Dr. Shereef Elnahal, Under Secretary for Health, U.S. Department of Veterans Affairs
Moderator: Maria Aspan, FORTUNE

Brainstorm Health 2023 - The VA: Modernizing Care For Those Who Served 

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The VA: Modernizing Care For Those Who Served 

I hope you enjoyed and learned from your lunch round table. We're going to start our afternoon of main stage conversations with a topic that is so vitally important and maybe doesn't get talked about enough. And that is the health well being and care of Americans veterans and how that critical mission gets undertaken. Nine million veterans are registered with the Veterans Health Administration to receive care that is the largest integrated health care system in America and overseeing it is not a small task. Doctor Sharif Nahal is the undersecretary for health at the US Department of Veterans Affairs. Doctor Elna is gonna join Fortune, senior writer Maria Aspen to talk about the big issues the va is dealing with right now which include suicide prevention, toxic exposure, the modernization of electronic health records, delivery of care. Much more. Please welcome to the stage, Dr Elena Hall. Thank you so much for being here and thanks so much for having me. You were confirmed to this role in July after it had officially sat open for five years, um during which there was really nothing going on in the public health world. Um What's it been like? Filling this role taking on this massive responsibility. And how are you prioritizing? Well, I first want to thank you Maria and Fortune for having this conference and getting leaders of all stripes together to talk about the future of health care and what we can do on behalf of our patients. And I really believe that we have the best patients in the world. We have people who wore the cloth of our country who, you know, experienced injuries, exposures to toxins and a lot of problems as a result of defending our freedom. And now, uh I have the honor of uh taking on a role where we can make progress on uh many of their issues. Uh For me, it's really been focused on doing the simple but important stuff better for veterans, getting veterans sooner, appointments be more responsive to veterans when they call us. And a lot of that has to do with doing the basic things, right. So getting enough people on board, we're on a hiring spree. We've hired over 27,000 people since the beginning of this fiscal year, we're likely to break 400,000 employees, hopefully by the end of the fiscal year and all of that's important because the president, as of last August signed a groundbreaking piece of legislation called the Pact Act, which finally afforded health care coverage and the ability for us to be there for veterans who were exposed to burn pits during their service in Iraq, uh more coverage for folks deployed in the Vietnam era conflict. Um and so many other exposures, Camp Lee, we're finally able to presume that their problems are related to their service and therefore uh cover the full cost of their care uh and be there for them with their health care. So it requires staff, it requires focusing on access to care, as I mentioned and it requires implementing all other aspects of that legislation, including researching uh many more conditions that may be associated with these harmful exposures. You know, uh Veterans Affairs. Put out an announcement today. I believe that there have been 500,000 claims uh filed since the pact Act was signed in August. How practically how have you dealt with expanding benefits uh in such a short period of time? Yeah. So uh our secretary was very clear since I came on and my colleague, uh Josh Jacobs, the undersecretary for benefits was just confirmed earlier today. Uh But he's been in the role now for just about as long as I have. Um And what I can tell you is we have been planning for a surge in benefits for quite some time. The backlog and the total inventory of claims is expected to go up and already has been going up as a result. Both he and I are on a hiring spree as I mentioned, getting enough people processing these claims in place to make sure those benefits are adjudicated as fast as possible. And then on my end making sure we're building our health care capacity as much as possible so that we don't see a backlog in appointments and increasing wait times, but rather at the very least level, if not improving access, all while we bring more care and more benefits to more veterans. I want to ask another about another big project and the basic thing that is not going very well. Electronic health records. Last week, the veterans, uh veterans affairs paused um its rollout of the $16 billion oracle C contract after, after there were at least four veteran deaths linked to um problems with this project. What went wrong and what's next? Well, I think the major issue uh with the implementation of the new health record was that the end user was not necessarily prioritized in terms of their experience from the beginning. And that means the product wasn't configured to their needs. And as a result, it takes, you know, 1.5 times as long to do most things as it did in our legacy system. At the end of the day, your success or failure as a health care leader depends upon that frontline employee having an easier workflow and doing their work more efficiently and effectively and frankly being satisfied with their work all the while. And when we first ruled this out, uh in the five sites that it exists now that simply was not happening for our end users. Um So instead of plowing through the initiative for reasons other than what's most important, which is enhancing care for veterans. Uh The secretary uh and I and the leader of that program decided to do a full reset where we're going to focus all of our resources and time prioritizing the end users at the sites where the Cerner system exists and iterative, changing the configuration of that product, changing our processes, training, commensurately uh to make it better. Are you stuck with that product? That electronic health record system? Well, I think there's one reality that is just not going to change, which is that we need a new electronic health record. Uh The sustainability of our existing system, which is a homegrown system. It was in fact one of the first E HR s in the United States and in the world uh developed actually under the radar by some of our clinicians many, many years ago. And so there's a big affinity for the system because it was designed for clinicians. E hr s in the private sector are of course designed for clinical care, but they're also designed for revenue cycle and billing. We don't have to worry about that thankfully in B A. Um And so as a result, we've had this system that is tailored to clinicians needs on the front end. But the sustainability of that system is just getting harder and harder, old programming language, legacy engineers who know this system that will eventually not be here and we have to change it. And so we've already on been on a pathway with Cerner and the Cerner Millennium System. Uh We have a lot of private sector partners who use the system and it works. So I know we can get there. And again, it involves people process technology