How VA Innovation Affects the Entire Health Care System

Dr. Ryan Vega

M arianne O’Hare : Welcome to Conversations on Health Care . This week we welcome Dr.
Ryan Vega , Chief Officer of the Office of Healthcare Innovation and
Learning at the Veterans Health Administration.

Dr. Ryan Vega: When you have that infrastructure, you're going to see innovation
that not only changes the experience or the care for the V eteran, but
it's going to spread across healthcare global .

Marianne O’Hare: Lori Robertson joins us from FactCheck.org and we end with a bright
idea improving health and well being in everyday lives. Now, here are
your hosts Mark Maselli and Margaret Flinter .

[ Music ]

Mark Masselli: President Abraham Lincoln said it best the obligation of the
government is to “ care for him who shall have borne the battle and
for his widow and hi s orphan. ” Today, the U . S . Department of
Veterans Affairs operates the largest integrated health system in the
country and running the VA requires a commitment to innovation in
order to meet the needs of over 9 million men and women V eterans.

Margaret Flin ter: Joining us to discuss innovation at the VA is Dr. Ryan Vega: . He leads
the Innovation Ecosystem within the Veterans Health Administration ,
and this initiative is focused on being the catalyst of mission driven
healthcare innovation that advances care delivery and service.

Mark Masselli: Dr. Vega, Welcome to Conversations on Health Care .

Dr. Ryan Vega: Hey, Mark, thanks for having me.

Mark Masselli: Well, you know, we have been following the Veterans Administration
for decades now and following their in novation , I remember back in
the 90s, they had just that incredible focus in on innovation. It sounds
like it's continuing and I'm wondering if you can explain more about
the Innovation Ecosystem and how it operates , and how does it fulfill
its mission of changing lives and saving lives?

Dr. Ryan Vega: Yeah, Mark, I think you really gave me the sort of the softball setup by
providing Lincoln's quote because one of the things you see in that is
that it's our obligation to care for , and that's really importan t because
that must extend beyond just the provision of healthcare , and so our
innovation mission must be the catalyst and the fuel to making sure
that we're thinking about upstream prevention and how we enable
downstream experiences that contribute to the Veterans’ entire
whole health and their journey . We're now combined three offices ,
and those offices focus on the ability to really test and validate
emerging technologies and solutions, using clinical simulation, really
thinking about testing a new solut ion out in an operating room, really
understanding the implications on the workflow and then deploying
it. We have our another office, our Innovation Ecosystem , which

Dr. Ryan Vega

thinks both about the interna l investments that we must make, as
well as how we create op portunities to bring industry . This could be
Fortune 500 companies and startups, these could be non - traditional
players . How do we bring them into the fold ? And then we sort of
complete that with our Center for Care and Payment Innovation , and
this is real ly important in healthcare because often solutions are
introduced into a market that it's not really fully prepared for,
whether that's how you pay for it, whether that's the IT solution or
even practice variation amongst providers so that solutions can re ally
create meaningful value for both patients, clinicians and the systems
that care for them.

Margaret Flinter: I was thinking, as you spoke, I'm not sure anybody survives in
healthcare without having some healthy degree of innovation. But
every healthcar e leader knows that to make meaningful innovation to
sustain it, to have it hit the mark of what you're trying to do. It's hard
to encourage, and it's even harder to implement, and maybe even
harder still, to sustain. So you referenced the Shark Tank, tell us about
that idea. How does it work , and how does it engage your people and
contribute to your success in this area?

Dr. Ryan Vega: Really, the idea is how do you create a culture where individuals on
the front lines now have access to this national oppo rtunity, this
national network where the work that they're doing at one VA has the
opportunity to spread across and we get hundreds of applications a
year . We really focus and get those down to the 10 that have some
level of evidence so there's pretty in d epth reviews on the practice or
the solution , and to those that really seem to have the most potential
for impact for Ve terans. This doesn 't have to just be technologies, it
can be processing changes, it can be even potential policy changes.
But the other piece of this is that our medical center directors and
even our network directors, they're bidding on these practices, which
means they're going to invest to get these projects replicated at their
site because they see a need, and it's that replication and that
willingness in their body and that enables us to really test solutions in
multiple different markets. We really get to test and get the solutions
out , and what you know about any innovation, it's a very narrow
funnel when you get to the end, not ever ything is going to make it ,
but this allows us to really energize the frontline to tap into that
entrepreneurial spirit, they're in the best position to understand
what's potentially going to work because they're th e ones actually
doing the work.

