VA and its bureaucracy

[Igor4sugry]

Following 1yr rotation at VA (not daily), I have come to see how the VA offers many resources yet manages access to care and these resources in a strange manner. What is cause of this on surface seems unrelenting bureaucracy. From doing paperwork to start the rotation, to scheduling patients, to having patients do simple things such as get EKG, to having to answer to pharmacists who decline to authorize meds due to their rules (one particular is Cymbalta, where they ask a trial of Effexor first). Then there is the electronic medical record that is stuck in 1990s and is completely inflexible, unsearchable, non-user friendly compared to things such as EPIC that we are used to. One more item I found interesting is the process of getting service connected (C&P?), which seems to have diagnoses made that I cannot see at all on exam (cyclothymic disorder? come on).

Other things are concerning as well including new patients who were referred to psych and prior to this few days ago saw primary care. Yet primary care didn't include any of their medical history in the chart (although it is the other system that lists their 10+complex medical problems (but the systems are completely separate and not integrated), and on the medical ROS there are medical concern that should have been addressed 2 days prior. I also notice that there are patients with quite complex medical histories who should be managed by MDs/DOs rather than mid-levels for whom these patients are clearly over their heads in terms of complexity.

In terms of psychiatric pathology the VA was more intense than our outpatient university clinic. Particularly in Axis II area. Overall great experience, but the VA has a lot to do with how many patients are seeking care in their system.

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[Shikima]

It is horrible. Just horrible. And to think, people want the Government to run healthcare on a grander scale? It would go bankrupt with piss poor service and limiting options.

 

[peppy]

Yeah that sounds like the VA all right. I enjoyed rotating at the VA because the vets were fun to talk with but decided not to work there due to the layers of bureaucracy.
That, plus I interacted with several employees there who seemed to be trying to get away with doing as little work as possible frankly. It's really weird to go from the VA to a private hospital where people actually are motivated to work.

 

[F0nzie]

I applied to the VA 2 years ago. Just last week (no joke) they called me for the first time saying "we received your CV..."

 

[Doctor Bagel]

I trained at a program where we spend 50% of our time at the VA (and they actually pay 50% of our stipends!, thanks VA!) and just completed a VA heavy fellowship, also funded by the VA. So the VA has some good stuff, including significant funding for mental health training. Our VA also has good doctors -- I've heard that's not true everywhere, but it's true here. And supposedly it's a not-too-horrible place to work, although it works better for some people than for others. I opted not to apply to VA jobs, but if I decide to retreat to full-time employment, I'll look there.

About CPRS versus Epic, CPRS is a pain, but you've got to give the VA props for having the first big EMR, and it's still functional. What annoys me is that it seems like IT isn't committed to having it running with the same reliability as other systems are. Sometimes remote access just doesn't work, and honestly that's not acceptable. CPRS is I think pretty good for data tracking and research, which is great. Epic is not designed to do that, which seems silly. Staff in general is just not as efficient at the VA -- I think I've said it before, but the VA functions kind of like a small town where you know Joe isn't the best, but he's a nice guy, so you let him keep his job. Sure, he's taking a smoke break for about 1/4 of his shift, but still, he's a nice guy. On the one hand, it's annoying, and on the other hand, it's a little charming. Also, Joe is probably a vet, so there's that.

VA eye-rolling horribleness -- the PIV system! My fellowship was set to end mid-July, and my PIV expired at the start of July. I actually did not renew it and could still do everything I needed to in the system except order controlled substances. Renewing it for 2 weeks would have been a huge waste for both the VA and me. If you've done the PIV thing, you know what I'm talking about. Hours and hours of time.

VA patient care -- it varies. Here, VA patients probably have about the best access to mental health care than anyone in the community excepting people with really good insurance and the ability to pay out of pocket for extras. The downsides are that you don't have a lot of choice about what you get or what's available. If you want to do exploratory type of work, you can't get that through the VA. Should you? I don't know.

VA patients -- yeah, they're tough. Lots and lots of Axis II and lots of institutional transference and benefit seeking (I can't really even blame them -- those service connections are very generous). Our country did a horrible thing by starting and continuing these wars and then recruiting people who we knew would do poorly just because we needed people. The VA is stuck dealing with that.

 

[Shikima]

Another thought - it's dept chief/management dependent on the quality of the work environment.

