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PegaWorld iNspire 2023: For Veterans Care, Less is More: Reducing Backlog Means Better Outcomes

To improve veteran care, OIVC is starting a journey to use low-code technology to modernize 54+ homegrown systems. Current complex systems make it difficult for the VA to proactively keep up with service demand. And as regulations continue to change, the VA must be able to adapt quicker. As an example, it previously took 90+ days to update a business rule to comply with an updated mandate.

Watch this replay to hear how Pega’s low-code platform is allowing the VA to access data faster, process claims more efficiently, and quickly change business rules as needed.


- Great, well, thank you for joining us for the first session on Tuesday of PegaWorld. I'm sure everyone has been having a wonderful conference. I know I have. It's so nice to be back in person and see people all the way, right? It's been wonderful. So today we're going to talk about the Office of Integrated Veterans Care at the Veterans Administration in the United States government. My name is Cindy Stuebner. I go by Cynthia, but Cindy is is my name. And I am the industry principal for the North American Government Public Sector. And I am really privileged to coordinate and present with two of our distinguished speakers today from the Office of Integrated Veterans Care. We have Rick Marble, who is the solution train engineer for the Office of Integrated Veterans Care. Rick has been working with the VA since 2015 and it's 2032. He is currently assigned to the integrated access and works with the Office of Information Technology to find solutions for integrated veteran care needs. He's currently working on VA Health Connect clinical contact centers modernization, say that three times fast. Community care scheduling and reference coordination. Rick is also a retired Air Force veteran and don't hold this against him, he is a Red Sox fan.

- One clap.

- Okay. We also have with us Brandon Gurley who is the program manager for the Integrated External Networks at Integrated Veterans Care at the US Department of Veterans Affairs. Brandon works in VA's office as a director for program oversight of integrated external networks. Brendan has worked for the VA for 19 years and most of that time has been spent helping the VA maximize third-party billing on the revenue operations side of the Veterans Administration with the remainder of that time spent streamlining claims processing activities across the enterprise. And Brandon, who has two teenage boys who are superstars on the golf course, is also a very talented wake surfer. So you've got some stuff to talk about after the session is over.

- I'm a wake surfer. I'm not sure the talented part, but I try.

- Look, you're more talented than I am. So with that, I'm gonna hand the mic over to Rick and get started.

- Thank you, Cindy. Welcome. Hope everybody had a great time. I know that I did. So we're here representing the Department of Veterans Affairs. We're a little bit different work stream. So Pega has been involved with the VA for several years on the financial side. And we're just beginning our baby steps or the beginning of our journey on the VHA side, on the Veterans Health Administration. So our mission is to fulfill President Lincoln's promise, which is to take care of those veterans that served in the military, their family, their caregivers, and their survivors. A little bit more about us by the numbers on the VHA side of the house. We are the largest integrated healthcare network in the United States. About 1,300 healthcare facilities comprised of what we call veteran integrated service networks or 18 regional networks that are out there and regional kind of the way that they're put together. 350,000 employees, full-time employees on the government side. But most importantly, we have nine million enrolled veterans in our program. And last year, over six million of those veterans received care through the VA. And our part here on the Office of Integrated Veteran Care is we are the advocates. We are out there trying to make sure that access to care, both internal with the VA and in the community are aligned and that we are making sure that our veterans and the associated beneficiaries have access to that care. So successes. So as I said, the VA's been working with Pega for a long period of time. We just started our piece there with VHA. It was last summer, met with the Pega team and we were looking for a software factory. How do we take care of some of our backlog and take advantage of some of the low-code, no-code software opportunities that were out there. Where would it fit within our organization? Clearly there are a lot of low-code, no-code platforms. We met with the Pega team, they did a fantastic job and we went through some of our backlog looking to see where would be a good place to start. And for us, we started with a program called Meds by Mail, which if anybody is familiar with the VA and our VistA system, Meds by Mail is built into our legacy VistA code. And we are looking to decommission that program in the future. And it looked like a good place for us to start. And the Pega team did a wonderful job. They have a program called Catalyst and their team came out, went through a great customer journey with us. For about two weeks, we talked to the pharmacist, the pharmacy technicians, the users that were going through the platform, the existing, what are the good and the bad that are happening with the existing system? And the great thing for us was they took all that information after two weeks and went back to the laboratory and came back two weeks later with a working prototype. Showed us the art of the possible as they kept mentioning throughout the course of our engagement with Pega. And we had a great working prototype that we could go back to our users, our pharmacists, our leadership and say this is what we can do with this solution. So that was a win for us. It kind of gave us an idea of how quickly can we move with low-code, no-code? The reality that the Pega team, whether or not they had an entire army out there, or just a small cadre of people doing the work, in two weeks, they had developed something that was useful to us. We couldn't use that initially. For anybody familiar with the VA, we have these wonderful things called processes and authorities to operate, but it showed us what was going on out there and how we could benefit from it. So to shift away from Meds by Mail as that's currently on hold until we decide to close down that legacy.

