The delivery of the full range of health and service benefits to veterans depends upon an effective and efficient information infra- structure. While there are exemplary pockets of innovation across the Department of Veterans Affairs (VA), the current VA infrastructure lacks the broad perspective that facilitates departmentwide data and information sharing.
The results are unnecessary costs and delays in acquiring and maintaining available information, and the placement of unnecessary demands on VA clients. Establishment of an effective information infrastructure will enable the department to streamline its operations and to provide more efficient service to its customers.
VA spends at least $600 million annually on procuring and maintaining information resources in support of its headquarters and field operations.(1) The department maintains client information in multiple, independent program systems. Veterans see VA as a multiple service provider. Multiple program systems cause a veteran or survivor to be asked the same questions repeatedly by VA, increasing the likelihood that the veteran receives the proverbial runaround, conflicting information, or both.
Dissatisfaction with how VA manages its information resources is broad-based. For example, the General Accounting Office (GAO) has criticized VA's information infrastructure and its inability to make the best use of its resources in delivering better services to the veteran.(2) VA's customers, through the veterans service organizations, have also recommended better management of the department's information resources.(3) Recently, the ranking majority and minority members of both the Senate and House Committees on Veterans Affairs advised VA Secretary Jesse Brown:
Nearly 27 million veterans and their families depend on the Department of Veterans Affairs for their benefits and services. Unfortunately, the effective and efficient delivery of veterans' services has, over the last 20 years, been severely impeded by increasingly inadequate, expensive and worn-out information systems.(4)
The inadequacies of VA's information systems affect every aspect of its operations. Specific information management initiatives, such as the Veterans Benefits Administration's (VBA's) Modernization Program, are under way to support various mission-driven objectives of individual VA administrations and offices. However, there are not enough incentives in place throughout the department to spur such cross-cutting initiatives by individual units in support of the needs of others, or to encourage information sharing about other units' technologies and systems. As a result:
--- No one knows the full range of benefits that a particular veteran receives.
--- Responsibility for follow-up action to veterans is fragmented among programs.
--- Cost-recovery and cost-accounting mechanisms need to be modernized.
--- Program operations are labor-intensive and result in high operating costs because they do not use information technologies to eliminate inefficiencies and redundancies in data and procedures. These problems will continue to worsen unless corrective actions are taken.
Several circumstances threaten to aggravate the situation further. While the veteran population is expected to decrease over the coming decades, the complexity of the interactions between VA and veterans is increasing. Outpatient visits to VA facilities, for example, have increased over 600,000 cases in each of the past two years.(5)
On another front, the Court of Veterans Appeals (COVA) has expanded veterans' due process rights since its creation in 1988. On the other hand, it has caused significant increases in the quantity and complexity of VA's workload.(6)
One more complicating factor is the likelihood that future health care reform initiatives will require VA to compete as a service provider. In that event, it will be at a considerable disadvantage without an information infrastructure (technology, standards, procedures, and management support) that promotes the most efficient methods for the acquisition, use, and dissemination of critical data.
VA has already considered many of these issues and has developed proposals and plans to fix individual problems. However, an overall strategy and infrastructure are lacking, and there is no consensus on the utility of combining medical and nonmedical information for each veteran to create a master veteran record (MVR). Among the actions that need to be taken are the following:
--- Technical impediments to departmentwide data sharing and information systems integration need to be identified, analyzed, and incorporated into an infrastructure baseline.
--- Improvement actions need to be considered, evaluated, and incorporated into an infrastructure action plan.
--- Data common across administrations and offices need to be identified and defined as part of the MVR concept, along with a determination of what requirements are now unmet because of the inability to merge medical and nonmedical data.
--- Mechanisms need to be established that will not only facilitate incorporation of departmentwide considerations in information systems planning, but also provide appropriate incentives for doing so.