 

[Armadillos]

Honestly I think one of the biggest problems at the VA is that for non physician jobs it seems they are required to hire veterans before others. Obviously nothing wrong with veterans, but anytime you drastically decrease the segment of the workforce your hiring from then its not good from an economic efficiency standpoint. Especially given that the segment of the work force being selected for is by default used to being part of an inflexible beaucracy.

From an economic standpoint "discriminatory" hiring practices are massively inefficient even if they are done for good reasons.

 

[whopper]

people want the Government to run healthcare on a grander scale?

I'm not accusing you of misleading anyone cause you didn't say it, but I'm going on a tangent cause it's highly related. I can pick apart and tell you a heck of a lot that I don't like with the ACA but it makes insurance companies compete against each other and not take huge amounts of money solely for the intent of profit. It's ridiculous that an insurance company whose mission is to pay for healthcare would put less than a significant amount to that mission.

People have a misperception that the ACA is government healthcare. It's not. It's not the VA either.

Now all this said the problems with the VA have been going on for decades. IF you've seen the movie Born on the Fourth of July it shows horrendous care being done in the 60s for Vietnam vets and this movie was done in the 80s. The GOP is trying to blame Obama for all of the VA woes only because of the VA scandal that was uncovered about 2 years ago but in reality has gone on as far as I know since the 60s.

 

[wolfvgang22]

Following 1yr rotation at VA (not daily), I have come to see how the VA offers many resources yet manages access to care and these resources in a strange manner. What is cause of this on surface seems unrelenting bureaucracy. From doing paperwork to start the rotation, to scheduling patients, to having patients do simple things such as get EKG, to having to answer to pharmacists who decline to authorize meds due to their rules (one particular is Cymbalta, where they ask a trial of Effexor first). Then there is the electronic medical record that is stuck in 1990s and is completely inflexible, unsearchable, non-user friendly compared to things such as EPIC that we are used to. One more item I found interesting is the process of getting service connected (C&P?), which seems to have diagnoses made that I cannot see at all on exam (cyclothymic disorder? come on).

Other things are concerning as well including new patients who were referred to psych and prior to this few days ago saw primary care. Yet primary care didn't include any of their medical history in the chart (although it is the other system that lists their 10+complex medical problems (but the systems are completely separate and not integrated), and on the medical ROS there are medical concern that should have been addressed 2 days prior. I also notice that there are patients with quite complex medical histories who should be managed by MDs/DOs rather than mid-levels for whom these patients are clearly over their heads in terms of complexity.

In terms of psychiatric pathology the VA was more intense than our outpatient university clinic. Particularly in Axis II area. Overall great experience, but the VA has a lot to do with how many patients are seeking care in their system.

You're exactly right, great summary. I work in a VA outpatient mental health clinic, and do emergency and inpatient consults. Lots of Axis II, and waaay more PTSD than you see in other settings.
The nicest thing about the VA's medical records is that I can use VistaWeb to get documentation on a veteran patient from any VA in the nation. I don't have to start from scratch just because my patient moved here from the Miami VA, for example.

CPRS does suffer from the same thing every EMR suffers from: administrators saying "just click one more button, write one more note, it only takes a few seconds", and before too long you are spending hours writing and clicking compared to writing one simple note. Paper charts have ended up being more efficient for everything except looking up past records.

Regarding the socialized healthcare aspect of the VA: most of my patients are older former enlisted soldiers, sailors, and marines who served their 2 to 4 years, got out, and did something like drive a truck or worked manual labor for another 15 years or so, or young veterans with little education and qualifications. If it wasn't for the VA, they usually wouldn't have any healthcare. Maybe they could afford the catastrophic care plans offered under the ACA....maybe. But then they wouldn't get all these benefits they deserve. Most of my patients get travel pay if they live out of town, for example. Who else is gonna do that for veterans?

The biggest problems in the VA are two fold from my desk:
1.) Bureaucracy must be slimmed down, meaning paperwork. The VA actually needs more people to process the mountains of paper work they have created over the years right now, but won't hire them. It would probably be least expensive to just grant the veterans their damn benefits and skip a lot of the paperwork. It's shameful how long older veterans have to wait to get benefits. Younger veterans (iraq, afghanistan) usually fare much better, probably because it's easier to find their records.
2.) The VA needs to quit changing expectations every year. They need to stick to their plan and execute it. Last year Congress passed bills increasing the maximum psychiatrist salary, and double the loan repayment program for psychiatrists. They need to do this for primary care, too. Yet, I'm told there is a hiring freeze this summer in a lot of regions because the political winds have shifted toward fiscal conservatives and the media has quit paying attention. So, time to save money by cutting services and stopping growth! It's bologna.