changes that have to happen over the course of at least the next year, if not longer. And what happens in the interim? Um How will you be dealing with electronic health records at all the sites that where the new system is not rolled out? We are confident that the current system can be sustained for some time uh with investments uh with, you know, the personnel that we have who are experts in it, that's not going to last forever. The effort for changing the electronic health record actually started 20 years ago. Uh with many different uh starts and stops and different ideas about how to achieve that. I think we can move to a commercial off the shelf system. But again, the way the system works right now is just not acceptable to our end users. Changing topics a little bit. I want to ask about veteran suicide, which you have called a public health scourge. What are you doing to address and prevent that? So veteran suicide is really one of the most important public health problems. We have to focus on as a country. The reality is more post 9 11 veterans have died by suicide than those who died in the conflicts to which they were deployed. And that's a really tragic fact. We have to band together as a country and solve this. And I use that sentence very deliberately because it's not just the V and that has everything to do with our approach. Of course, we have to make sure our crisis response is robust. The veterans crisis line has to respond to calls within seconds, coordinate care that needs to follow up. We're focused on that. We have excellent performance with our veterans crisis line even though we've seen increases record breaking increases in the last several months. Uh But we also have to work upstream and focus on the social determinants of health as well. And a lot of that involves fortifying the social network around veterans. So we funded uh to the tune of over $50 million community based organizations that are fortifying that social support network around veterans, making sure that uh folks have assistance from the point of transition uh in the military uh to, you know, much later in life. Um And a lot of that has to do with community veteran engagement boards, uh getting uh stakeholders to really support veterans in all aspects of their life. I'll also say that there's a lot of evidence based public health measures around what we call lethal mean safety that really matter. Introducing a gun lock and a lot of our veterans own guns can be a life saving measure. Adding seconds minutes to the period of time it takes for a veteran to activate their gun can be a moment where you can intervene. It can be a chance for that veteran to think twice about doing that. So there are many ways of doing this gun locks are one of them having, you know, two point gun locks is particularly helpful where the caregiver or a spouse of a veteran has to be present to be able to unlock the gun. And of course, there's different levels of adoption there. But lethal means safety is a huge measure that can acutely prevent suicide while we address the root causes veteran by veteran. I'm also fascinated by the Housing First program. The V has been doing because it does address homelessness as a way of treating the whole patient. I wondered if you could talk a little bit about how that works into veteran suicide and mental health. Yeah, I'm just so proud of our homelessness team. You know, veteran homelessness has been another scorch, you know, no veteran should be homeless. These are folks again who sacrificed themselves and served our country. And so just over the last several years, we've seen a substantial reduction in veteran homelessness because we now have the formula end to end on what we can do to assist folks in getting into permanent housing. So last year, we shattered our, our goal of housing, 38,000 veterans, we housed over 40,000 into permanent housing, not just transitional. And on top of that, we are using the housing first method which really focuses and prioritizes housing before all of the wraparound services because that stable social environment is so important if you have any hope of preventing recidivism and getting folks out of the difficult situation they're in. And so we have the benefit of course, of coordinating directly with housing and urban development. The hud bash vouchers specifically tailored to veterans help with rent assistance. And at the same time, we provide health care, we provide food and security work and so many other services to wrap around veterans in the system. So we have the same goal this year, 38,000 veterans, we also have a goal of making sure that 95% of veterans we do place in permanent housing do not return back to homelessness because right now, we're seeing the number of absolute homeless veterans fall every year, which is a good thing. We can't let that cycle go backward regardless of the global macroeconomic trends. I wonder if you could close by telling us a little bit about your approach to innovation, which I believe was your focus during your first stint at the va how do you bring that to solving the addressing the massive challenges that you're now overseeing? Yeah, I spent time in my first stint at the building, the Innovation Infrastructure, uh and the structure that we use to identify best practices and scale them across a system of 170 medical centers, hundreds of clinics. Um And I think that infrastructure has led to a lot of amazing developments that are directly relevant to veteran care. I really think the players focused on making the daily life of front line employees and health care systems easier will succeed in the long run. Because right now, we have just a legacy of patchwork systems that every large system has acquired over time. They don't talk to each other. They require significant manpower to make sure those interfaces are sustained and that the workflows are achievable for the front line. But we haven't yet seen innovators as nearly as much as we should look at that front line employees experience and extend outward with human centered design to figure out how they can actually be assisted with new technologies like A I Another lane where we're really focused is making sure that the really tangible emotional aspects of care that veterans enjoy can be reproduced in a virtual environment. So we have a big push on augmented reality, virtual reality. We have 60 V medical centers using these technologies to assist veterans with PTSD, reproducing, triggering mechanisms and training veterans to be able to sustain and do well with them. But also things like phantom limb pain if somebody is an amputee, they can often sense that their limb is still there. And in fact, feel pain in that limb. If you wear augmented reality goggles that reproduces a mirror image of your other leg for a lot of veterans, their pain goes away. So think about the potential of bringing in virtual group visits with other veterans across the country, peer to peer support, just working again backward from what veterans need and using the new technology, whether it's A I or X R to achieve that is really our focus. Thank you so much. I'm afraid we're out of time, but thank you so much for making the time to be here today. My pleasure.