Finally, while the relationships between VA's information activities and those of the Departments of Defense (DOD), Health and Human Services (HHS), the Treasury, and Labor are known, operations are hampered by the lack of data standards and difficulties in data access. For example, the average time associated with the transfer of medical records from DOD to VA is 65 days, and Treasury provides separate Internal Revenue Service files to individual VA components.(7)
Developing an integrated view of the broad range of VA program benefits available to an individual veteran is embodied in the department's MVR concept, which resembles programs implemented effectively in the private sector. For example, the United Services Automobile Association (USAA) undertook a program in the 1980s to integrate the data it had on customers, who typically participated in several different USAA programs. The overall effort took six years and cost $130 million, and yielded measures of success that included the following:
--- reduced support costs,
--- improved productivity,
--- reduced staff turnover,
--- increased market share (i.e., the percent coverage of the USAA potential customer base rose from 75 percent to 95 percent), and
--- vastly improved service.(8)
USAA is proud of the fact that while it has more than 14,000 employees (nearly the same as all of VBA) engaged in client services, each client calling the association is speaking with an employee who has immediate access to the caller's file.(9) Establishing the MVR concept is supported by Secretary Brown as part of his plans to strengthen VBA's modernization initiatives.(10)
The MVR idea would apply to VA's medical care programs, as well as its compensation and pension, vocational rehabilitation, education, home loan, insurance, and burial benefits programs. From a medical standpoint, it is vital to quality care that all data--acquired in any part of the health care and medications system--are accessible as soon as possible in any part of the overall system. Given the aging of VA's patient population, for example, this appears to be more critical for VA than private-sector hospitals, because the patient may not be able to help in providing information.
Many opportunities exist for federal agencies to share information, and VA maintains data that could be matched with other agencies to save federal dollars. For example, ties with DOD are especially feasible (as well as critical) because both the DOD and VA health care systems use the same programming language and data standards. Commonalities between the DOD and VA systems are so great that Congressman G.V. (Sonny) Montgomery recently called for tying the two systems together and providing cradle-to-grave information on soldiers and veterans.(11) It is also worth recognizing that even the 300,000 headstone distributions made annually by the National Cemetery System (NCS) could provide additional notice to HHS and other departments that some changes in their entitlement programs may be warranted.
The need to move forward quickly with the development of the MVR seems to be compelling. First, there is considerable evidence that the service needs of veterans are not being met, and a more coordinated information management approach is integral to fulfilling this need. Second, VA recognizes that there is a wide dispersion of data and that better information management is cost effective. For example, in the appendix to its June 1993 draft MVR Plan, the department identified 18 different systems within VA and other federal agencies that contain a variety of data about veterans.(12) Data sharing and matching across federal agencies since 1991 has resulted in hundreds of millions of dollars in savings.(13)
VA has several modernization initiatives now under way to address some of these concerns, but an agreed-upon MVR design has not been defined. The sooner the design is known, the less the risk of increased costs and delays in existing modernization efforts.
Numerous GAO reports have also suggested that the lack of timeliness and completeness of data have impeded VA debt collection and cost recovery efforts.(14) Given that bad debts and write-offs increased from $680 million to $1 billion at VA between fiscal years 1991 and 1992, there is a strong business case for almost any effort that offers the potential to better coordinate veteran information to ensure that scarce dollar resources are most effectively used to serve veteran needs.(15)
The Department of Veterans Affairs should move expeditiously to strengthen and modernize its information infrastructure, with an emphasis on establishing the scope of the MVR.
The adoption of a departmentwide information infrastructure, based upon the concept of an MVR, will enable VA to shift from a strictly program-based approach to one that also has a veteran-based orientation, and to pursue its modernization efforts as part of an integrated framework.
As noted earlier, however, an overall strategy and infrastructure are lacking, and there is no uniform agreement on the utility of combining medical and nonmedical information for each veteran to create an MVR. Secretary Brown has endorsed the MVR in principle. Nevertheless, the concept and its benefits need to be spelled out further to provide managers with the information they need to make decisions about resource trade-offs required in their programs to support the initiative. There may be limits that should be incorporated in the design of the MVR, and these also need to be defined.
The information infrastructure must enable persons needing access to all records of a veteran being served or cared for to have such access, regardless of where the data are stored, and with adequate provision for its privacy and security. Other measures to be considered include the following:
--- the use of expert, imaging, and voice recognition systems that offer great promise for the reengineering of business processes throughout VA; and
--- compatibility with the output-oriented performance measurement system discussed in the National Performance Review (NPR) initiative titled "DVA09: Establish a Comprehensive Resource Allocation Program."
