The Business of Government Hour

 

About the show

The Business of Government Hour features a conversation about management with a government executive who is changing the way government does business. The executives discuss their careers and the management challenges facing their organizations. Past government executives include Administrators, Chief Financial Officers, Chief Information Officers, Chief Operating Officers, Commissioners, Controllers, Directors, and Undersecretaries.

The interviews

Join the IBM Center for a weekly conversation about management with a government executive who is changing the way government does business.

Dr. Jonathan Perlin interview

Friday, December 2nd, 2005 - 20:00
Phrase: 
"Healthcare today and in the future really has to be about the patient. The information has to follow the patient. Our system is increasingly designed not to orient around the facility's needs to organize and deliver care, but around the patient's needs."
Radio show date: 
Sat, 12/03/2005
Intro text: 
Perlin discusses how VHA is moving away from provider- and facility-centered healthcare to more patient-centered healthcare that is driven by data and medical evidence. According to Perlin, patient-centered healthcare at VA means care that is not only...

Perlin discusses how VHA is moving away from provider- and facility-centered healthcare to more patient-centered healthcare that is driven by data and medical evidence. According to Perlin, patient-centered healthcare at VA means care that is not only consistent and reliable but also care that is compassionate and that integrates across health and disease.

Perlin also discusses how VHA is demonstrating health information technology leadership. For example, the HealtheVet initiative and the VistA electronic health record system are two new major initiatives. Today, VA has a totally electronic environment.

Lastly, Perlin reflects on and gives advice to those who are interested in a career in public service, especially in public health.Missions and Programs; Organizational Transformation; Strategic Thinking; Leadership

Complete transcript: 

Tuesday, July 5, 2005

Arlington, Virginia

Mr. Kamensky: Good morning and welcome to The Business of Government Hour. I'm John Kamensky, a senior fellow at the IBM Center for the Business of Government. We created the Center in 1998 to encourage discussion and research into new approaches to improving the management of government.

You can find out more about the Center by visiting us on the web at www.businessofgovernment.org.

The Business of Government Radio Hour features a conversation about management with a government executive who is changing the way government does business. Our special guest this morning is Dr. Jonathan Perlin, the Undersecretary for Health in the Department of Veterans Affairs. In this job he�s also the CEO of the Veterans Health Administration or VHA, which is the largest integrated health system in the U.S.

Good morning, Dr. Perlin.

Mr. Perlin: Good morning John, it�s a delight to be able to chat with you this morning.

Mr. Kamensky: Thank you, and joining us in our conversation, also from IBM, is Vernecia Lee. Good morning, Vernecia.

Ms. Lee: Good morning, John; good morning, Dr. Perlin.

Mr. Perlin: Good morning.

Mr. Kamensky: So let�s ask our first question; can you tell us about the early history of the Veterans Health Administration and its mission and how it became a world renowned leader in healthcare?

Mr. Perlin: Well, this is a great time to answer the question about the history. In fact, this year, July 21st, we celebrate the 75th anniversary of what is now the contemporary Veterans Health Administration. In fact 75 years ago, Herbert Hoover signed an executive order claiming a dedicated health system for the care of veterans.

More recent history was really shaped after World War II, but the true recent history of VA was shaped in the last 10 years. Our conversation this morning�s about transformation and just to kick it off by saying, we are not your father�s VA, we are a new VA that uses state-of-the-art technologies and looks forward to not only celebrating the past but a very exciting future.

Mr. Kamensky: That�s interesting, can you tell us about some of the major programs and services of the Veterans Health Administration?

Mr. Perlin: One of the greatest things about VA is that our mission is so clear. Our mission is derived from President Lincoln�s second inaugural address, wherein he proclaimed the country�s responsibility to �care for those who shall have borne the battle.� And this is really our care, we have one mission, we care for veterans, we care for veterans.

And the Veterans Health Administration actually has four statutory missions. The first is patient care for veterans throughout the country; for illnesses or injuries that are acquired during service or for the other issues that veterans who are eligible for using VA care may have, but we are also the largest contributor of graduate medical education in the country, collectively training over 80,000 health professions trainees a year, through affiliations not only with 107 medical schools, but 1500 schools of health professions.

