“OFF WE GO INTO THE WILD BLUE YONDER”
Pat DeLeon, former APA President – Division 55 — June, 2017
Signs of a Unified Federal Health Care System?
Those intrigued by the seeming inconsistencies which exist when reflecting upon the role of the federal government as a provider of health care should develop an appreciation for the importance of historical precedent, as well as the vision/responsibility of individual members of Congress and especially of Congressional Committees. The professions of psychology and nursing often advocate for the holistic and psychosocial-environmental-cultural elements of health care, pursuant to the vision of the World Health Organization (WHO). “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1948).” There is growing scientific evidence to support this orientation. Those who appreciate the all-important nature of prevention should especially seek out federal programs prioritizing the “environment” in which health care is provided.
And yet, the Bureau of Indian Affairs and the Indian Health Service are in different federal departments. The Food and Drug Administration is administratively located within the Department of Health and Human Services, while its budget is the responsibility of the Agriculture Appropriations subcommittee. And, those interested in pursuing funding for developing women-in-technology STEM initiatives, especially for those residing in rural America, should consider seeking funding from the Department of Agriculture, where support for the nation’s land-grant universities has long resided. Elaine Foster, who had a wonderful career for over two decades as a USAF prescribing psychologist (RxP), has noted how she could still prescribe necessary psychotropic medications for her patients as a USAF civilian contractor in a DoD clinic, but not in the local VA clinic which was just across the parking lot. “I could no longer prescribe to that same patient I’d been prescribing to while he or she was active duty. The current VA restrictions are illogical…. Because New Mexico recognizes prescribing psychologists, I can now prescribe to our veterans, but only in New Mexico and only through a third party contractor…. This just does not make sense.”
Prior to being confirmed by the U.S. Senate as the first non-Veteran Secretary of the Department of Veterans Affairs, Dr. David Shulkin served as the VA Under Secretary for Health. In that capacity, in January 2017, he approved the unprecedented expansion of nursing practice within the VA, which is the largest employer of nurses and psychologists in the nation, as well as the largest health care system. VA advanced practice registered nurses (APRN) (other than nurse anesthetists) now possess full practice authority, without the clinical oversight of a physician, regardless of State or local law restrictions, when working within the scope of their VA employment. This includes taking comprehensive histories, providing physical examinations and other health assessment and screening activities, diagnosing, treating, and managing patients with acute and chronic illnesses and diseases. APRNs can order laboratory and imaging studies and integrate the results into clinical decision making; prescribe medications; and make appropriate referrals for patients and families, etc. “To achieve important Federal interests, including but not limited to the ability to provide the same comprehensive care to Veterans in all States… this section preempts conflicting State and local laws relating to the practice of APRNs….”
During its deliberations on the FY 2017 Appropriations Legislation [P.L. 115-31] the Appropriations Committees noted that: “Concerns remain with the progress being made by the Departments of Defense and Veterans Affairs to fully develop, procure, and deploy an interoperable electronic health record solution. The two systems must be completely and meaningfully interoperable…. Given that full deployment of this new electronic health record is not scheduled until fiscal year 2022, the Department of Defense is expected to continue working on interim modifications and enhancements to the current system to improve interoperability in the near-term….”
Notwithstanding Congress’s generous timeframe, on June 5, 2017 Secretary Shulkin announced his decision on the next-generation Electronic Health Record (EHR) system for his Department. “The health and safety of our Veterans is one of our highest national priorities. Having a Veteran’s complete and accurate health record in a single common EHR system is critical to that care, and to improving patient safety. Let me say at the onset that I am extremely proud of VA’s longstanding history in IT innovation and in leading the country in advancing the use of EHRs. It was a group of courageous VA clinicians that began this groundbreaking work in the basements of VAs in the 1970’s that led to the system that we have today, known as the Veterans Health Information Systems and Technology Architecture, or VistA….
