue to speak out against those who seek to harm the V.A. by putting their personal agendas in front of the well-being of our veterans.
As many of you know, I am a physician, not a politician. I came to government with an understanding that Washington can be ugly, but I assumed that I could avoid all of the ugliness by staying true to my values. I have been falsely accused of things by people who wanted me out of the way. But despite these politically based attacks on me and my family’s character, I am proud of my record and know that I acted with the utmost integrity. Unfortunately, none of that mattered.
“Hold the physician in honor, for he is essential to you, and God it was who established his profession. From God the doctor has his wisdom, … his knowledge makes the doctor distinguished, … He endows men with the knowledge to glory in his mighty works, Through which the doctor eases pain and the druggist prepares his medicines; Thus God’s creative work continues without cease in its efficacy on the surface of the earth. Offer your sweet-smelling oblation and petition, a rich offering according to your means. Then give the doctor his place lest he leave; for you need him too. There are times that give him an advantage, and he too beseeches God that his diagnosis may be correct and his treatment bring about a cure. He who is a sinner toward his Maker will be defiant toward the doctor.” Sirach 38
By DIANNA CAHN | STARS AND STRIPES Published: December 22, 2015
SAN ANTONIO — The former commander of the U.S. Special Operations Command got personal during a conference of federal medical professionals.
For most at the conference, it was an opportunity to share advances in science and medicine and the latest tools in treating the prevalent or the confounding wounds of war.
Adm. William McRaven offered up a story. He took his audience to a day in 2010 when he was at Bagram Airfield in Afghanistan and got word that two of his SEALs had been shot in a close fight. McRaven ran across the road to the combat hospital and watched as the doctor struggled in vain to save each of his men. Unable to do so, the young doctor slid to the blood-soaked floor and simply wept.
A year later, McRaven met the widow of one of the SEALs and shared the details of that day. It gave her closure, she told him, to know that people who cared were present when her husband died.
The story was emotional, one told in order to drive home to his audience of medical professionals the power of compassion in medicine – even when it can’t save a patient’s life.
But in its telling, McRaven was forced to stop in his tracks and take a long pause before he could complete his story. For 10 seconds, the audience sat in silence as he struggled through his own emotions to find his voice. It drove home yet another lesson: No one – not the top warrior nor the highest star admiral – is immune to war’s toll.
“Ever since I’ve come back it’s been like that,” McRaven said later, during a brief interview. “I’ve told one story a dozen times and I still can’t get through it.”
McRaven now serves as the chancellor of the University of Texas, where he runs an academic system that has 14 medical institutions – eight universities and medical schools and six health science centers.
He sees himself as the CEO – running a large institution by building relationships with the people who work there and providing them with the resources they need. It’s a reasonable next step for a top military commander.
But he also brings with him a lifetime of experience with military medicine – from an active boyhood filled with regular visits to the military facility at Lackland Air Force Base in Texas where his father was an Air Force pilot, to his 37-year military career during which he suffered severe injury and raised his children on military health care.
As a child, the medical care seemed more like “a processing station,” he said. But his mother valued compassion in medicine and believed she saw those qualities in their many trips to the doctors.
Later, when there were complications during the birth of his children, McRaven saw the limitations of military medicine. He lived in Virginia Beach in the early 1980s, when Portsmouth naval hospital was in such bad shape, he said, that there were not blankets for the children’s’ ward and military families had to raise money for hospital supplies.
After a scandal, the military began pouring money into the hospital, and the change was “immediate apparent,” McRaven said.
It told the service men and women that the military cared, he said. And it made him realize how investment can lead to a dramatic improvement in quality and equally, how rapidly that can decline “if we fail to pay attention.”
Without a doubt, McRaven said, the training that special operations medics and corpsmen go through is the most demanding in the world – years of advanced trauma and emergency care training before the medic or corpsman can join a special operations unit.
He wondered if it was worth it, he said, until on July 18, 2001, McRaven was in a serious parachuting accident. It “ripped my pelvis apart” and tore all the muscles out of his stomach. He was in serious shock when the medics arrived. But he is convinced that the corpsman who treated him likely saved his life and at the very minimum, saved his way of life.
The latest wars have brought even more dramatic improvements to military medicine and tremendous investment in its infrastructure across the world from combat hospitals to medical air evacuations to trauma centers such as Landstuhl Regional Medical Center in Germany and Walter Reed National Military Medical Center in Bethesda. All of it, he said, is predicated on doctors who maintained their compassion.
