Editorial: VA’s Scheduling System Betrayal

Four months after a waiting list scandal forced the Secretary of Veterans Affairs Eric Shinseki to resign, I asked the new VA Secretary, Robert McDonald, if he thought the VA had enough money in the budget to procure a new commercial scheduling system to ensure that veterans could get the care they needed, when they needed.

“We tried to put the money we needed in the act that was recently passed. I can’t predict the future,” McDonald said in answer to my question during a press briefing at VA’s headquarters in Washington, D.C. “But I think we’ve done a good job of that. As we work through this scheduling system, we’re going to be very eager to find an off-the-shelf product that is proven effective. The off-the-shelf product will become very important as we move forward. I thought it was a brilliant piece of work by [Deputy Secretary Sloan Gibson] and the team to come forward and say, ‘we are going to take an off-the-shelf product.’ ”

Eighteen months and $11.8 million later, VA’s resolve is wavering. VA chief information officer LaVerne Council and Veterans Health Administration Under Secretary for Health, David Shulkin, told Congress Thursday that they are now unsure how or if they will proceed with the $624 million Medical Appointment Scheduling System (MASS) contract awarded last year.

“We want to be certain that continuous modernization of a 40-year-old electronic medical record is an appropriate decision,” Shulkin said.

Instead of moving out aggressively on a commercial system with a proven track record, Shulkin and Council did the unthinkable: They decided to develop their own in-house upgrade to the scheduling module of VA’s main electronic health system, known as VistA. That’s right—even after a major scandal involving deliberate manipulation of the scheduling system that led to the deaths of veterans, VA thought it was appropriate to tackle the development themselves.

VA is testing an intermediate VistA Scheduling Enhancement tool at two medical facilities. If the employees like it, VA will continue with the deployment.

As a veteran, such inept decision-making is infuriating. But what makes the situation worse is the fact that these decisions are being made because of money—the money that McDonald told me in 2014 was already in the budget for a new commercial system.

“The entire VSE rollout will cost taxpayers $6.4 million. If we roll out MASS, which is an absolute option for us, the pilot alone will be $152 million,” Shulkin said, explaining to lawmakers how VA was struggling to balance the needs of veterans with the agency’s duty to be good stewards of taxpayer dollars. “It will take us 10 months to roll it out in three sites, and that’s if VA stays on schedule with its pilots,” he said. “We have not ruled out MASS. I want to be absolutely clear about that.”

Shulkin and Council may not have ruled out a commercial replacement system through MASS, but that doesn’t explain what he said next about VA’s plans for the VistA Evolution pilot testing that is underway.

“I have the user evaluations, which are tremendous,” Shulkin said. “It’s planned to roll out to 11 VA [facilities] by the end of this month or the next six weeks, and then a national rollout.”

To his credit, Shulkin got one thing right when he acknowledged “we still have an access crisis” at the VA. Yes, something has to be done to improve the situation in the near term, and VSE is an important part of that. But to consider not moving forward with MASS—a comprehensive commercial health management system awarded under a competitive bidding process—is tantamount to reneging on the promise made to veterans that the scheduling and access problems will be fixed.

McDonald brought Shulkin and Council (who worked for McDonald at Johnson & Johnson) to the VA to inject new thinking into the bureaucracy. But they have failed. The VA is a bureaucracy with a culture beyond repair. The wounds of the scheduling scandal are not even close to being healed and VA’s leaders have handed the task of modernizing that system right back to the people who created it.

“This seems like déjà vu all over again to me,” said Rep. Ann McLane Kuster, D-N.H. “VA has already wasted nine years, $127 million without an update to its scheduling system, after finding a commercial product and abandoning that for an in-house solution that could not deliver an adequate update. We cannot and will not let this happen again.”

  1. Anonymous | - Reply
    Unfortunately, the $600 million scheduling systems from Epic is also based on outdated technology. In fact, the owner of Epic started out as a developer at the VA and derived her own EHR from what she took from the VA. It's not a coincidence that both systems are written in mumps and use the cache database. One difference is that Epic's client software (Epic is an old style client-server system) is written in Microsoft Visual Basic - a technology that was discontinued by Microsoft in 2005. It's no wonder that the VA is hesitant to spend the huge amount required to replace their old scheduling system with another outdated system. The best option would be a complete replacement of VistA (including its scheduling component) with a modern, cloud based enterprise class EHR. None of the legacy EHR vendors offer such a system, but there is at least one such new system available today and several more coming in the next few years.
    1. Anonymous | - Reply
      It is too bad that all of your facts are completely wrong. You apparently read a book from the 1980's to write your slanted dissertation. The solution being implemented by VA is lipstick on a pig and does absolutely nothing to enhance a Veterans Access to Care. The same invisible appointment slots that exist in VistA today, are still going to be invisible with the new interfaces that are being deployed as part of VSE. Secondly, the Veteran Appointment Request mobile application is simply a way for Veterans to request an appointment. It is the same, protracted, waiting list that Veterans endure today. Epic's Cadence Scheduling system leverages the extreme performance of the Cache database, one of the fastest DB's in existence, and feature rich web and mobile user interfaces, along with business-rules driven appointment scheduling to fill every available appointment slot within the Medical Center or CBOC, and further enhances access to care by searching across facilities to provide appointments in locations across VA. Something that VSE/VAR & VistA cannot do today. At the end of the day, there is little efficiency and enhanced visibility in VA's custom solution. I would also like to point out that VA has spent far in excess of $6M to build VSE/VAR to date, and the $152M to pilot Epic's Cadence is an order of magnitude higher than the price proposed for the pilot.
  2. Anonymous | - Reply
    Maybe instead of spending that kind of money on a worthless computer program they should use it to hire more Doctors and Nurses, not to mention Mental Health professionals. $600 million would go a long way to help with the short fall. It is not the scheduling in the computer it is the availability of the services, that is where the shortfall is.
  3. Anonymous | - Reply
    Comment above brings up a good point. But, we need both. You need the computer system to understand the demand and shortfall. And of course the doctors/nurses/facilities to meet the needs. We also need one EHR across DoD and VA. While in theory the Defense Healthcare Management System Modernization (DHMSM) program will mean a new EHR for DoD that can share information with VA systems - wondering if this will really pan out.
  4. Anonymous | - Reply
    it is not the system was flawed, it was the way it was used. Any system can be abused.

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