Emergency Medicine in the VA: The Battleship is Turning

Abstract

The US Department of Veterans Affairs (VA) has long had a reputation for making emergency medicine a low priority, and change is overdue, critics charge. After dramatic upgrades in other areas, the system is now working to bring its emergency departments (EDs) up to code. The critical challenge will be whether these efforts can overcome chronic funding shortages and rising pressures on the system's capacity.Mainstream media attention arguably paints a distorted picture of the VA, magnifying isolated or even irrelevant incidents and ignoring the qualities that have made many veterans fiercely loyal to VA hospitals. For millions of patients, the VA provides superb care at no personal cost. Some commentators1Longman P. Best Care Anywhere: Why VA Health Care Is Better Than Yours. Polipoint, Sausalito, CA2007Google Scholar describe the VA as a worthy model for a future national health care system.Over the past decade and a half, the Veterans Health Administration (VHA), the VA's medical branch, went from being a near-synonym for slipshod care—and a rhetorical punching bag for opponents of public sector involvement in health care delivery—to an example of how a large system can perform well clinically by realizing economies of scale, eliminating obstacles associated with private insurance, and wisely implementing medical informatics.2Stires D. Levenson E. How the VA healed itself.Fortune. 2006; 153 (May 11): 130-136PubMed Google Scholar Structural reorganization and procedural reforms3Kizer K.W. Pane G.A. The “new VA”: delivering health care value through integrated service networks.Ann Emerg Med. 1997; 30: 804-807Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar initiated by Kenneth W. Kizer, MD, MPH, undersecretary for health from 1994 to 1999, then upheld by his successors (currently Brig. Gen. Michael J. Kussman, MD, US Army, Ret.), have instituted rigorous accountability mechanisms, sharply upgrading the system's performance as measured by external reviews4Asch S.M. McGlynn E.A. Hogan M.M. et al.Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.Ann Intern Med. 2004; 141: 938-945Crossref PubMed Scopus (418) Google Scholar, 5Jha A.K. Perlin J.B. Kizer K.W. et al.Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.N Engl J Med. 2003; 348: 2218-2227Crossref PubMed Scopus (567) Google Scholar, 6Arnst C. The best medical care in the U.S. Business Week.in: 2006: 50-56Google Scholar, 7Oliver A. The Veterans Health Administration: an American success story?.Milbank Quarterly. 2007; 85: 5-35Crossref PubMed Scopus (138) Google Scholar and surveys of veterans.8Stein R. VA care is rated superior to that in private hospitals.Washington Post. 2006; (Jan. 20): A15Google ScholarThe VA, a cabinet-level department, operates the nation's largest integrated health care system: it includes 153 hospitals along with over a thousand other sites of care such as ambulatory/outpatient clinics, nursing homes, and rehabilitation programs. In 2006, VA facilities treated over 5 million people, including 773,600 inpatients and over 60 million outpatient visits. With a statutory mission comprising education, research, and civic emergency management as well as clinical care, the VA has also helped train over half the nation's practicing physicians. For any institution that large to implement change, the metaphor of a large naval vessel fits. Battleships and aircraft carriers do not turn on a dime.EDs, Near-EDs, and ED WannabesAmid the VA system's overall improvements, however, it is only beginning to make comparable strides in emergency medicine. A 1993 study in Annals by Gary P. Young, MD,9Young G.P. Status of clinical and academic emergency medicine at 111 Veterans Affairs medical centers.Ann Emerg Med. 1993; 22: 1304-1309Abstract Full Text PDF PubMed Scopus (8) Google Scholar observed that in 111 VA hospitals surveyed, what passed for EDs varied widely in the scope of services provided and the preparation of physicians involved. While all these institutions provided emergency care, and all but one were open 24 hours a day, 7 days a week, only 19% of them had staff physicians either residency trained or board certified in emergency medicine. Non-emergency-trained physicians (staff and moonlighting non-staff) were performing emergency care in facilities variously designated as EDs, emergency rooms, evaluations and admissions, admitting offices, or areas for acute, urgent, or ambulatory care. None of these institutions was a Level I, II, or III trauma center, though 96% were capable of providing appropriate care to patients with minor trauma. House staff specialties included emergency medicine in only 7% of these hospitals.Some of these institutions were well aware that emergency medicine was being shortchanged—26% were either actively recruiting or planning to hire trained and/or board certified emergency physicians—but the clear