We are also a large research organization. We do research that is meant to improve the health and well-being of veterans. We have a nearly $1.7 billion research program in basic sciences, in clinical sciences, trials of new medications and those sorts of things. In health services research where we critically examine how healthcare is delivered, importantly in the area of rehabilitation, so we can help veterans achieve their maximum function. And finally our fourth mission is to work with the Department of Defense and provide back-up to the Department of Defense and in fact to the country during times of emergency.

Ms. Lee: Thank you so much. VHA is just a very large organization; can you provide us with a few facts and figures, the number of employees, your budget?

Mr. Perlin: VHA is the nation�s largest integrated health system and the numbers are somewhat staggering. There are 25 million veterans in the country. Today there are 7.6 million veterans who�re enrolled and eligible for care through their enrollment. In any given year, about 5.2 million patients will come to us for care.

We deliver that care across the country through 1300 sites and that includes over a 170 medical centers, over 870 community-based outpatient clinics, 207 Veterans Readjustment Counseling Centers or Vet Centers, a variety of other long term care programs, also home care programs and Telehealth.

Our workforce approaches nearly 200,000 persons. There are 58,000 nurses, 14,500 doctors who work for us directly, plus another 25,000 doctors who are faculty at 107 of the nation�s medical schools. And another 35,000 residents who are doctors in training, who are licensed but completing their training, who are also part of an additional workforce.

So on top of that 200,000, there are approximately another 100,000 health professionals, a 140,000 volunteers; so all told, nearly 450,000 people come through VA in any given year. The budget that provides care for veterans is approximately $30 billion.

Mr. Kamensky: Wow, when you were appointed Undersecretary for Health back in April of this year, could you tell us what you see as your role and the responsibilities of the positions of the Undersecretary for Health?

Mr. Perlin: My first role is that I�m the chief advocate for veterans� health. We have really made it our specialty, our expertise not only to understand military occupational health but the health issues of veterans and this really divides the two groups; first, there are those things that are directly attributable to service.

The unique experiences and exposures of serving in the military, and then there are those things wherein veterans reflect the health issues of the broader population, challenges of ageing successfully, the challenges of chronic illnesses, including, by the way, obesity and diabetes, something that our Secretary, Jim Nicholson, is very passionate about making sure that our nation�s veterans and in fact all of our nation�s citizens are as healthy as can be.

And so advocacy for the veteran, for veterans� health issues, responsible management to make sure that these really substantial resources are utilized as effectively and efficiently, quite simply as I like to characterize it, provide veterans with safe, effective, efficient and compassionate healthcare.

Mr. Kamensky: Well, what positions have you held previously and how did they prepare you to become an Undersecretary?

Mr. Perlin: Well, I feel very fortunate to have had a variety of positions in training. I�m not sure that anyone really has specific preparation for all of the dimensions I mentioned, but I feel very fortunate in training. I�m an internist; I was a specialist in internal medicine, my clinical training, and in fact also have a Ph.D. I did research in molecular neurobiology and I also have a Master of Health Administration, which is like an M.B.A. directed towards the business of healthcare. So I feel very fortunate to have had that formal training.

Most recently, before I became Undersecretary for Health, which required, you know, senatorial confirmation following a nomination by the President, I had served for about 14-1/2 months as the Acting Undersecretary of Health. It was a very, very good on the job training.

Prior to that, I served for two years as the Deputy Undersecretary for Health and I think probably, most important to my preparation for this role is that I was hired into VA central office by Ken Kizer about seven years ago, to lead the Office of Quality and Performance in developing performance measures to help with VHA�s transformation. We measure only pervasively, some would even say obsessively, holding ourselves accountable for high quality outcomes.

Mr. Kamensky: That�s great, that�s a really fascinating background. How is VA becoming the leader in understanding and providing services uniquely related to veterans� health? We�ll ask Dr. Jonathan Perlin, Undersecretary for Health at the Department of Veterans Affairs to explain this to us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Kamensky: Welcome back to The Business of Government Hour. I�m John Kamensky and this morning�s conversation is with Dr. Jonathan Perlin, Undersecretary for Health at the Department of Veterans Affairs. Joining us on our conversation is Vernecia Lee.

Dr. Perlin, I understand that the number of veterans enrolled in receiving care in the VA healthcare system has risen dramatically and continues to rise. What are the numbers now and why are they increasing?

Mr. Perlin: Well, John, the numbers today are out of the 25 million veterans in the country, about 7.6 million are enrolled with us for care. In any given year, about 5.2 million will be patients, and there are a number of reasons that veterans are coming to us. I think, first and foremost is that, as we�d like to say, we�re not your father�s VA.