Before I sound too negative, I was delighted to assist a veteran who earned a silver star, multiple purple hearts, and other medals today. It was an honor to serve that nice gentleman who sacrificed a lot in his personal life to serve his country. The VA needs to make it easier for us to help men and women like that.

 

[Shikima]

I'm not accusing you of misleading anyone cause you didn't say it, but I'm going on a tangent cause it's highly related. I can pick apart and tell you a heck of a lot that I don't like with the ACA but it makes insurance companies compete against each other and not take huge amounts of money solely for the intent of profit. It's ridiculous that an insurance company whose mission is to pay for healthcare would put less than a significant amount to that mission.

People have a misperception that the ACA is government healthcare. It's not. It's not the VA either.

Now all this said the problems with the VA have been going on for decades. IF you've seen the movie Born on the Fourth of July it shows horrendous care being done in the 60s for Vietnam vets and this movie was done in the 80s. The GOP is trying to blame Obama for all of the VA woes only because of the VA scandal that was uncovered about 2 years ago but in reality has gone on as far as I know since the 60s.

The statement was not in support for a single-payor system which many on social media are crying for.

And ACA is turning out to provide less services, with higher deductibles and cost people more than previously. It hasn't caused insurance companies to compete.

 

[OldPsychDoc]

I could've written the OP word for word 15 years ago...

 

[jjmack]

I agree with almost all of this post, except I often prefer CPRS to Epic. Yes, it's clunky and stuck in the 1990s, but once you learn the secrets it's often easier.

 

[WingedOx]

I agree with almost all of this post, except I often prefer CPRS to Epic. Yes, it's clunky and stuck in the 1990s, but once you learn the secrets it's often easier.

Seriously. CPRS was designed to run on 1996-era computers and runs with ease on any computer less than 20 years old.

meanwhile, it always seems to take 20 minutes to click through all the meaningful use menus on Cerner each encounter because I have to stare at an hourglass for 45 seconds each time I hit a button.

 

[WingedOx]

Following 1yr rotation at VA (not daily), I have come to see how the VA offers many resources yet manages access to care and these resources in a strange manner. What is cause of this on surface seems unrelenting bureaucracy. From doing paperwork to start the rotation, to scheduling patients, to having patients do simple things such as get EKG, to having to answer to pharmacists who decline to authorize meds due to their rules (one particular is Cymbalta, where they ask a trial of Effexor first). Then there is the electronic medical record that is stuck in 1990s and is completely inflexible, unsearchable, non-user friendly compared to things such as EPIC that we are used to. One more item I found interesting is the process of getting service connected (C&P?), which seems to have diagnoses made that I cannot see at all on exam (cyclothymic disorder? come on).

Other things are concerning as well including new patients who were referred to psych and prior to this few days ago saw primary care. Yet primary care didn't include any of their medical history in the chart (although it is the other system that lists their 10+complex medical problems (but the systems are completely separate and not integrated), and on the medical ROS there are medical concern that should have been addressed 2 days prior. I also notice that there are patients with quite complex medical histories who should be managed by MDs/DOs rather than mid-levels for whom these patients are clearly over their heads in terms of complexity.

In terms of psychiatric pathology the VA was more intense than our outpatient university clinic. Particularly in Axis II area. Overall great experience, but the VA has a lot to do with how many patients are seeking care in their system.

The problem with a lot of what you wrote is that VAs tend to vary widely between sites. Cymbalta was a n0-go where I trained but it's on formulary where I'm at now. The quality of how well a VA department is going to be almost entirely dependent on the leadership at each site.

I mean, basically the entire second paragraph is an issue with individuals rather than "the system." and nearly all of these complaints have parallels in the private setting. Every setting has quirks with scheduling patients, for example.

 

[scudiera]

Agree with so much of this that I'm not going to write more on the nursing/non-MD staff issues, the PIV, and the insidious culture of inefficiency that finds its way into how physicians direct patient care if they aren't always vigilant to it.

All of this said, I'm glad I get a chance to train here, and to provide care to these folks. And I've managed to become much more proficient in CPRS in the past year! (Though I still roll my eyes when CRPS admins talk about how it's so great for data collection). Some of the neat tricks I've learned in Epic, like generating my own dot phrases, doesn't work here, but there are perks to CPRS nonetheless.