conclusion, confirmed by external pressure from The Joint Commission and other reviewing bodies, was that emergency care in the VA system was not up to community and national standards.Allocating tight budget resources elsewhere may have had some justification, considering the specialized patient population. “VA emergency departments don't get as much true emergency medicine as everywhere else,” says Kessler. “Many do not get ambulance runs from 911; hardly any trauma comes here… [and] most VAs don't see any pediatrics and few women.” Depending on the number of veterans in the catchment population, VA EDs are also typically smaller than those of other hospitals; in some, studies of usage patterns have indicated low patient volume after hours, suggesting that 24-hour coverage was not optimizing resources.Even after the reforms initiated under Kizer, procedures and facilities varied widely between centers. Kristi L. Koenig, MD, during her service as national director of the VA's emergency management office from 1999 to 2004, reports, “I heard a saying at the VA: ‘If you've seen one VA hospital, you've seen one VA hospital.’” Standardization of procedures, she notes, has been a critical goal since the Kizer years.Dr. Koenig was the first official appointed to her position (focusing largely on disaster preparedness) after it was retitled to require an emergency physician. “They were already looking at bringing in emergency medicine expertise” at the time she was hired, she says, and the effort to redress the shortage of emergency medicine specialists has continued. Now director of public health preparedness and professor of clinical emergency medicine at the University of California at Irvine, Koenig places the shortage of board certified emergency medicine colleagues in a historical context. “Emergency medicine is a relatively new specialty, only around for about 30 years,” she notes.Anachronistic EnvironmentAnother emergency physician (who preferred to speak anonymously) described a lingering resistance to an emergency medicine practice philosophy on the part of the internal medicine specialists who still run most of the VA's EDs and related facilities.“It's the only emergency room I've seen that does not have all EM physicians running it,” this physician commented. “They're internists, and the way they approach patients is not like an emergency perspective. They take hours to work them up…. They underestimate or overestimate certain things, based on their experience. As emergency physicians, we learn to make sure we rule out the most dangerous and most prevalent first.”While praising certain aspects of the VA's emergency care, particularly its capacity for handling psychiatric and substance abuse problems, this physician compared the atmosphere to the 1970s, before emergency medicine was recognized as a distinct specialty and department, when emergency rooms had separate medical and surgical sides. “When I've discussed this and said, ‘Why don't we have more ER physicians?’” internist colleagues have countered, “‘Why are you making the assumption that bringing in ER physicians would improve care?’”A Harvard study published in 2004,10Landrum M.B. Guadagnoli E. Zummo R. et al.Care following acute myocardial infarction in the Veterans Administration Medical Centers: a comparison with Medicare.Health Services Research. 2004; 39: 1773-1792Crossref PubMed Scopus (34) Google Scholar finding problems in the care that veterans with acute coronary syndromes were receiving at VA hospitals, “pinpointed the EDs as the place to begin improvements if you wanted this care to change,” says Gary Tyndall, MD, national director of emergency medicine (a new position within the VHA) and director of the emergency department at the Syracuse VA Medical Center. “VHA recognized this and began to concentrate on adding resources and developing an administrative process to look at EDs and to make recommendations for improvement.” A new Emergency Medicine Field Advisory Committee (EMFAC) has formed and prepared a report, under official review at this writing.EMFAC members Tyndall and Olszyk summarize some of its statistical findings: of 153 VA hospitals surveyed nationwide, 120 now have departments that meet new criteria for full ED status; one has a contract to provide services at an outside facility, and there are 34 urgent care centers (17 at facilities with EDs). Two of the EDs (Wichita, KS, and Palo Alto, CA) are Level II trauma centers, and 4 (Salem, VA, Lexington, KY, Milwaukee, WI, and Southern Nevada) are Level III. Of 464 full-time and 665 part-time physicians practicing in the EDs and urgent care centers, 82 are board certified by the American Board of Emergency Medicine (ABEM) and 92 are ABEM and residency trained, with another 24 holding the alternate American Academy of Physician Specialists' Board Certification in Emergency Medicine (BCEM). Of the remainder, 799 are internists.A Uniform MandateA recent policy statement, VHA Directive 2006-051,11Standards for Nomenclature and Operations in VHA Facility Emergency Departments. 