This is an organization that provides the highest quality healthcare. It�s one of the few places in America where you can go see your doctor, a nurse or pharmacist and they all have your health records electronically, so you don�t have to keep restating what your medical history is or wonder if everyone�s got the information appropriately.

And in fact, I say this not only because I�m proud of it, I�m proud of the employees in VHA and the passion and their dedication to the mission of serving veterans, but we have the ability because we measure our performance in numbers that can be verified, which others have published on, like the RAND organization, that the care in VA is the best that you can get in the country.

In fact, the RAND article, came out in December 21st Annals of Internal Medicine, compared VA care to 12 other healthcare organizations, some of the best in the country, and the RAND doctors, their conclusion, patients from VHA received higher quality care according to broad measure and this was on 348 different indicators of quality, disease prevention and treatment.

So the veterans who are coming to VA know it�s perhaps the best kept secret in the country. Besides that we also know that we�ve changed; we know that it�s tremendously important for veterans to be where veterans are and 10 years ago we were a hospital system, today we�re a health system, there�s much better care because the focus is on health promotion and disease prevention. And this model means that we have many outpatient clinics where we can work with veterans to help them maintain their health and manage chronic diseases.

As well, candidly, we have a very robust prescription benefit, it�s one of the best deals around. So much medicine today is managed with pharmaceutical prescriptions that veterans find the ability to have high quality health system, which has their full electronic health record, which by the way and maybe we can talk about this later, they can now dial into through something called My Healthy Vet, the veteran�s personal health record and put all of that care in a friendly environment that�s oriented towards the needs of veterans together with the pharmaceutical benefits that really round off the care, we think those are the main reasons: Easy access, high quality, good information and a veteran-centric, patient-centric environment.

Ms. Lee: Thank you so much, Dr. Perlin, you�ve just given a lot to think about, you talked about, early in the segment about providing better service, veterans coming first. You also just talked about easy access. I know you have a lot of initiatives within VHA, can you talk to us about CARES?

Mr. Perlin: Well, CARES, thank you, Vernecia, for that question. CARES is one of those great governmental acronyms. It stands for Capital Asset Realignment for Enhanced Services, and my favorite part of this is the ES, enhanced services. In fact, we in the late �90s were accused by the General Accounting Office, not the Government Accountability Office, of spending millions of dollars on maintaining unused space.

And we take care of places for many veterans today as we did a decade ago. We need to make sure that our facilities and our resources are where the veterans are. And so by helping to evaluate some of the sites that were underutilized, we�re able to redirect funds into the areas and needs of today�s veterans.

For example, the secretary and I just were proud to be at the ribbon cutting in Chicago, at the Hines VA Medical Center where we�ve just opened a brand new spinal cord injury and a new blind rehabilitation center. And in fact using the proceeds of closing one of four hospitals, literally, within a few miles of each other in Chicago, we were able to be building a new 300-bed bed tower; 21st century environments for 21st century veterans offering 21st century care.

So CARES is a process wherein we�re evaluating our portfolio and saying, �What is the most effective, most efficient, most patient-centered way to provide the care to veterans?� And in Chicago, the ability to look at ourselves critically and say, okay, four tertiary referral or four major hospitals within a few miles of each other is, I�m sure, less efficient than having fully staffed programs, high enough volumes to provide the highest quality and the proceeds of being able to close one of those facilities allowed us to open, you know, two new specialty care centers, blind rehabilitation and spinal cord injury and begin our way on putting up a new 300-bed tower.

We consider that the down payment on the CARES process, which is looking around throughout the rest of the country with the outcome intended to be just like that, the ES of CARES, the Enhanced Services for veterans.

Ms. Lee: Thank you so much. Can you also -- I know VA is focused on a lot of special interest areas as it relates to veterans health. You talked about spinal cord injury, are there other special emphasis areas that you focus on that you�d like to share with us today?

Mr. Perlin: Well, thank you very much for that question, because the VA, I don�t think it�s perhaps fully appreciated that it�s been the leader in defining a number of fields. Some have to do with rehabilitation of individuals who experience serious injury and service to their country such as spinal cord injury. But VA is also a world leader in blind rehabilitation, as I mentioned.

