Health IT lessons from the VA: A Q&A with CTO Charles Worthington

In the aftermath of the failed rollout of HealthCare.gov, the White House created the U.S. Digital Service. Charles Worthington's job there was, as he put it, to "help the government be more awesome at delivering software."

In 2017, he became chief technology officer of the U.S. Department of Veterans Affairs, the second-largest federal agency and home to the country's second-largest health system.

Mr. Worthington's team of about 100 employees supports the 8,000-plus-strong IT department at the VA to ensure it's effectively using technology across its 171 hospitals. He leads digital transformation and innovation projects, pilots new technologies and helps set standards.

Becker's recently sat down with Mr. Worthington for a (virtual) Q&A on the health IT issues he's spending his time on these days and what other hospital systems can learn from the VA.

Note: This conversation has been condensed and lightly edited for clarity.

Question: What has changed about your work in your five-plus years as CTO?

Charles Worthington: When I started, some of the concepts of the modern style of delivering software were still pretty new in government: things like DevOps, where you have an integrated development and operations team, cloud computing, continuous integration and continuous deployment.

We now have a very robust cloud program. That's the default decision for most of our applications now. We also have integrated development and ops teams that are aligned by product area.

Q: How much of your time is spent on health IT vs. other functions at the VA?

CW: Maybe 50 percent or so. One of our portfolios is the veteran-facing, veteran experience portfolio and that spans healthcare.

VA is a payer as well. We have a Community Care program where we act as a payer. And then we have a whole benefits arm which is like an insurance company or a bank in a way, where the key business function is processing applications or claims and then adjudicating and issuing payments based on them. My team supports different projects in all of our portfolios in addition to the underlying infrastructure, of data and computing.

Q: What health IT issues are you spending most of your time on these days?

CW: I am spending a lot of time focused on the patient experience. That's a place where the VA has invested a lot of energy.

We have over a million users every month accessing some sort of health feature. Our tools are some of the most adopted in the country in terms of the percentage of our patients that are using them.

Q: What health IT or digital innovation at the VA are you most proud of?

CW: During the pandemic, part of our organization was going to 100 percent telework and then another part of our organization, our healthcare system, was basically in fight-or-flight, crisis mode. So simultaneously our IT teams were both scaling up telework and making sure we had enough capacity in hospitals. We were standing up new ICU units and remote ICU units in some places. We were able to really quickly pivot our technology programs to support our healthcare team in whatever they needed.

Telehealth is another great example. We quickly went from fewer than 2,500 telehealth appointments a day to about 40,000 a day.

Q: What health IT lessons might smaller hospital groups or standalone medical centers learn from a health system as large as the VA?

CW: It's hard to go wrong focusing on the patient and really designing backward from there.

And you've got to be doing surveys and collecting a lot of data. After every appointment, we're sending out a survey to hear how it went. And all of that gets fed into the operations of the VA, and that's how you can track how well you're doing.

We also have to make sure the technology we're building works for the clinicians and helps them in their job — using the tactics of human-centered design, really making sure we're focusing on those end users.

The health IT ecosystem is obviously growing fast. It's got a couple of really big vendors in it and then a lot of fragmentation. There are a lot of small players. To make that work well for the providers, we really need to focus on standards in the health technology space so systems can confidently buy solutions and know they're going to work regardless of their EMR. Getting more health systems invested in this standards process will help everyone by making those health technology systems more interoperable and increasing the pace of innovation. That's something even small systems should be thinking about — how much are they focusing on standards or supportive standards in their purchases?

Q: What has the VA's EHR experience taught you about what it would take to create a national health information exchange?

CW: Part of our EMR adoption is giving us access to some of the big health information exchanges. We've definitely been focusing on the veteran population and enabling better patient matching. We're trying to enable the VA to benefit from all those different HIEs that are getting to national scale.

Q: What would you say is coming for the future in health IT?

CW: We're just at the tip of the iceberg at how patient experience is going to be transformed with technology. We released a flagship mobile app for iOS and Android last year. Even without a lot of active promotion, that app has gained a ton of traction. We're at around 800,000 users. And it's got a 4.8 star rating in the App Store with tens of thousands of ratings. In my own life, the way I interact with most Fortune 500-sized entities has transformed from the web to via an app. As quickly as health systems are able to switch to delivering great app experiences, users are going to meet them right there.

There have been a couple months recently where over half of our web traffic has come from smartphones or tablets. I see the VA putting more of our core functions into the app to make it even easier for our patients to quickly access those most routine transactions, things like messaging their doctor or managing a health appointment or their prescriptions. That sounds like bread and butter, but I feel like health systems have not fully gotten there yet. There's a lot of room to grow there for the VA certainly and probably for other health systems.

I'm also pretty bullish on how wearables are going to impact healthcare delivery. As we see things like glucometers and more sophisticated devices come down in price and become more accessible, there's a huge untapped opportunity to connect that data to healthcare delivery. In our innovation ecosystem at VA, we've got a number of pilots going on looking at how those devices could be incorporated into healthcare.

There's a lot of talk about artificial intelligence and machine learning, and obviously we're investing in that. There's a ton of opportunity there. One thing that I don't hear much about is finding ways to standardize health data. It feels like every CTO I talk to is investing a ton of their resources focused on analytics just trying to get data normalized and standardized in a way they can actually use.

Because the tech ecosystem in healthcare is so fragmented, that's a big inhibitor to actually applying these sophisticated algorithms. We're seeing a lot of really exciting AI use cases that work if you're all in on their specific, narrow, vertical slice and you've been using their product. But if you're trying to draw insights from one part of your system and compare them with another — maybe you've got different EMRs operating — that's a huge issue that will hold back our ability to really advance in that space.

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