2006Google Scholar establishes uniform definitions for EDs and 2 other facility types (intensive care units [ICUs] and urgent care units), removes the other ambiguous designations, sets minimal levels of emergency care that all VA EDs must provide, and mandates that any hospital with an ICU must also have a true ED: open and staffed 24/7/365, with laboratory, pharmacy, radiology, and other essential services, including care for mental health emergencies. Obstetrics and pediatrics are not mandated, although Olszyk notes that 4 major VA centers (Bronx, Albuquerque, Southern Nevada, and North Chicago) do provide pediatric care. EMFAC is also developing recommendations for next generation patient tracking systems, equipment and hiring guidelines, and other aspects of quality improvement and standardization.The selected patient population and the VA's particular strengths, such as what Koenig calls its “incredible expertise in logistical issues,” arguably make the system better suited to special responsibilities—including its fourth mission, increasingly emphasized after 9/11: assisting DoD, the Department of Homeland Security, and other agencies in emergency preparation and management12Koenig K.L. Homeland security and public health: Role of the Department of Veterans Affairs, the US Department of Homeland Security, and implications for the public health community.Prehosp Disast Med. 2003; 18: 327-333PubMed Google Scholar—than to participation in local 911 systems. Still, as the veteran population continues to expand, the large Vietnam-era cohort ages, and the younger group returning from ongoing conflicts in Afghanistan and Iraq continue to manifest high rates of post-traumatic stress disorder (PTSD),13US Government Accounting OfficePost-traumatic stress disorder: DOD needs to identify the factors its providers use to make mental health evaluation referrals for servicemembers.2006Google Scholar the VA's increasing demand for emergency medicine expertise is intuitively clear.Loyal, Even to a FaultThe distinctive atmosphere of VA hospitals appeals strongly to many veterans. Kessler notes that many VA centers also provide a range of nonmedical services such as cafeterias, gyms, department store-scale canteens, educational programs, space for Veterans of Foreign Wars meetings, and general gathering points. Although many veterans who qualify for VA enrollment use other insurance for their health care, or use the VA only for its prescription program, many find a home away from home in an institution where staff and fellow patients understand their service experience.Complaints about the VA chiefly involve bottlenecks in gaining access. Once enrolled, patients hail the high quality of care, and to a large degree the advances in quality reflect the system's prescient embrace of medical informatics. With coordinated electronic health records allowing access to complete, up-to-the-minute patient information from any VA facility, physicians can rapidly assess a patient's history, medications, allergies, laboratory results, electrocardiograms, imaging studies, and other variables.This technology—the Computerized Patient Record System (CPRS) running on a customized operating system, the Veterans Health Information Systems and Technology Architecture (VistA), using the MUMPS (Massachusetts General Hospital Utility Multi-Programming System) language developed at MGH in the 1960s—obviates reliance on often-patchy paper records or patients' notoriously incomplete memories. It also reduces costly duplication of tests and overly defensive inpatient admissions in the absence of explanatory information such as a recent negative stress test or baseline lab value. In the ED, where practitioners never know whether they'll see a patient again, the long term continuity of information is a welcome advantage.A Clear Vista“When I started in North Chicago 3 years ago,” says Olszyk, “I went out to the community emergency departments in the area, and everyone had a different system. There's McKesson, IBEX, Picis, Cerner—and because there's so many, it tells you that no one really has figured it out perfectly yet.” The VA, however, has figured it out well enough to be the envy of other hospital networks. VistA/CPRS combines robust storage with rapid parallel processing and data extraction; it has a relatively steep learning curve and does not link as easily with other systems as later Java-based applications, but Olszyk describes this as a security benefit in a system storing sensitive information. The system's resilience was proven during Hurricane Katrina, when veterans were the only evacuees from New Orleans whose records remained available to physicians around the country.VA pharmacy procedures have achieved considerable economies of scale, in part because sheer volume creates a strong price