 

[wolfvgang22]

Agree with so much of this that I'm not going to write more on the nursing/non-MD staff issues, the PIV, and the insidious culture of inefficiency that finds its way into how physicians direct patient care if they aren't always vigilant to it.

All of this said, I'm glad I get a chance to train here, and to provide care to these folks. And I've managed to become much more proficient in CPRS in the past year! (Though I still roll my eyes when CRPS admins talk about how it's so great for data collection). Some of the neat tricks I've learned in Epic, like generating my own dot phrases, doesn't work here, but there are perks to CPRS nonetheless.

CPRS has a template system that has the equivalent of EPIC's dot phrases and smart texts. I use it a lot.

 

[heyjack70]

Does the va let you dictate notes? Dictation is the best.

 

[NickNaylor]

I've just finished my first week ever at a VA (my medical school did not have an affiliated VA hospital that we rotated at).

Perhaps it's just this particular VA, but holy Christ, there is zero chance I could ever imagine working here. I would echo the sentiments regarding the patients - I've found them to generally be extremely respectful and, for the most part, relatively compliant with your recommendations for them. Perhaps it's the authoritarian regime of the military, but I've enjoyed those aspects of caring for veterans. The VA system itself, though, is a complete cluster****, and I have zero desire to work within it.

 

[Igor4sugry]

CPRS has a template system that has the equivalent of EPIC's dot phrases and smart texts. I use it a lot.

I figured out the template system and it did make things much more efficient.

As naive resident it was quite an experience to interview a patient that unleashes his 30+ years of hatred at the VA system (and a strange realization that it is not directed at me at all, and this veteran keeps appointments). I wonder if they do this to new docs for some specific vs subconscious need.

 

[scudiera]

CPRS has a template system that has the equivalent of EPIC's dot phrases and smart texts. I use it a lot.

I do take advantage of the templates and patient data objects to the best of my ability but there's still a lot of clunkiness to the system. AFAIK you can't build conditional dot phrases in CPRS as you can in EPIC and I appreciate the on-the-fly ability of dot phrases for importing specific information (eg. 3 most recent lab results or most recent radiology report) as you write out a note whereas in CPRS there's some drag/dropping involved that in my experience doesn't always work or give you what you want w/o extensive reformatting.

That and most people just write their notes using the default notewriting funtion and CPRS fills it up with 95% poorly formatted boilerplate crap so you just glaze over anything pertinent if you're trying to read more than one or two notes and miss something important until you read the note for the 3rd time. I hate reading PCP notes which are like 5 pages long, with an ugly A&P hiding at the bottom underneath the past 8 months of Glc and LDLs and patient's service connection. They're probably under huge time constraints and don't have the luxury of reformatting and they probably need to have all that stuff in their for billing purposes but... it's ugly and interferes with efficient patient care. I try my best to use templates and cut out as much of the BS as possible, and leave my A&P at the very top.

Edit: Care to guess where I just spent the past month? (And I actually had a fantastic time for the most part) BTW with respect to doing things for "the new doc" at our VA apparently the nurses like to haze the new medicine night floats by hammer-paging them for Glc in the 130s and BPs of 150s/80s until they learn to be nice and friendly with everybody instead of running around like a headless chicken who just got 10 pages while talking to them. You learn fast.

 

[whopper]

In response to Shikima-the ACA is far from perfect. I'm not even sure we're better with it than without it though sometimes I suspect that is the case. Even if it is overall a better thing to have we're certainly experiencing problems from it. Right now where I work the ER for the past month has been at more than 200% our capacity and the cause is directly due to the ACA. It allowed more people to have healthcare but there are not enough PCPs to carry these people so these people go to the ERs instead of a usual PCP such as a family practice office.

Anyways, an article written years ago from my former forensic PD.

http://www.nationalaffairs.com/public_interest/detail/at-the-va-it-pays-to-be-sick

 

[heyjack70]

ACA exchange insurance sounds like a horrible deal for the middle class from everything I've read. Big premiums, big deductibles. If you actually have to use it you can't afford to. The ACA Medicaid expansion has helped the lower socioeconomic strata in states that have actually expanded, but as we all know, Medicaid is the worst payor out there and, unless you've heard otherwise, doesn't even cover overhead costs for seeing patients let alone earning money to take home. I fear the day single payor arrives and it is Medicaid for all.