- [Brandon] There's no red tape in there whatsoever.

- No, we might still be cutting. But VA Health Connect is another thing that we've taken advantage in VHA with low-code, no-code software. What is VA Health Connect? This is the digital front door for our veterans. They can pick up a phone, call one number, and we have four core services out there. If they need to call up and change their appointment, check in on their appointment, cancel, reschedule, they get a notice from the VA to come back to clinic. We could take care of those using this low-code, no-code software where we pulled everything in. We used to have 600 different call centers and we pulled all those call centers into those 18 regions that I mentioned. And the crazy thing when I got there was they said, "Well, we handle about 45 million phone calls a year." And I went, "A million with like an M?" You know, it is a lot. We take, you know, between 100 and 170,000 phone calls every day from the veterans calling in. And with those 600 call centers that we had out there, each one was tied to those 1,200 facilities. And as we tried to get some scalability on that and pull it in, now we found that our staff was having to log into multiple instances of our EHR or VistA. Each site had their own programs and process. So the clinical contact center modernization was to kind of pull that all in and see whether or not we could get some scalability. And of course, the pandemic happened, which sped that up. Obviously, people were not going out. People were only going to the hospital when it was necessity. And our digital front door idea really blossomed. It opened up a lot of opportunities for what we call alternative modalities, telehealth, video, those kind of things so that our veterans did not have to worry about leaving the house, entering the area of the pandemic to come to the hospital over something that might be able to be taken care of over a telephone call. So our four core services, you know, about 50%, 50, 60% of our calls are on scheduling. About 25% are for pharmacy. So you know, you dial in if you have a question over pharmacy. They go right down the button and we can renew their prescriptions, we can refill, we can set up an appointment to get with a physician to take care of things. And for us, obviously during the pandemic was this clinical triage. Our veterans can call up immediately and get a nurse on the phone, like press the button, press three and talk with a nurse about your symptoms that you're currently having. About 16% of our phone calls are in that avenue, which is a form of like telehealth. Our nurses are out there again, trying to look at all the systems that are available. It was very difficult for them to navigate multiple systems and be on the phone with the patient and make sure that we were being safe. So as they kind of roll through the clinical triage, you know, whatever the answer might be, dial 911, go to the emergency room now. Maybe their symptoms can be taken care of with telehealth or a video visit depending on the triage. And the last part, you could see it's just about 3/10 of a percent, we just stood up our first version of virtual clinic visits, which means that based on your triage and your symptoms, if you need to be seen within the next 24 hours, we have the capability to set up a virtual visit, either video or telehealth with a clinician to take care of you, assuming that it is appropriate for your symptoms. So I'll hit the next slide here. You know, what were our staff looking at? A lot of applications and low code, no code and the framework associated with it allowed us to pull in all those systems into one clean customer relationship management tool that allowed our nurses to be able to look, see things that were going across multiple VistA sites. For our schedulers, we can see all their appointments, not just the appointments in the VistA site that they were looking at. We can see all their medications, all the directives that are out there in one tool. So it has been a wonderful way to reduce our handle time as we don't have to navigate multiple tools. It picked up our average speed of answer and we get a wealth of data out of these platforms that we didn't have in the legacy tools. You know, we can look at each step in the process, how long that took. We can identify where our bottlenecks are, where we can optimize and where we can move forward. So wonderful experience with low-code, no-code. Kind of bringing us back to where are we now. So I mentioned it was last summer we had just started and for anybody who's worked in the Office of Information Technology or in the VA on the IT side, we are getting ready to deploy into production a system that we just dreamed about last summer. That is incredible. It is very difficult to replace the system and get it out there. In this case, we had already looked with the Pega team over our backlog. One of our programs is called CHAMPVA. It's for our beneficiaries. It's not necessarily the veterans themselves. It falls under some of our congressionally managed programs. And we took a look at what our backlog looked like and this was our operational value stream. This process called, you know, display and reentry, you could see DAPER. So document and paper. I gotta see the name.