negotiation position with drug companies. The greatest improvements stem from the automated prescription system. The VA's 7 Consolidated Mail Outpatient Pharmacy (CMOP) centers, the nation's first The Joint Commission-accredited mail pharmacy system, have adopted automated techniques that free pharmacists from manual dispensing, a labor-intensive, monotonous, and error-prone task; CMOPs have essentially eradicated prescribing and dispensing errors. Senator Daniel Akaka (D-HI), chairman of the Senate VA Committee, reported to colleagues that “while the error rate for prescriptions in the US is between 3 and 8%, the error rate in VA is less than one one-hundredth of one percent.”14Akaka D. Floor statement to Senate Veterans Affairs Committee, Jan. 23, 2007.http://www.senate.gov/∼veterans/public/index.cfm?pageid=12&release_id=10761Google ScholarVeterans' consequent loyalty to the VA is gratifying to officials and staff physicians, though not always medically warranted. During her cardiologic training at one VA hospital, Koenig recalls, “we had some cases of veterans with acute MIs who had traveled many miles, sometimes 3 or 4 hours, to come to the VA hospital”—bypassing closer EDs and worsening their own clinical risks. When she served on the National Policy Board, Koenig strongly recommended instructing all patients to call 911 instead of driving and to seek the closest ED, knowing they could be transferred to their familiar VA once they were stabilized. “There does seem to be a mentality, in terms of education of veterans, telling them to come to VA hospitals, which in general is good, because they have the electronic medical record, and that's where they have special services—for example, if they have amputations or PTSD,” she says. “But when you're talking about an emergency…this can be problematic.”“We get a lot of calls saying this vet wants to come in or transfer,” reports Kessler, “and he doesn't sound quite stable, but he's insisting on care, and we basically say ‘No, it's not medically advisable,’ and they'll just get up and leave. They'll take a cab over here, when I wouldn't even send somebody in an ambulance.” Commentators have cited clearer messages about the importance of reaching the closest ED in true emergencies—and the working hours at VA facilities lacking full-service EDs—as a critical aspect of patient communication. The VA customarily pays for emergency care at non-VA hospitals for enrolled veterans, but some veterans appear either unaware of this policy or reluctant to risk incurring costs.Dr. Tyndall described similar experiences to a local reporter: “I've told patients, ‘You could have died from this,’” he said. “And the veterans will say, ‘I'd rather die than leave my family with a bill that would take 5 years to pay.’”15Mulder J.T. Man on a mission.Syracuse Post-Standard. 2007; (Feb. 8)Google Scholar This exchange was cited in the Senate VA committee's recent budget hearings,16Fiscal Year 2008 Budget for Veterans' Programs: hearing before the Committee on Veterans' Affairs, U.S. Senate, 110th Congress, First Session, February 13, 2007. U.S. Government Printing Office, Washington2007Google Scholar throwing a national spotlight on the problem of ED access.Progress Versus the Demographic/Financial PincersAccess is a function of financial constraints on the system, which have always been severe and are likely to get worse. Former US Army E-5 and service-connected disabled veteran Larry Scott, founder and editor of the veterans' online information service VAWatchdog.org, cautions that even the recently publicized congressional appropriation of an additional $3.7 billion for VA hospitals is insufficient: it represents a 3.8% increase over the current year, easily negated by general inflation (let alone health care-sector inflation).“If you go back and look at VA budget increases over the last 7 years,” Scott comments, “what you're going to find is that although the current administration can claim that in their seven years in office they have increased the VA budget over 70%—that is a true number—what happens is they stop halfway through that sentence. You get the ‘dot dot dot,’ and the rest of the sentence, which you never hear, is ‘that isn't adequate’. … No administration has ever adequately funded VA health care.”Analyses of resource allocation by the VA's Capital Asset Realignment for Enhanced Services (CARES) commission, piloted in 1998 and instituted nationwide in 2002, subjected some EDs to closure, consolidation, or conversion to urgent care center status. One set of veterans who are eligible for VA care according to federal regulations have been blocked from registering for 5 years. Scott envisions more such cuts affecting research, maintenance, and possibly other VA functions.