It�s also a great leader in the care of amputees, amputation technologies in VA are absolutely state-of-the-art. We mentioned some of the things that are being developed. One that I am tremendously excited about, I think most people today know about something called the cochlear implant, which allows people who have damage to their outer ear function to have a chip installed that receives the sound and translates that into electricity that the brain can pick up and translate into hearing.

One of the things that�s going on in Atlanta is development of the artificial retina. And this sounds like science fiction, but it�s real. This is a chip that can be implanted in the eye. And it, actually like a video camera, responds to light and color and shape in the environment and it translates that just like a video camera into an electric signal and that electronic signal goes to the nerves, and lest you think this is science fiction, it�s been implanted in 10 patients with macular degeneration, one of the diseases of an ageing population.

This is VA�s other contribution, beyond expertise in traumatic injury rehabilitation, especially of geriatrics and gerontology really grow up in the care of older people, that specialty really was developed in VA. And one of the areas I�m most proud of is VA�s leadership in mental health care. Mental illness is a societal challenge, and in fact this is a very exciting era.

The President chartered a commission to see what improvements might be made during his administration in the care of individuals with disabilities and this was called the New Freedom Commission. There was a section on metal illness and mental healthcare. And the goals of this commission and our goals in VA are to move our thinking from a model of maintenance of individuals with illness to a model which really has its goal for recovery; reintegration into social roles, and we believe with some of the new developments and new drugs available that we can contribute to the aspirations of helping Americans with challenges to their mental health, regain as much function as possible and sometimes even complete recovery.

Ms. Lee: Thank you, what is evidence based research and how does VHA use it to provide the best possible care to veterans?

Mr. Perlin: Well, Vernecia, thank you very much for the question on evidence based research. It really grows from a concept called evidence based medicine wherein the medical decision-making is made based on formal review of the literature. Now, this is a fairly new approach and that probably sounds a little frightening to those who must be trained before this term, which is about 15 years old, came about -- we always wondered, well, what we were doing previously, random access of medical care?

But in fact evidence based medicine is a discipline where the literature is formally reviewed using criteria to say, okay, how do you weigh this article which looks at, you know, a case report on a patient, with this article which comes from a study of a large number of patients but retrospective, with this article which looks at a large trial where one -- which we call a placebo-controlled randomized trial that where -- where one arm gets the treatment and the other arm doesn�t get the treatment.

And these different types of approaches to research have inherently different power or predictive power in terms of determining how good the treatment, if that�s what�s being studied, is likely to be in a particular population. And so one case report or one individual is obviously very, very different than the power of what we call a double blind placebo-control trial, and the ability to generalize from the one-case report, the entire population is very, very different from all its study.

And so evidence based medicine actually looks at these different types of research and says, �Okay, what is going to be the most successful approach for actually providing care, not in a trial, but to real patients in the real world?� And this is one of the great things about our electronic health record and our clinical decision support is that there are 10,000 new articles a day that go on to the National Library of Medicines index, something that�s available by the way to all consumers as PubMed.

But even to expect your doctor to be able to read 10 articles a day, let alone 10,000, is unrealistic in this information age. And so we need tools where we can synthesize all that literature, so we bring the patient the state-of-the-art care, and that approach is called evidence based medicine, make sure that when we make clinical decisions they�re really backed by the best evidence possible and the electronic health record helps to make that clinical decision support available in real time while the doctor, nurse, or nurse practitioner or a physician�s assistant, or psychologist, or any health professional is actually working with the patient.

Ms. Lee: How is VA moving away from facility-centered healthcare to patient-centered healthcare?

Mr. Perlin: I love that question, because when you go to the doctor or a hospital and you think about where your records are, like most Americans, you probably think they�re scattered all over the country. Your health record, ironically, is hardly about you, and in 2005 it�s more about the institutions that provide the care to you. And that�s really wrong.

Healthcare today and in the future really has to be about the patient; the information has to follow the patient. The information has to be available when the patient wants it and where the patient wants to receive their care, and so our system is increasingly designed not to orient around the facility�s needs and the facility�s means to organize care and the delivery of care, but around the patient�s needs and we hear the term patient-centered care often bantered about, that�s sort of a buzz phrase now for family care.

Let me tell you exactly what I mean when we say patient-centered care at VA. We mean care that normally built-in safety of the system property. We mean care that�s not only consistent and reliable and built-in quality as a system property, we mean care that�s compassionate, care that integrates across health and disease but also across diseases.