- [Brendan] I knew you'd have to look.

- You knew I wasn't gonna get it, right? Document And Process Enabling Repository. So this is a wonderful program that works, that needed to be upgraded and taken care of. As you can see, we had a bottleneck. This is high contact and high paper and Pega fit right in. We looked at all the opportunities that were out there, did our homework. The key one is how fast can we get to market with this? How fast can we take care of those people that are trapped in that bottleneck of eligibility on the CHAMPVA side? As you know, to fulfill that President Lincoln Promise, we want to get rid of those bottlenecks and speed access to care. So we went through it. Implementation began in late February. We're currently in UAT, we're getting ready for a June release. And that is very fast for a piece of technology that's... You know, in the VA, sometimes it takes several months just to kind of get off the ground. The rapid prototyping and the capabilities that we saw with this platform helped us move quickly, which is what our goal was. And with that, we'll talk about the future.

- Absolutely. One slide. I effectively secured a trip to Vegas for one slide and it's like the most boring slide in the whole conference with just a bunch of words and bullets. Bbut I'm here. I was color analyst too for you. So, all right, so healthcare reimbursement has changed a lot in VA over the years. I've been in the private sector for a few years. Been in VA mostly, 19 years in VA. So clearly, first bullet there, 300 million healthcare invoices. The volume is substantial. 47 billion, I think we're actually over 50 billion now expenditures. That is just the last two and a half years. So obviously, the numbers are staggering. Before I go into the next few bullets though, healthcare reimbursement looked a lot different in the old days. We used to have the process set up where VA had local contracts with providers and there are still some of those local contracts out there. Today they're referred to as VCAs but there are few and far between. The model has changed. The model is now where VA is using Community Care Network to establish a network of providers. And at the same time we're paying our two TPAs, Optum and TriWest, to process claims on our behalf and establish a network for us. So we're really more in a pay and chase model now as compared to what we used to be. And the transition's been quite challenging. And I think these next few bullets here, we're gonna kind of get into our hurdles, our challenges and then how we're gonna use kind of this platform to help us get through some of those challenges. And I'm not sure if some of you guys have attended the United Health Fraud Office or fraud demo earlier.

- The fraud demo yesterday.

- Yeah. But that is where we want to be. So basically, they're in 2023 and we're in 1923 right now. So I am very envious of where they are. But we aspire to be there. So again, we operate similarly to industry payers through a pay and chase model. Obviously, that requires a lot of backend research or claims research. My staff spend a lot of time doing research to identify potential risk areas. And when they're doing this research, they have to access many disparate systems. And you guys have heard this has been a recurring theme throughout this conference. Many disparate systems and you know, constantly having to log in with, you know, seven or eight, nine different systems. And so, you know, it's our goal to continue to work with the Pega team to establish that central location for them to log in and for all of those disparate systems to feed in and streamline the process. So nothing groundbreaking there, but we are excited about moving forward with that effort. Let's see, again, this builds off the momentum that Rick has mentioned earlier with Health Connect, but it's using low code. And yeah, last bullet, I've kinda already said this, this again will allow us to be more proficient in conducting our research. So really excited about doing that. Our model is, like I said, pay and chase. So I think we have like a 99% payment rate and so it's very loose when we reimburse the TPAs. They pay on our behalf. They do all the adjudication, the pricing, the pricing is established according to contractual terms that we have with them. But you know, we're trying to ramp up to validate those payments. It's incumbent upon us to validate that those payments are accurate and there's no fraud out there. And of course, they have an obligation to identify fraud as well but we also have an obligation to, you know, check behind and make sure that those types of things are being done. So looking forward to implementing, you know, maybe a couple of different Pega solutions to help us wrap that up, get a handle on it. And that's my one slide.