“You've got 5 major groups of veterans now who are stressing the system,” Scott says. The first are World War II and Korea veterans, reaching the age where they need long term care; the second, Vietnam veterans, includes many whose health problems were exacerbated by exposure to Agent Orange. “I really think we're just scratching the tip of the iceberg there,” Scott adds. “I think we will see these people's health as a population deteriorate rapidly over the next few years.” Those who fought in the first Gulf War, some of whom have the unexplained Gulf War Syndrome—“We know they're sick; we don't know why”—constitute a third group.The fourth are the new veterans of Afghanistan and Iraq, who according to the National Defense Authorization Act of Fiscal Year 2008 (Public Law 110-181) have 5 post-deployment years to use VA services, then are cut off unless they fall into one of the system's 8 priority groups for enrollment.17US Department of Veterans Affairs. VA Health Care Eligibility and Enrollment: All Enrollment Priority Groups. [http://www.va.gov/healtheligibility/eligibility/PriorityGroupsAll.asp]Google Scholar These groups range from veterans with service-connected disabilities or conditions precluding employment (group 1) through those lacking service-connected status but with personal income below certain annually determined thresholds (group 8). Enrollment eligibility each year depends on appropriated funds, and though no one has been thrown out, new enrollments from group 8 have been cut off since January 17, 2003.The fifth unexpectedly large group, Scott says, “the one nobody anticipated” and the one that led to the 2003 cutoff, comprises middle-aged and older veterans who previously had non-VA health insurance but now find themselves either unemployed or underemployed, either stripped of coverage or unable to afford the premiums. “A guy exposed to Agent Orange who's got Type II diabetes and has a good health plan somewhere else says ‘The heck with the VA… my Kaiser or Blue Cross covers this, everything's fine.’ Boom, he suddenly has no health insurance. Guess where he goes? We're seeing a ton of that, and that is only going to get worse as this economy keeps going south.” Scott notes that Senator Ikaka has come out and acknowledged that when all these pressures are factored in, funding even with the latest “increase” amounts to a cut.A Personal ViewThe VA's clinical performance looks all the more remarkable in the context of this financial and demographic squeeze. Scott is both a longtime observer and an enthusiastic booster of the VA, based on personal experience: “Where emergency care is available, it is the best. … As a matter of fact, last year they saved my eyesight.” He noticed a dark spot in his vision and recognized the symptoms of a detached retina. “They got me in, got me flat, and had an on-call ophthalmologist there in about 20 minutes, who had an ophthalmic surgeon there in another 20 minutes. They hustled me over to the university—by the way, this was on a holiday weekend—and the next thing you know, they were doing detached retina repair. The doctor says in another hour, hour-and-a-half, I could have lost my eyesight…. In a local walk-in, pay-as-you-go clinic, I probably would be blind in my right eye.” The US Department of Veterans Affairs (VA) has long had a reputation for making emergency medicine a low priority, and change is overdue, critics charge. After dramatic upgrades in other areas, the system is now working to bring its emergency departments (EDs) up to code. The critical challenge will be whether these efforts can overcome chronic funding shortages and rising pressures on the system's capacity. Mainstream media attention arguably paints a distorted picture of the VA, magnifying isolated or even irrelevant incidents and ignoring the qualities that have made many veterans fiercely loyal to VA hospitals. For millions of patients, the VA provides superb care at no personal cost. Some commentators1Longman P. Best Care Anywhere: Why VA Health Care Is Better Than Yours. Polipoint, Sausalito, CA2007Google Scholar describe the VA as a worthy model for a future national health care system. Over the past decade and a half, the Veterans Health Administration (VHA), the VA's medical branch, went from being a near-synonym for slipshod care—and a rhetorical punching bag for opponents of public sector involvement in health care delivery—to an example of how a large system can perform well clinically by realizing economies of scale, eliminating obstacles associated with private insurance, and wisely implementing medical informatics.2Stires D. Levenson E. How the VA healed itself.Fortune. 2006; 153 (May 11): 130-136PubMed Google Scholar Structural reorganization and procedural reforms3Kizer K.W. Pane G.A. The “new VA”: delivering health care value through integrated service networks.Ann Emerg Med. 1997; 30: 804-807Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar initiated by Kenneth W. Kizer, MD, MPH, undersecretary for health from 1994 to 1999, then upheld by his successors (currently Brig. Gen. Michael J. Kussman, MD, US Army, Ret.), have instituted rigorous accountability mechanisms, sharply upgrading the system's performance as measured by external reviews4Asch S.M. McGlynn E.A. Hogan M.M. et al.Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.Ann Intern Med. 2004; 141: 938-945Crossref PubMed Scopus (418) Google Scholar, 5Jha A.K. Perlin J.B. Kizer K.W. et al.Effect of the transformation of the Veterans Affairs Health Care System on the quality of care.N Engl J Med. 2003; 348: 2218-2227Crossref PubMed Scopus (567) Google Scholar, 6Arnst C. The best medical care in the U.S. Business Week.in: 2006: 50-56Google Scholar, 7Oliver A. The Veterans Health Administration: an American success story?.Milbank Quarterly. 2007; 85: 5-35Crossref PubMed Scopus (138) Google Scholar and surveys of veterans.8Stein R. VA care is rated superior to that in private hospitals.Washington Post. 2006; (Jan. 20): A15Google Scholar The VA, a cabinet-level department, operates the nation's largest integrated health care system: it includes 153 hospitals along with over a thousand other sites of care such as ambulatory/outpatient clinics, nursing homes, and rehabilitation programs. In 2006, VA facilities treated over 5 million people, including 773,600 inpatients and over 60 million outpatient visits. With a statutory mission comprising education, research, and civic emergency management as well as clinical care, the VA has also helped train over half the nation's practicing physicians. For any institution that large to implement change, the metaphor of a large naval vessel fits. Battleships and aircraft carriers do not turn on a dime. EDs, Near-EDs, and ED WannabesAmid the VA system's overall improvements, however, it is only beginning to make comparable strides in emergency medicine. A 1993 study in Annals by Gary P. Young, MD,9Young G.P. Status of clinical and academic emergency medicine at 111 Veterans Affairs medical centers.Ann Emerg Med. 1993; 22: 1304-1309Abstract Full Text PDF PubMed Scopus (8) Google Scholar observed that in 111 VA hospitals surveyed, what passed for EDs varied widely in the scope of services provided and the preparation of physicians involved. While all these institutions provided emergency care, and all but one were open 24 hours a day, 7 days a week, only 19% of them had staff physicians either residency trained or board certified in emergency medicine. Non-emergency-trained physicians (staff and moonlighting non-staff) were performing emergency care in facilities variously designated as EDs, emergency rooms, evaluations and admissions, admitting offices, or areas for acute, urgent, or ambulatory care. None of these institutions was a Level I, II, or III trauma center, though 96% were capable of providing appropriate care to patients with minor trauma. House staff specialties included emergency medicine in only 7% of these hospitals.Some of these institutions were well aware that emergency medicine was being shortchanged—26% were either actively recruiting or planning to hire trained and/or board certified emergency physicians—but the clear conclusion, confirmed by external pressure from The Joint Commission and other reviewing bodies, was that emergency care in the VA system was not up to community and national standards.Allocating tight budget resources elsewhere may have had some justification, considering the specialized patient population. “VA emergency departments don't get as much true emergency medicine as everywhere else,” says Kessler. “Many do not get ambulance runs from 911; hardly any trauma comes here… [and] most VAs don't see any pediatrics and few women.” Depending on the number of veterans in the catchment population, VA EDs are also typically smaller than those of other hospitals; in some, studies of usage patterns have indicated low patient volume after hours, suggesting that 24-hour coverage was not optimizing resources.Even after the reforms initiated under Kizer, procedures and facilities varied widely between centers. Kristi L. Koenig, MD, during her service as national director of the VA's emergency management office from 1999 to 2004, reports, “I heard a saying at the VA: ‘If you've seen one VA hospital, you've seen one VA hospital.’” Standardization of procedures, she notes, has been a critical goal since the Kizer years.Dr. Koenig was the first official appointed to her position (focusing largely on disaster preparedness) after it was retitled to require an emergency physician. “They were already looking at bringing in emergency medicine expertise” at the time she was hired, she says, and the effort to redress the shortage of emergency medicine specialists has continued. Now director of public health preparedness and professor of clinical emergency medicine at the University of California at Irvine, Koenig places the shortage of board certified emergency medicine colleagues in a historical context. “Emergency medicine is a relatively new specialty, only around for about 30 years,”