And so S hark Tank has really sort of fostered that both
entrepreneurial spirit , and some of the practices we have seen come
out of that are not just changing and saving lives in the VA, but they're
actually spreading across American hospitals and saving lives ther e as
well.

Dr. Ryan Vega

Mark Masselli: And you've written in the New England Journal of Medicine about the
four critical elements that support the development and deployment
of innovation in a health system, workforce capacity to actualize
innovation, an organizational infrastructure that supports integrated,
repeatable pathways for change, and a strategic external partnership
and collaboration. I'm wondering how you came to those points and
do you think t he VA is meeting them right now?

Dr. Ryan Vega: I think we came t o that by a lot of trial and error, which fortunately,
part of innovation is about failing, failing forward , failing in learning.
But I have failed way more in this role than I have succeeded. But
those characteristics seem to be very, very important for h ealthcare,
partially, because when you talk about the human capital, and
certainly two and a half plus years through the pandemic, we're
seeing the toll that not investing in human capital can have on the
system as a whole. You need that capacity, you need that human
capital to be the not only evangelists, but the individuals who are
going to carry the torch for , right . It's really, really hard , and so if
you're not investing in your people, if you're not giving them the tools
that they need to drive the ch ange and continuously investing in their
ideas and their solutions that piggies back into well, how is your
culture . It has to be a culture that creates safe spaces to fail forward.
Meaning a lot of what we do in our innovators network is make large,
small investments, meaning less than a million dollars or investing in
hundreds of different projects or ideas, recognizing that the majority
of them will never mature. But that's not necessarily the point. It's
those hundreds of employees that are going throug h that experience
that are learning new skill sets, and how to apply them to problem
solving that grows. But really what we've seen since this sort of
ecosystem has evolved is a growing and I use the word sort of lightly
group of evangelists. These are ind ividuals out in the field who are
better equipped to solve problems, they're coming up with great
solutions, whether it impacts one V eteran or millions, they're going to
continuously be committed to that mission of the innovation role, and
how it solves pr oblems today, tomorrow and in the future for the
American Veteran.

Margaret Flinter: Well, I think you're such a force for training ; an enormous number of
healthcare professionals in the U . S . did s ome of their training at the
VA, so it's good to know they' re getting kind of the vaccine for
innovation there . You wrote that the VA is perhaps an unlikely source
for this type of innovative talk and certainly I look back and think
about who had the Electronic Health Record before anybody else?
Veteran Affairs ha d Electronic Health Record , your patient aligned
care teams . So are you saying that maybe because it's VA and people
aren't expecting that innovation that some of your successes don't get
the same uptake or spread around the country , what's your thought
on that?

Dr. Ryan Vega

Dr. Ryan Vega: Yeah, I look, I think that's the challenge of being in government .
There's a sentiment or a sense, generally that government is slow and
inefficient, and probably not sort of the beacon of innovation that
maybe we associate Silicon Va lley or other markets with. But I do
think it's sometimes hard, where you have constant drumbeat of
information that paints the VA or other agencies in sort of a more
negative light, and I get it, that's what's going to drive press or certain
clicks, so to speak. But the reality is that if you look at the history of
healthcare innovation, and some of the leading research and
development, VA has moved healthcare in America, and globally,
forward. We were doing so during the pandemic, in the utilization of
po int of care manufacturing so 3 D printing, and how we were able to
create both diagnostic testing swabs , personal protective equipment .
We were doing so years and years and years ago when we invented
the first cardiac pacemaker. So I think that's our histor y. I think what
enables us to truly drive transformation is a commitment to the
mission because I'm not beholden . I don't have some of the same
market constraints that our commercial partners may , and I have
clinicians and providers who, whether they're in California, Alaska, or
Florida, or walking into a VA hospital or showing up to work every
day, united by the same mission. So they're collaborating. So I've got
some of the best and brightest minds across the country, coming
together to solve these proble ms. When you do that, when you have
that infrastructure, you're going to see innovation that not only
changes the experience or the care for the veteran, but it's going to
spread across healthcare global ly.

Mark Masselli: Thinking about the importance that mission has , and we certainly
were all put to the test during those early days of COVID. I know our
own organization, we were able to set up the second mass
vaccination site in the United States, and so we need it to be able to
turn on a dime and really r e - imagine the delivery system. But the
Innovation Ecosystem , you talked about this just a moment ago, really
also responded in remarkable ways. Can y ou share that with our
audience?