- That was the one slide. So here's a busy one for you. Like I said, we're beginning our journey on the Veterans Health Administration side. The Office of Information Technology drives a lot of our architecture. We are aligned with them looking at the value of low-code, no-code software. The fact that it can be efficient, we can reutilize the code. It is fast. The capabilities that we witnessed with rapid prototyping, being able to see things change on the fly in the lesser environments enable us to make requirements quicker as opposed to, you know, the massive Word documents of let's tell you in a million words what we'd like to have. This gives us the capability to say this is really what we would like to have. This is what we expect the workflow to look like for our people. The usability aspect that comes with that. Something that as our CIO says is delightful for our users to utilize. You know, our legacy systems, anybody in claims knows the rolling green screens. That may be very usable for the people that have been using it for years. But it is a tremendous cost for us in the next generation to teach people how to use legacy systems. They just don't look like they do in the rest of the world, right? You grow up and you go to college and go through all that stuff and technology is very fast, it's speedy, it looks different. And then you come to the VA and we've gotta teach you how to use a roll and scroll screen, and that's not cost effective for us. So, you know, driving factors that we have: legislation. We have changes to legislation that comes down the pipe. We can predict a lot of it but it doesn't become a fact until it is signed into law. And then a lot of times, we have to be reactive at that point to go ahead and get our technology aligned with the legislation. That is a very expensive and time-consuming process. We look at low-code, no-code software like Pega as a capability that we can quickly make change, reduce our backlog, meet the requirements that are put out there in the statutes and ultimately, take care of our veterans. So a lot of opportunities with that as Brandon was talking on the community care side.

- Yeah, no, I was just gonna add to what you were saying. We still have like the business requirements documents and those types of things. Like, we're not going to have all of those things but doing it in the environment that you just described is just, it's a much less painful process for our business analysts who are documenting the BRD documents and then for the end user as well because if you're doing it in that environment, then it seems like everyone gets to the end goal quicker. Whereas if you're just using words without going through this process, it seems to take much longer to get there.

- I think we've all been at that point where that wasn't what I was asking for. We see it at the end of a sprint all the time, right? It works a lot better when we give 'em a picture.

- Yeah.

- And I'm an IT guy so I can assure you that the development teams appreciate that. This is exactly what you want. It makes life a lot easier for them as well. So we have plenty of drivers in modernization. You name it, community care is growing very big. Our legacy, the systems that we stood up over the last seven years, we've gotta work through those things. A lot of emerging healthcare items. I hit on E911. In VA Health Connect, we're remote. We've got a nurse that's sitting in St. Louis taking a phone call from somebody in Oklahoma. If there's a problem with that patient on the call and they're nonresponsive and they have to hit 911, it is a process to figure out where the local 911 number is. They can't just dial it off the softphone. So things that are emerging that we have to be very quick to make sure that we are taking care of our patients, being prepared for the things that go along with these alternative modalities 'cause the goal would be, you know, when you're talking to that patient, if there's a problem, you should be able to quickly connect with emergency services as fast as you could if you would've dial your cell phone 911. And where do we go in the future? So our spaghetti chart. Community care was stood up very rapidly and it works. We are doing great things. Our veterans have never had more access to care than they have right now. We have opened up the doors, we've effectively stood up an insurance company to go out there and kind of work through all of this. But with that, we stood up 54 systems very rapidly and there is a lot of opportunity for reducing waste, optimizing the system, making it easier for our users and then providing the data that we need to make educated decisions as we move forward to improve access to care. With that, that is our last slide, Cindy.