“At VA, we know where almost all of our Veteran patients are going to come from – from the DoD, and for this reason, Congress has been urging the VA and DoD for at least 17 years – from all the way back in 2000 – to work more closely on EHR issues…. (T)he bottom line is we still don’t have the ability to trade information seamlessly for our Veteran patients and seamlessly execute… with smooth handoffs. Without improved and consistently implemented national interoperability standards, VA and DoD will continue to face significant challenges if the Departments remain on two different systems. For these reasons, I have decided that VA will adopt the same EHR system as DoD…. It’s time to move forward, and as Secretary I was not willing to put this decision off any longer…. Because of the urgency and the critical nature of this decision, I have decided that there is a public interest exception to the requirement for full and open competition in this technology acquisition….
“In many ways VA is well ahead of DoD in clinical IT innovations and we will not discard our past work. And our work will help DoD in turn. Furthermore VA must obtain interoperability with DoD but also with our academic affiliates and community partners, many of whom are on different IT platforms. Therefore we are embarking on creating something that has not been done before – that is an integrated product that, while utilizing the DOD platform, will require a meaningful integration with other vendors to create a system that serves Veterans in the best possible way. This is going to take the cooperation and involvement of many companies and thought leaders, and can serve as a model for the federal government and for all of healthcare…. This is an exciting new phase for VA, DoD, and for the country. Our mission is too important not to get this right and we will.”
During her tenure as Interim CEO, Cynthia Belar established the position of APA Director of Military and Veterans Health Policy and appointed Heather O’Beirne Kelly to serve as the first director for this critical initiative. Heather has worked for APA for nearly two decades and one of her top priorities is to facilitate the acceptance of appropriately trained prescribing psychologists (RxP) within the Department of Veterans Affairs. She recently testified before the House of Representatives urging the adoption of a pilot RxP project, similar to that once contemplated by then-VA Secretary Anthony Principi under President G.W. Bush. Will the clinical inappropriateness of Elaine’s experiences become the catalyst for change – perhaps by the adoption of a national federal scope of RxP practice for psychology? Thinking of the future, both DoD and VA have long been on the cutting-edge of effectively utilizing telehealth with excellent clinical results.
Developing That All-Important Grass Roots Interest
This summer I was invited to participate on a convention program entitled “Doing the Most for the Many: Psychological Scientists Who Inform Public Policies” at the 29th annual convention of the Association for Psychological Science (APS) in Boston. On our panel, which was the first of two, was Massachusetts State Representative Ruth Balser and APA’s Elena Eisman (who previously served as executive director of MPA). Approximately 4,500 colleagues attended the convention and their enthusiasm for the future was palpable, especially among the early career attendees. Our panel provided a personal perspective from the state, association, and federal level. On the second panel Elizabeth Gershoff passionately described her efforts, over a prolonged period of time, including testifying on the Hill, on behalf of our nation’s youth.
“Corporal punishment remains legal as a form of discipline in public schools in 22 states (and in private schools in 48 states). APA has long opposed school corporal punishment, having passed a resolution calling for its end back in 1975. After I briefed his Department of Education senior staff, the former Secretary of Education John King issued a statement in November, 2016 to Governors and state heads of education in which he urged states to end the use of corporal punishment in schools based on demonstrations of harm to children and on discriminatory use of corporal punishment against boys, black students, and students with disabilities. In January 2017, Representative Alcee Hastings (D-FL) introduced H.R. 160, the Ending Corporal Punishment in Schools Act of 2017, that would tie state receipt of federal education funds to a ban on corporal punishment in public schools.” Solid scientific (or clinical) evidence, personal presence, and dedication over the long-term in the public policy process are critical. There was considerable enthusiasm among the audience and both Ruth and Elena reported subsequent discussions with attendees who expressed a willingness to become personally involved as a result of their presentations.
“We live in fame, or go down in flame.”
Pat DeLeon, former APA President – Division 55 — June, 2017