Dr. Ryan Vega: So we've been investing in point of care manufacturing, whi ch is really
this idea that you can utilize 3 D printing to create anything you can
imagine seeing on a desktop computer and specifi c software, dating
back to 2014 - 15. But really began to pick up steam with the
development of our 3D printing network and tha t was in place before
the pandemic hit. So it really enabled us to leverage the breadth of
talent across our VA medical centers that were doing this type of work
to really push American healthcare forward , in how we can utilize
manufacturing in the walls o f the hospital. During times of the
pandemic, this was really supply chain resiliency and producing
materials , but it's really grown beyond that now that we're
understanding how customized orthotics and prosthetics and

Dr. Ryan Vega

personalized surgical instruments and in the future, actually bio -
fabricating tissue and bone and in our lifetime, likely organs. So I think
that's one example of what you saw coming out of the pandemic. But
certainly out of necessity, we were able to really pull together that
talent and driv ing forward .

You also saw small projects that have grown into really remarkable
solutions . We had a pilot going on in the Massachusetts area where
we were utilizing Rideshare , particularly just to get V eterans to and
from appointments. These are V eterans that may have difficulty
getting transportation, and certainly giving them safe transportation
was really important, instead of just letting that pause during the
pandemic, because clinics were closed, and they pivoted and utilize
that, to actually deliver food and materials and goods that were
needed veterans who relied upon those services, or who were
concerned about going out into public. And then from there, really
grouped, people saw the power of using these types of solutions , and
so you saw collabora tions and public private partnerships with Uber
Health , and the impact has just been phenomenal in the American
Veteran and how we're really creating that ecosystem that's enabled
us to leverage multiple different capabilities from internal and
external, t o deliver a world class experience.

Margaret Flinter: I was thinking as you were talking about some of the 3 D printing
work, especially the new tool, you know, the new object , there’s
sometimes easier for teams on the frontline of delivering care to
embrac e and adopt than innovating the way people work together,
innovating the way they communicate. How have you in VA evolved
to engage people to win the hearts and minds of people about
disrupting processes and changing things that ha ve they've done for a
lon g time?

Dr. Ryan Vega: I don't think that's ever going to not be a challenge. So innovation is
always going to be at odds with existing operations if you're trying to
change the way that something is delivered or experienced. I think
one of the ways you do that is, at least in mitigating some of the initial
resistance , is you have to bring people in early on to the design phase ,
and you can leverage design thinking or human centered design. And
as you're going through how to enhance a particular experience or
approach a problem , everybody wants to make things better. But
sometimes we're looking at things through very, very unique vantage
points . So it's not about sort of saying we're going to make your
process better. It's really about how do we collectively come together
and create a new experience or a new outcome . So I think it starts by
bringing people in very early on to the design phase . If they're part of
the solution, generally, the resistance is a lot less . It still is never going
to be perfect and i nnovation in particularly if you look in other
markets, you know, those new entries, those new disruptors, they're

Dr. Ryan Vega

not looked at kindly. But that's just sort of a fact of how innovation is
and the key characteristics is bringing those individuals, those la rge
diverse stakeholders into the process very early on, makes a huge
difference.

Mark Masselli: And you know, the VA is trying to be a force multiplier, right, really
using the partnerships that you've developed. Talk to us about some
of the results of th ose partnerships, and they impacted the sort of the
ripple effect, if you will, across the country's health care system.

Dr. Ryan Vega: Yeah, one that I think really just speaks to VAs role and unique
position within the larger American health system is on e called
HAPPEN . So this was a nurse researcher who was doing great work
about understanding how to reduce non - ventilator associated
pneumonia. But her work had really exposed the idea that something
as simple as brushing teeth, reducing the potential bact eria in the
mouth for V eterans could really reduce non - ventilator associated
pneumonia , and that is a project that actually showed really great
results at one VA Medical Center, it gotten to the Shark Tank , it won ,
it started to be replicated at multiple d ifferent hospitals , and after
result after result kept showing that Whoa, things are actually getting
a lot better. I remember hearing from multiple skeptics early on, who
now are saying, Okay, I've been proven wrong, and I'm glad I have .
But it was that a bility to sort of replicate in multiple markets in
multiple settings and continuously get the data that the interest of
some of our other F ederal agencies, folks like the CDC, the American
Hospital Association, and other private health systems begin to tak e
notice, to say, this is an issue across all hospitals in America . This is
potentially a solution. It's pretty inexpensive , and what you started to
see was that role as VA is not only sort of the driver, but really the
convener . We have large populations and access to mass amounts of
data where we can really understand things such as, hey, we've got
this bundle, do we implement it for everyone, not only we're
informing our own drive and how we're going to do this, but the rest
of healthcare can adopt that. So we've seen a reduction in non - verbal
associated pneumonia that means that's a reduction in the number of
deaths . And so this is something that I think we're really proud of
because when we are unable to get this solution, this information,
scaled more broadly across the American health system , and as a
result, we're going to see people's lives be saved.