Think about the patient with diabetes and heart failure, two diseases that often occur together. And think about that patient, who in 2005 might have in one context, their diabetes managed by an endocrinologist and the diabetes case manager or disease manager and the heart failure managed by a cardiologist to another, this is the same patient.

It�s not very patient centered if you�re having your care in this kind of uncoordinated manner. Our goal is to make sure that the care integrates across health and disease, disease and disease and environmental care, be it the hospital, the clinic, or the home and to facilitate truly patient centered care.

Our electronic health record which exists throughout all of our hospitals and clinics, long-term care settings and even associates with our personal health record, which is available to the patient, the veteran in their home, follows the patient, and that�s really where we�re headed with the health record.

Information is not about the facility, not about the location, not about the disease but about the patient, and that allows all the people who may interact with the patient, wherever and whenever, to really focus on the patient, go for true patient centered care that�s safe, effective, high quality, compassionate care.

Mr. Kamensky: That�s really fascinating, how VA cares for, that�s just very interesting. How has the Veterans Health Administration reduced the number of medical errors? We�ll ask Dr. Jonathan Perlin, Undersecretary for Health of the Department of Veterans Affairs to explain this to us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Kamensky: Welcome back to The Business of Government Hour. I�m John Kamensky and this morning�s conversation is with Dr. Jonathan Perlin, the Undersecretary for Healthcare at the Department of Veterans Affairs. Joining us in our conversation is Vernecia Lee.

Dr. Perlin, in our previous segment we were talking a little bit about how information is following the patient. We were talking also about dialing into -- the patients could actually dial into or get their information online. We�ll talk a little bit more about how the Veterans Health Administration is demonstrating health information technology leadership.

Mr. Perlin: Well, John, thanks for that question. As I mentioned earlier, the VA today, it�s a totally electronic environment. Up until recently I�ve been able to see patients over the Washington VA, I literally never touch paper. And I tell you this because the President�s Information Technology Advisory Committee came out with some fairly compelling, frightening statistics about some of the shortcomings of using this, as the President phrased it, horse and buggy technology in the 21st century.

Do you know that across the United States today, not in VA but across the United States; one in five hospitalizations occur because previous records weren�t available? And every seventh lab test is repeated because previous records weren�t available. When I see patients at the Washington VA or anywhere in VA and have the benefit of the electronic health record, I don�t have to guess why they�re there.

I don�t have to look a woman in the eye who might be there to follow up on a biopsy to rule out cancer and say, �I�m sorry, Ms. Smith, could you tell me why you�re here today?� I have never had that conversation. And I don�t know whether that�s high quality or better safety or better compassion, probably all of the above. But our electronic health record means the records are available 100 percent of the time. And the ability to have this information available means that we�ll first, I mean � if I�ll order a drug that the patient�s allergic to, that information is always there and not only that, if I try to order a medication that the patient is in fact allergic to, a known allergy, it will stop me, say, you really don�t want to do that.

And I will say to the computer, �Thank you, I really didn�t want to do that.� Or a drug that the patient�s lab says is inappropriate. Even better than that there is real time clinical decision support. Say if I see a patient, say, for something as common as high cholesterol, I get a reminder, clinical decision support says, �It�s time for this patient to be screened for high cholesterol.�

And if the number comes back high, and in fact it automatically is put into the next chart note, so I don�t have to remember to go look that up, it�s automatically in the next chart note, it actually fires up another reminder that says, �Hey, Mr. Smith�s cholesterol is high, if you want do something about it, here are some options.� And then it presents me with some options; we talked about evidence-based medicine earlier this morning, and in fact it gives me an option, it�s not just a reasonable option, but the best evidence-based choice for the particular medication. And it goes one step further because we care for over five million veterans. You can imagine our pharmacy bills are pretty high. We want to make sure that we not only have the evidence-based labor, but the most cost effective labor as well.

And so medication has recommended us not only the top notch in terms of their particular class of drugs, but the one that is the least expensive within that class. And with one button, I�ve just had decision support to prevent an error -- error check to prevent an error, decision support to make the best evidence-based choice and better than having to read the hieroglyphics of my typically bad doctor�s handwriting, perhaps, a typically worse -- there is no written record of that, it�s electronic.

Yeah, it can point out a copy of the prescription for the patient, but more importantly within the system that electronic order goes to one of seven computerized mail outpatient pharmacies around the United States. And those mail outpatient pharmacies not only allow us to distribute medications very cost effectively, where our inflation for prescription has been less than an eighth, one-eighth of what the inflation has been outside of VA, allows us to operate with your Six Sigma performance.