The June 1993 draft MVR Plan recommends a requirements study and economic analysis.(16) An effort of this type is a critical first step in establishing the business case for the MVR and developmental priorities. The next step planned is the design of the MVR itself. This will include the establishment of data and system interface standards for use in connection with the entire range of VA's current modernization initiatives.
This recommendation will result in a simpler, more efficient management system for VA, with increased focus on and responsiveness to individual veterans. It will also directly support Secretary Brown's vision for the VA to function as a unified department delivering benefits and services in a high quality, cost-effective, and timely manner to veterans and their families.(17) Finally, it conforms with governmentwide goals for data matching, with resulting improvement in the quality and efficiency of federal information management initiatives.
This effort should be budget neutral if VA is given flexibility to (1) transfer funds between programs and object classes, as recommended in the NPR initiative titled "DVA03: Eliminate Legislative Budget Constraints to Promote Management Effectiveness," and (2) to recover costs associated with recoveries under the proposed Federal Credit and Cash Management Act of 1993.
Nevertheless, the most critical aspect of this effort is that its value be apparent to the program officials who will benefit from its implementation. Therefore, consideration should be given to allowing any savings resulting from this effort to be retained within VA programs to improve service and benefit delivery to veterans. Strong leadership will be required to implement this recommendation in a timely manner.
1. U.S. Department of Veterans Affairs (VA), IRM Program, FY 1991 - FY 1997 (Washington, D.C., undated), p. 6.
2. U.S. General Accounting Office (GAO), Veterans Affairs IRM: Stronger Role Needed for Chief Information Resources Officer, GAO/IMTEC-91-51BR (Washington, D.C.: U.S. General Accounting Office [GAO], July 24, 1991).
3. Kenney, James J. , et. al., The Independent Budget for Veterans Affairs, Fiscal Year 1994 (Washington, D.C., undated), p. 22.
4. Letter from John D. Rockefeller, IV, Chairman, Senate Committee on Veterans Affairs; Frank H. Murkowski, Ranking Minority Member, Senate Committee on Veterans Affairs; G.V. (Sonny) Montgomery, House Committee on Veterans Affairs; and Bob Stump, Ranking Minority Member, House Committee on Veterans Affairs, to Jesse Brown, Secretary of Veterans Affairs, May 4, 1993.
5. U.S. Department of Veterans Affairs, Financial Statements, Fiscal Year 1992 (Washington, D.C., March 31, 1993), p. 2-11.
6. See U.S. Congress, House, Committee on Veterans Affairs, Subcommittee on Compensation and Insurance, testimony of R. J. Vogel, Deputy Undersecretary for Benefits, Department of Veterans Affairs, April 21, 1993.
7. Interview with James Edwards, VA, July 14, 1993.
8. Graham, Kenneth W., Image Processing at USAA (San Antonio, Texas: United Services Automobile Association, May 1992), p. 2.
9. Teal, Thomas, "Service Comes First: An Interview with USAA's Robert F. McDermott," Harvard Business Review (Cambridge, MA: Harvard University Press, September-October 1991).
10. Letter to Leon Panetta, Director, U.S. Office of Management and Budget, from Jesse Brown, Secretary of Veterans Affairs, June 24, 1993.
11. Smith, James M., "Rep. says DOD, VA Should Merge Hospital Systems," Government Computer News (July 19, 1993), p. 90.
12. U.S. Department of Veterans Affairs, Master Veteran Record Plan (Washington, D.C., June 17, 1993), p. 2-8. (Draft)
14. U.S. General Accounting Office, VA Health Care: Better Procedures Needed to Maximize Collections from Health Insurers, GAO/HRD-90-64 (Washington, D.C.: GAO, April 6, 1990).
15. VA, Financial Statements, p. 4-2.
16. VA, Master Veteran Record Plan, p. 8.
17. See Public Notice from Jesse Brown, Secretary of Veterans Affairs, Secretary's Vision (Washington, D.C., April 2, 1993).
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