Accelerating VA's Prominence as a Learning Healthcare System Despite Shifting Tides
Having been a health services researcher in VA for nearly 30 years, I have observed that the system appears under constant duress, some times more than others. Every President taps new VA leadership, and we await their mission and vision, and how to operationalize that vision into serving Veterans. Congressional relationships run hot and cold, especially in election years when VA can be a target for political ambitions, while we speculate on the prospects of the next year's federal budget for VA and VA research. For those of us who conduct partnered research with national program offices in the hopes of fostering evidence-based practice and policy, we observe these recurring events with apprehension as operations funding for evaluation and quality improvement ebbs and flows in often unpredictable ways. Ultimately, we never know if the funds or, for that matter, our partners will be there the next year. This has become standard operating procedure.
What is less standard are the pressures and threats to the system that have perhaps unexpectedly moved VA toward being a learning healthcare system (LHS). When I started at VA—the same year as the release of Tom Cruise's Born on the Fourth of July—there was no national primary care program. Veterans had become inured to the hours-long waits in walk-in clinics as residents repeatedly asked them the same questions visit after visit because their paper medical records were often not available. A few years later, prospects of healthcare reform under then President Clinton led VA to assess Veterans' likely response to getting a "national healthcare card," which would have enabled them to seek care elsewhere should the reforms go into effect. Data suggesting that some three of four Veterans would leave VA created a survival threat to the system.
Instead of folding, VA rapidly implemented primary care teams, using data from an HSR-designed national survey as a roadmap for designing new models of care. Thereafter, then Under Secretary for Health Kenneth Kizer transformed the system through strategic planning and supportive legislation that reformed eligibility, capitated funding, launched VA's electronic medical record (EMR), created accountability through executive performance plans with explicit metrics, and involved HSR&D researchers in system evaluation and research. The result was a national LHS without parallel in the United States, as evidence mounted that the resulting VA system outperformed Medicare and private-sector care.
Within roughly 10 years, VA's pre-eminence was thought to have languished with the advent of patient-centered medical homes and broader implementation of EMRs, integrated healthcare delivery systems and other innovations outside VA. In reality, VA's quality advances had led to large increases in Veteran utilization without the proportionate budget increases needed to accommodate demand, increasing pressure on the system and leaving less organizational slack for innovation. In the late 2000s, VA primary care leaders began planning in earnest for VA's medical home model—Patient Aligned Care Teams (PACT)—with HSR-driven innovation and evaluation embedded in every step of implementation through the operations-funded PACT Demonstration Laboratory Initiative.
Initial funding for PACT was taken off the top of VA budgets, with funds returned to facilities when required changes (e.g., 3-to-1 staff-to-provider staffing ratios) were made. Guidance on how to make these changes at the outset, however, was limited and training resources variable, while the total number of VA quality metrics had grown to more than 750 red, green, and yellow boxes in massive spreadsheets that local managers had to weed through. PACT rollout was also challenged by variable implementation, provider burnout, and less-than-hoped-for early outcomes, but this early evidence drove national adjustments and redesigns reflective of an LHS in action. Subsequent analyses have demonstrated impacts of higher levels of PACT implementation on patient and provider experience, quality, and use. By 2014, the "access crisis" increased pressure on PACT providers to see more patients in the absence of full implementation and resources.
Legislation aiming to solve access problems through expanded use of community care has been tied to political agendas supporting privatization of Veterans' care, reflecting VA's latest survival threat. At the same time, comparative studies demonstrate that VA care is, by and large, still better than care in the community. How VA ultimately weathers the current storm is yet to be determined, but VA's integration and alignment of science with informatics, incentives, and culture dedicated to systematic improvement on a national scale may yet propel VA to the full promise of an LHS. As Nietzsche said, "that which does not kill us makes us stronger," as each jolt to the system appears to awaken new waves of innovation.
HSR&D's focus on LHS research, in addition to provider behavior and Veteran engagement, should come as no surprise. VA's embedded research program has provided the foundation for innovation, implementation, and opportunity for 90 years, first as an incentive to attract highly-qualified physicians, and later, with the advent of VA's HSR&D Service, to establish the groundwork needed to generate relevant evidence and innovation for ongoing system improvement. HSR&D can serve as the substrate for transformational evidence-based change and concomitant improvements in population health, if we can communicate our scientific findings in ways that the many stakeholders in Veterans' care can easily understand and use. VA HSR&D researchers must further develop their competencies in multilevel stakeholder engagement and in communication of evidence and LHS principles to preserve our continued value, relevance, and impact.
We have been testing these strategies for several years now through the VA Women's Health Research Network (WHRN), which is comprised of a national consortium of researchers and clinician educators, a practice-based research network (PBRN), and a multilevel stakeholder engagement initiative. WHRN provides training, technical support, and dissemination to advance VA's women's health research agenda, leading to briefings to diverse audiences within and outside VA. Now spanning 60 VA medical centers and over 300 community-based outpatient clinics, which together serve half the women Veterans seen in VA, the PBRN facilitates multisite research, which is often required to include sufficient numbers of women Veterans. As women's health research and PBRN use grew, the importance of multilevel stakeholder engagement in conducting practice-based research became more apparent, resulting in recently completed work to better understand what it will take to more consistently reach LHS goals. Initially, we relied on top-down research deployment, but true PBRNs provide engagement opportunities for frontline employees.
We began fielding practice scans (brief surveys about local care arrangements) and card studies (anonymous 1-page feedback surveys to women Veterans in clinic) that are collected in a few weeks rather than a few years, with summary results shared with participating sites and national program offices. We launched a Collaborative, where 25 sites voted to adopt already tested innovations from a prior PBRN trial, without additional resources, with the exception of training and technical support provided by WHRN at a distance. Lessons from implementation science and engagement are being redeployed to train frontline providers and staff how to implement evidence locally, and how to communicate more effectively with their teams, local facilities, and VISNs. The external evidence and support we bring are, in turn, being systematically integrated with local data and experience as they deliver care in real-time. Our trial evidence suggests improved team functioning and lower burnout, resulting in built-in champions for ongoing innovation, dissemination, and spread. Frontline providers' testimonials and hands-on support of their colleagues go well beyond what we as researchers can often provide. Next, we are working on engaging women Veteran patients as members of the learning team, leveraging local grassroots groups and our national Women Veterans Council.
Whether these efforts bear fruit or not, we see the elements of VA's already-present LHS in everything we do and observe: a workforce dedicated to LHS principles if only given the opportunity to learn and share; infrastructure and informatics capable of rigorous internal evaluation and formative feedback; and a shared mission and vision to bring evidence to bear on improving Veterans' health outcomes and quality of life. During VA Research Day on the Hill, Dr. Carolyn Clancy described VA's research program as the system's "crown jewel," not only because of the promise of scientific discovery, but also the tacit knowledge of our roles as key players in VA's prominence as a LHS. In the months and years ahead, we will weather the shifting tides together, as we have before, by bringing our collective efforts to bear on priority problems faced by VA and the Veterans we serve, bridging the gap between innovation and implementation, and turning challenges into opportunities for science to contribute meaningful solutions.