- So if we have any questions, I can hand the mic to anybody and I just ask that you identify who you're with and tell us your name before you ask the questions. So do we have any questions in the audience? There's a lot of light shooting over here. Great.

- Thanks, Cindy. So you're building this on Pega platform as a service?

- Some of 'em. So we're looking at all the platforms, but Pega is, thank you. I use my military voice. So obviously as we go through these things, we look at all the opportunities that are out there. Pega is one of the platforms that we are currently using and we see the benefit that goes with it.

- [Audience Member] Well, I imagine you have concerns with privacy, individual information and health information.

- Absolutely.

- [Audience Member] So tell a little bit about your experience with Pega paths along that. Have you gone through the RAMP process?

- Yes, so Pega, in order to be a platform or a software as a service in the VA, you have to be FedRAMP approved on the cloud. And what does that mean? You've gotta go through all the wickets associated with we're dealing with patient healthcare information. We're talking about PII and we're not talking about a little bit of it, we're talking about nine million veterans and their families. So it is a significant risk to the VA to make sure that our platforms meet those requirements. So confidentiality, a key one is access. It's great to have data but we need it today. We can't have systems that are not reliant, that they're robust and they can go out there and work when we need the data. So yeah, we have to run through... Show of hands, anybody familiar with the authority to operate? Oh, I'm so sorry. So yes, we go through a full authority to operate in all the privacy to fill the squares to make sure that we're doing the right thing for our veterans. Does that answer your question? You're welcome. Any other questions? If you could. There we go. I got a feeling this one's for you.

- I'm interested in your rapid prototyping and especially, thank you, how you structure the team. So does the business analyst, you know, structure a prototype that then gets passed over to like a developer proper or how does that work?

- So that's a great question. We relied on the Pega Catalyst team to start off with. So they brought in experts to show us the art of the possible, what could happen with rapid prototyping, how quickly can we develop some of the ideas and the workflow that go with it. There is a process that we're gonna have to learn through to get the right people with the right skills to be able to implement such rapid prototyping. But we rely on our contract partners. It's not only Pega but all the platforms that are out there to follow that process. We see the benefit of rapid prototyping and the capabilities that we can quickly deploy as opposed to some of the lessons that we learned in the past, which is we go through our development process, we fill out all the paperwork with an authority to operate and then realize that well, we don't really have defects, we just have gaps in our requirements. And that sometimes elongates our process two to three times what our expected return was. So we are looking forward to rapid prototyping 'cause we got a good idea of what it'll look like at the beginning. Does that? Thank you. Anybody else?

- Yeah

- Cindy.

- So are you using a Pega customer service solution or is it a Pega BPM solution you're building? So you mentioned like you're going to support for the call center, right? So for that call volume, you are choosing the Pega customer service?

- For VA Health Connect, we did not choose Pega, but it is a low-code, no-code solution that is similar. So right now, our two things that we're working on in VHA are Meds by Mail. So that's kinda on hold until we figure out what to do with that legacy platform and currently working through our DAPER process. But we've seen the benefits of the software and the capabilities that go into it and I think Debbie and the Pega team can probably tell you exactly what platform that we're on. I'm pretty sure that we're on... We're on the healthcare platform.

- Okay, thank you.

- Thank you. You get to run. Now, she's a Yankees fan, so... We'll see if she slide in a second base.

- [Krishna] Hi, my name is Krishna. And you mentioned a system of systems. I'm sure there would be some legacy systems. So how do you communicate with those legacy systems from your application or the solution that your team is building?

- Great question. How do we communicate all these disparate systems that we have out here? So that's been my role as the solution train engineer and our contract partners, which is, I use the term we plan a wedding and it's hard 'cause you know, Uncle Bob and Aunt Mary don't often get along and we need to make sure that we're working through those interpersonal things. But each one of our applications in our system of system, they have their own roadmaps. It's important that we figure out where can we work with them on their timelines? How can we align our priorities to make sure for the enterprise that we are doing the right things? And with a system, you know, this is only a small piece of what the VA is. This is just our little piece of Community Care. When we start going out to the 130 VistA systems and all the other things that we have out there, it is a significant winning. It takes a lot of time to get with all our contract partners, the full-time employees that are often in charge of these programs and align the priorities and the funding to make sure that we can get the ball going. And then on the other end, for IVC, we have to make sure that our people and our process are ready to consume it. It's one thing to come up with a great idea and we build it in technology and then the users go, "That's not really the way we do it out here." So we have a whole change management process that we've gotta implement, you know, in that system of systems thinking. We've gotta take a broader look and sometimes it is very complex but we're working at it. Yes, ma'am.