The mythical Six Sigma is a failure rate of 3.4 per million. Our success rate is operating right now at 5.85 sigma, and we will push it to Six Sigma. The people elsewhere in medicine ask, �Is Six Sigma applicable to healthcare?� and I would submit the answer is �yes.�

You asked about preventing errors. Maybe I�ll just take a moment and tell you what happens to that same prescription to the patients in one of our hospitals. From the point I put in that electronic order for prescription in the computer, it would go to robotic dispensing in the pharmacy. And when the medication is actually brought to the bed side of the patient, the nurse who administers the medication will actually stand a barcode on the medication or IV, and stand a barcode on the patient�s wrist band making sure 100 percent of the time that it is the right medication in the right dose being delivered by the right person to the right patient at the right time. And that may seem like a large checking and that�s true, and it might seem like much ado about nothing, but let me share with you one of the frightening statistic.

Not in VA hospitals, but across America, one out of every six and a half hospitalizations is affected by a medical error, a medication error, a drug event serious enough to compromise the patient�s condition, increase their length of hospitalization and not surprisingly increase the cost of care. We are taking those errors out of medicine.

Mr. Kamensky: One of the things that I�ve learned in the government service is that a good chunk of success depends on partnering with others. I understand that the Veterans Administration does a lot of partnering with others.

Mr. Perlin: Yes, we do. Partnering is tremendously important and their partnerships really range the gamut. Other federal partners, we partner with the Department of Health and Human Services in terms of fighting this epidemic of obesity and diabetes. The Surgeon General and the Secretary of Health and Human Services really -- leading goal is to help Americans improve their health outcomes by reducing the toll of obesity and diabetes. We�re partnering with the Department of Health and Human Services to make our electronic health record available particularly to unreserved and rural Americans for whom this will be a good record to use.

Partnering with the Department of Defense to make sure veterans, particularly those returning from combat receive seamless care, a continuum of service from the care that they might receive while in active duty to the care that they receive when they come into VA as veterans. We partner with academia. There are 126 medical schools in the country. We�re affiliated with 107 of them. We partner with 1500 schools of health professions education�s programs and this not only advanced knowledge in the country, but it�s also in and above supporting the needs for care within VA, provides health professionals across all disciplines for all of America, particularly important in the era of nursing shortage and a future projected doctor shortage.

And we partner with the private sector. It�s hard to imagine an industry organization in private given the breadth, the expanse of our business with whom we don�t have partnerships. We partner in development of new technologies through rehabilitation, we partner across information technologies to make things like this electronic health record available to veterans and indeed to all other Americans. And so our partnership is really a part of the recipe for success.

Ms. Lee: Thank you so much, Dr. Perlin. You spoke earlier about and mentioned your RAND report. Are there other things that you�re looking at doing in terms of continuing to improve your medical errors and improve patient safety?

Mr.Perlin: Well, Vernecia, thank you very much for the question about the RAND study, and we�re really proud of that because, I�m sure it�s the VA that sets the benchmark for quality in the country today on 348 measures of improving quality and disease prevention and disease treatment. So healthcare has a great way to go. And so this is something that we continue to work on.

I mentioned the bar-coded medication administration and you can imagine that improves the safety and quality of delivering medications. We�re going to be introducing a program where all of our lab tests are bar-coded as well. Let me give you -- just paint a word picture of something that happens throughout hospitals in America, something that I used to do.

When I was a resident in training, we used to go around to our patients in the morning and draw their bloods, in one pocket we had test tubes and in the other we had a label with the patient�s name and identifying information on it. And I hate to frighten listeners but it was remarkable that the labels and test tubes of bloods matched as much as they did. Isn�t there a better way in 2005? The answer is, absolutely.

Doesn�t it make sense that using that same sort of bar-coding that we should have a secure label that securely identifies that this blood sample is from you, as opposed to being from someone else, our electronic health record provides decision support, but increasingly the ability to provide the decision support not just to the healthcare professionals, but importantly to the patient is absolutely critical and the patient will be able -- and is able now to look at health assessments and some patient are able to -- if they have questions about their medications, check medications and even question their doctors and nurses and health professionals in ways that people didn�t think about just a few years ago.