But still missing is full medical collaboration between military agencies and the civilian world.
“All my presidents within the University of Texas system understand my emphasis on collaboration,” he said. “Collaboration should become the new normal.”
After 9/11, McRaven said, the wars flattened the hierarchy that had existed. Because of the nature of urban warfare, young troops were in charge of towns. It was risky, he said, but they did magnificently “and they learned to collaborate.”
“For us old folks out there, collaboration is tough, but it’s simple for the young kids who come up.”
Another example of collaboration were the civilian doctors – whether volunteers or reserve and National Guard – who brought their skills to the wars. They served alongside military doctors, taking care of service men and women, and at the same time, got experience in types of trauma care they would not have been exposed to at home.
McRaven once again turned the conversation personal. Five years ago, he was in Afghanistan when he was diagnosed with chronic lymphocytic leukemia, a typically slow-growing cancer that attacks normal blood cells, making it difficult for the body to fight infection. The doctor told McRaven he needed to be sent out of Afghanistan immediately, have his spleen removed and start on chemotherapy. He told the admiral his career was over.
But by the time McRaven got home, his wife had done some research and arranged for her husband to see a top civilian oncologist who looked at his numbers and said McRaven’s cancer was indolent and while he needed to be monitored, he was fine.
The doctor said when it came to oncology, the military was still practicing medieval medicine. The doctor offered to get together with military oncologists and teach them. McRaven eagerly accepted but when he tried to organize it, he hit up against a wall.
“Everybody put roadblocks in front of me,” he said. “I tried for a year and a half to pull great oncologists from the civilian sector to be able to have a forum with military doctors but we couldn’t pull it off. Why is that the case? That should never be the case.”
Fourteen years of war has been a boon for military medicine, McRaven said, and will likely save thousands of lives in the future. But collaboration between military and civilian health care is crucial moving forward, he said.
The nation’s largest physician group is calling for an end to electronic health record “abuse” which is relegating doctors to the role of data entry clerks and leading to widespread professional burnout.
According to the American Medical Association, the problem of physician burnout is impacting about 50 percent of practicing doctors, and EHRs are squarely to blame, given that for every hour physicians spend on direct patient care they spend two hours on EHR data entry and other administrative tasks.
“Doctors are spending excessive time on data entry, contributing to physician burnout, with implications for quality of care,” AMA President Barbara McAneny, MD, told the opening session of the group’s Interim Meeting, held this week in National Harbor, Maryland.
In addition, McAneny charged that “much of the EHR technology is dysfunctional” and fails to provide clinicians with the kind of clinical information that they require to perform their jobs effectively.
“It grew out of the billing software, so it doesn’t give us the decision support or the information we need,” she said. “The vendors of these systems like to paint doctors as Luddites who don’t like technology. They need to understand that we love technology—we just want technology that works.”
Making matters worse, McAneny contends that health plans and hospitals “use data blocking or inconvenience to keep patients trapped in their systems.” Ultimately, she concluded that “doctors just want the results of the tests.”
Likewise, AMA CEO James Madara, MD, told the audience that in healthcare today there are “vast structural gaps (in) achieving true data liquidity and interoperability” and “gaps in how clinical data is organized at the point of care (as well as) gaps in availability of delightful tools that make more effective use of physician time.”
Madara warned that the “lack of timely, trusted and better organized data—as well as a lack of data liquidity—all conspire to diminish the visibility of our practices.” He added that, “it’s like driving a car with a windshield covered in snow.”
To address this shortcoming, AMA last year launched a new digital platform—the Integrated Health Model Initiative (IHMI)—designed to improve, organize and share healthcare information among stakeholders through a common data model.
According to Madara, the IHMI data model delivers more accurate, actionable, clinically validated and organized data to better serve patients.
“IHMI has already developed a prototype demonstrating how remote blood pressures, taken in the right context, can be captured and organized within a distant medical record, without archaic paper, faxes or note keeping,” he said. “This coming year, as part of the model to address hypertension, IHMI will also capture often overlooked elements, such as patient goals and social determinants of health.”
Madara added that AMA has recruited Tom Giannulli, MD, to lead the next phase of IHMI as chief medical information officer.
“Tom is both a physician and bioengineer and launched leading-edge digital companies, such as the first EHR for the iPhone—a company that was later acquired by Epocrates,” he concluded. “These are not trivial projects, and they will take some years to develop and implement. But imagine if we had deployed these same patient- and physician-focused approaches years ago when our current electronic platforms were being built—our healthcare system would be in a far better place today.”