- [Audience Member] Jackson, I'm a contractor.

- Do you think, and this is more of an acquisition. Thank you. This is more of an acquisition question. So we see the RFPs and we see a long list of requirements and then for the most part, there's an RFI and sometimes the government will talk to us and sometimes they won't necessarily talk to us. So I've seen on DOD where they do prototypes or MVPs. Do you think that the VA, do you envision the acquisition catching up with where you're trying to go?

- So great question. I'd like to sidestep the acquisition process. We have some experts that on the legal side would talk about some of the things that we can and cannot do on the acquisition side, right?

- We can also connect with you after and let you inquire with the right folks as to what's possible but I mean, I agree what you're saying but there's particular POCs that you can engage to ask those questions and you might be surprised the answer that you'll get. So yeah.

- But in general, we are trying to find ways. Technology's changed. The old days of put out a requirement with a million things that were great ideas three years ago and have finally made it through all the wickets, they finally get funded, they finally get prioritized and we build it and they've been overcome by events. The process has changed. We no longer do that. We see that a lot. And those are some of the things that we're trying to address in our procurement process. And how do we move forward with some of the existing teams that we have on staff and contract vehicles to do that rapid prototyping? Does that help? You're welcome.

- There. I think it's on. Okay. Hi, Leslie Flagler with SAIC. Just wanted to clarify, are you currently hosted in Pega Cloud software as a service or are you hosted on prem specifically as it relates to your ATO? Are you in Pega Government platform or are you in the commercial platform? And then the third part of that, we've heard so much about gen AI and process AI and all of those great things. Do you foresee those things getting FedRAMPed so that you guys can take advantage of those or what are your challenges there?

- Well, the AI question hit us, but on the first part, we are in both of our, yeah. So we have on-prem and we are in the Pega Cloud. Again the, the FSC, the financial side of the house has been doing this for a long time. We're in our infancy on the VHA side, but looking to take more advantage of these opportunities. Concerning the AI side of the house. So we're clinical. We have to be very, very careful when we approve an application that may make clinical decisions or bias a clinical decision without the associated research and proof. So that puts us in a very, you know, how are we going to get there, you know? And we use the scenario, if you were to change a triage tool that our nurses were going through and change the order of the questions because the AI said that the right question to ask was, I don't know, swelling in the ankle as opposed to is your heart beating too hard or something like that. Those are clinical decisions with clinical impacts and they have another level of, I'll say non-IT agreement that the Veterans Health Administration is gonna walk through that and they've got some really smart people that are doing the research to look at what is the art of the possible in AI and how do we ensure that we didn't, on the IT side, artificially bias a decision on a clinician? Does that answer your question?

- And also from the AI side, for healthcare reimbursement, I mean, obviously, we have opportunities there. I think the one area of concern for me is sometimes when you're getting into complex claims data, it can get a little... AI can be a little tricky to use in those instances. So I think just generally speaking, some high-level reports using AI for high-level reimbursement reports, dollars spent, claim volume, those types of things, I think it's very helpful in that realm. But I'm not so sure it's the silver bullet for all of your analytics for healthcare reimbursement. But plan on using it to the fullest extent possible.

- Absolutely, to drive some decisions. You know, sometimes the answer is not let it do it, but let it give us the the ideas so that we can do the research and prove it out.

- [Cindy] Do we have any other questions from the audience? Well, okay. Well, thank you very much for.


Desafío: Excelencia operativa Industry: Sector público Tema: Excelencia operativa Tema: PegaWorld Tema: Transformación digital Área de producto: Automatización inteligente
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