Mr. Kamensky: How are you recruiting, training and retaining employees at the Veterans Health Administration?

Mr. Perlin: Recruitment and training is critically important for a health system of our size as this -- in much of healthcare and one of the great enticements to working in VA is that we have the electronic health record. In fact, formal survey of nurses found that nurses felt safer in their practice of healthcare knowing that there was electronic record and that information didn�t get lost and there were things like the bar-coded medication administration to mean that they weren�t risking giving the wrong medication to a patient.

And so a vibrant high technological environment is one of the features. Secretary Nicholson, I often ask people, what brings you to VA, invariably the answers are the same, first admission, serving veterans. It is so clear that whatever people�s feelings about the world in general, they�re passionate about the care for veterans. Last year is an example when the hurricanes hit Florida and the Southeast, 800 of our employees made themselves available within 24 hours, not only to support veterans but to support communities in Florida and the Gulf Coast. This is the type of people who work for VA, the mission.

Second, is the model of medicine. We practice healthcare, we don�t practice insurance. People who work for VA spend their time caring for the patients, and it�s sort of -- it is a fun environment to work in, and third, the fact that we are the largest provider of health profession�s training, means that there are always lots of vibrant, bright, challenging individuals in the environment. The teachers or the staff absolutely love being at the state-of-the-art in terms of professional knowledge and nursing or medicine or psychology in these training environments and conducting research.

And the derivative of this great environment means that our veterans are getting care that�s important by people who are at the top of their game. So mission, model and teaching research and other environmental attributes like the health record mean that VA really is an employer of choice in healthcare.

Mr. Kamensky: That�s really true. Well, what does the future hold for the Veterans Health Administration? We�ll ask Dr. Jonathan Perlin, Undersecretary for Health at the Department of Veterans Affairs to explain this to us and the conversation that management continues at the The Business of Government Hour.

(Intermission)

Mr. Kamensky: Welcome back to the The Business of Government Hour. I�m John Kamensky and this morning�s conversation is with Dr. Jonathan Perlin, the Undersecretary for Health at the Department of Veterans Affairs. Joining us on our conversation is Vernecia Lee.

Dr. Perlin, could you tell us how the veterans� population has changed over time and what it would look like in the future and how this is going to affect the Veterans Health Administration?

Mr. Perlin: Thanks, John, for the question. The veterans� population is relatively stable through 2022 and today they�re about 25 millions veterans. Overall the veterans� population is aging a bit. Sadly, some of the most senior veterans of World War II are beginning to pass away at fairly high rates. But over the next two decades veterans of Korea and the Vietnam War become more senior and about half of the veterans we take care of will be over age 65.

The number of older veterans, those who are over age 85 will triple over the next five years, in that short period of time. As well though, I don�t want people to think that VA is -- it�s just older veterans. In fact, when we look at a picture of today�s military and you realize that 14 percent of the military are women. And in some places as many as 20 percent of our outpatients under 50 are women.

And so when I said earlier on the basis for a transformation of quality that we�re not your father�s VA, we�re also not your father�s VA in terms of the demographics. We take care of lots of veterans and even active duty service members who are in their 20s and 30s and 40s. We take care of women and offer a whole range of age appropriate and gender specific care and we�ve talked to a lot of members about performance, I�m proud to say that VA is the national benchmark in providing breast cancer screening and surgical cancer screening. So we want to make sure that for women we offer the highest quality, age appropriate, gender specific care as well. So in many ways it�s not your father�s VA.

Mr. Kamensky: Well, what do you anticipate in the next five to ten years in terms of what�s going to happen in the Veterans Health Administration?

Mr. Perlin: Well, I think VA doesn�t want to react to the next 10 years. We want to anticipate the next 10 years, and the next ten years in medicine and healthcare are tremendously exciting. I think the rest of the world may catch up to us in terms of the electronic health record. So we actually want to be ahead of the curve and bring these new technologies to veterans. Let me give you some examples of what I think are coming down the pike in healthcare. I think healthcare will be increasingly decentralized. The hospital will be a place that�s really reserved for emergency care and surgery and intensive care.

Much more care will go on in the community. Much more care will be medication oriented. And already if you look around we see, you know, imaging centers and surgical centers. I believe there�ll be blood draw centers and even -- I don�t want to name any named brands, but there are clinics where patients can get care within 30 minutes. And this is in the private sector and I think the healthcare will increasingly decentralize. And what�s so important about that is not only will it be more convenient, but information becomes all the more important in terms of linking all of that information together.

What about the information we bring to the care of patients? We�re into an era where right now, electronic health records can provide decision support, reminders for flu shots, reminders for pneumonia screening, cholesterol checking, the sorts of things I�ve mentioned. The future is even more exciting. The future suggests that now that the human genome has been sequenced, that when I go to my doctor in the future on the basis of my unique genetic makeup, they will be able to make better choices in terms of which medication will work.

And perhaps even more remarkable in terms of which medications to avoid, which ones are going to have bad, perhaps even fatal side effects. In VA, we want to make sure that as our health record matures that we can be there to harness the power of genetic information to make sure that we provide patients with truly personalized healthcare in the future. And so the future is very, very exciting.

About making sure that we build in to the VA health system, system properties: Safety, protecting patients from errors, quality, making sure that the care is consistently reliable, efficiency, making sure that the taxpayers� resources, the veterans� resources are used to provide the maximum health benefit and in terms of making sure that we know why are patients there, being able to use technology in the community to help an older veteran age successfully in home. Maintain not only a community relationship, perhaps, even a spousal relationship of 60 years by supporting them with technologies in their home, we believe we can even build not only safety, effectiveness, efficiency, but compassion, and so the future is just tremendously exciting both for VA and the rest of healthcare.

Ms. Lee: What other goals, Dr. Perlin, would you like to see VHA accomplish and what role do you see IT playing in VHA meeting those goals in the future?

Mr. Perlin: Well, again, the electronic health record information technologies will really be the glue that holds all of information -- all of healthcare together, particularly with the decentralization I was mentioning. But there are so many challenges to current healthcare, that and the ability to combat medical errors, the ability to build in quality and to be truly compassionate, I think, are the aspirations. And being able to harness the power of understanding people�s genetic makeup will be not evolutionary but revolutionary in terms of being able to bring the right treatment to the right patient at the right time.

Ms. Lee: You�re such a visionary; what are some of the future challenges you think VHA would be faced with and how do you plan to address them?

Mr. Perlin: Well, I think the challenge is constant. Our mission is simple; we care for veterans, and whatever the current world events -- like returning for combat veterans and providing the best rehabilitative care to the challenges of healthcare overall. Caring for an aging population, to the challenges of new diseases, and I hope that we never experience an epidemic like SARS. But being able to combat potential epidemics be it an influenza epidemic, VA has to be at the forefront in terms of doing the research, translating that research to clinical practice and making the experience of VA available to all Americans.

As we believe in many instances, electronic health record and performance measurement are model for health policy and improved health outcomes for all Americans. And the opportunity to do that in an environment, we were training tomorrow�s health professionals means that we really can help to provide a service not just to veterans but to the country.

Mr. Kamensky: Dr. Perlin, we always like to close our show with the same question. What advice would you give to a person interested in a career in public service, especially in public health?

Mr. Perlin: Well, the advice I give them is that there is no organization I can think of with a more noble mission in caring for America�s veterans. And we would welcome those people who are visionary and passionate and dedicated and skilled to look at a career in VA. I can tell you that our website is www.va.gov, and on that website you can find employment resources where you can also learn more about VA. You can also learn more about the patients� personal health record, two-thirds of it is available today and full access for patients who are part of our system will be available on Veterans Day, 2005.

And the website for veterans -- not just those who are using VA, but the website for health information and maintaining your personal health record is www.myhealth -- m-y-h-e-a-l-t-h -- .va.gov. And the overall website, www.va -- that's victor alpha for you veterans -- .gov.

Mr. Kamensky: Well, thank you. Vernecia and I want to thank you for fitting us in your busy schedule and joining us this morning. This has been The Business of Government Hour featuring a conversation with Dr. Jonathan Perlin, the Undersecretary for Health at the Veterans Health Administration, which is in the Department of Veterans Affairs.

Be sure to visit us on the web at www.businessofgovernment.org. There you can learn more about of our programs and get a transcript of today�s fascinating conversation. Once again that�s www.businessofgovernment.org.

For The Business of Government Hour, I�m John Kamensky. Thank you for listening.

Dr. Jonathan Perlin interview
12/03/2005
"Healthcare today and in the future really has to be about the patient. The information has to follow the patient. Our system is increasingly designed not to orient around the facility's needs to organize and deliver care, but around the patient's needs."

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