Margaret Flinter: And speaking of partnerships, many of the people who listened to or
watch this program or connected to Community Health Centers , or
Fe derally Qualified Health Centers , two of the largest systems of care
in the U . S . and both very mission driven. What kind of partnerships
are exist today between the two groups, and particularly as you've
tried to ensure that V eterans can get care in their communities close
to where they live and work? I know, there's been more of a focus on

Dr. Ryan Vega

maybe trying to build some bridges there.

Dr. Ryan Vega: Yeah, Margaret, in the 2018 Mission Act , there's a little provision, but
it enabled VA to establish the Center f or Care and Payment
Innovation , and the first pilot that came out of the Center for Care
and Payment Innovation was called VETSmile . There's a large over a
million veterans who receive care in the VA , but because of the way
that certain statutes are writte n, don't qualify for dental care. And
this was an opportunity to utilize that particular piece of legislation
and what's called waiver authority to go to Congress and say, hey,
look, if we were to change that piece of the legislation, and expand
access to dental care, by utilizing our Federally Qualified Health
Centers and our academic partners, we could get a larger number of
veterans into dental homes , and we know that a huge part of starts in
the mouth . But it also has big impacts on your social life , on your
ability to get a job and things like that. So VETSmile started in New
York and New Jersey, using the Federally Qualified Health Centers to
create dental homes for veterans referred through the program. And
it's just been remarkable to see that the pr ogram is growing. The
team hopes to have this scaled across the United States large number .
I think it's now over 1 , 000 different procedures that have been
performed. So those Federally Qualified Health Centers have been
vital to the ability for us to impr ove that accessibility to dental
services , and that partnership through that innovative model has
really demonstrated the power of that collaboration. So I think by the
time that it's over, you're going to see a new era of sort of what that
means for VA an d Federally Qualified Health Centers department plus
our academic affiliations, these go back 75 years. So they're vital
pieces of the puzzle, not only from the training aspect, but how we
deliver care to veterans.

Mark Masselli: Our health center s had a l ongstanding relationship with our veterans
here, participate in the standout every year and 100 people delivering
care from our team is certainly the dental program , and healthcare is
expensive, but I'm wondering if you might give some parting thoughts
to those who are just beginning innovation and I really want you to
maybe to focus in on those Plan - Do - Study - Act teams, you know, those
capturing engagement of staff and really trying to have them as we've
talked about earlier be force multipliers with small ideas, maybe some
advice for that smaller organization who's really saying, I want to do
it, I just don't know how to start.

Dr. Ryan Vega: So a couple of things, you can never spend enough time in the
discovery in the design phase. So I think that is abso lutely crucial. It
does not cost much to sit down and really understand the problem
through somebody else's lens. So I think utilizing human centered
design, and spending as much time as you can really understanding
the problem and that problem from multip le different stakeholders

Dr. Ryan Vega

and perspectives generally gets you to a better solution. Not always,
but I'm willing to bet that more often than not will. The second is, I
really think it's important to remind people this idea of value . It's
really a dynamic co ncept. You can't say, Okay, here's how we define
value. And the reason I say that is because one, it's really hard
healthcare, t wo, we generally looked at it from a cost standpoint, but
that's not the case, mean what’s valuable to me may not be valuable
to you, what’s valuable to one population may not be valuable to the
other . Value is a very dynamic concept , and if we can measure it as
such across multiple different domains, things like how accessible was
the care , how efficient was and how equitable was it . These are things
that now actually enable us to move beyond just the idea of cost, and
really start to look at solutions that we can actually deploy at scale
that will really begin to bend the cost curve . We've sort of been
talking about this for a lon g period of time, costs are still going up. But
I think it's this idea that if we move away from that very narrow,
limited lens of value, that you really will find solutions that are going
to move the needle. So those two things , I think, are really , reall y
important for teams that are starting.

Margaret Flinter: Well, thank you Dr. Vega, for all that you and your team and your
colleagues are doing to serve our nation's veterans , but also to
contribute to healthcare in general in this country. For our liste ners,
you can always learn more about Conversations on Health Care and
sign up for our email updates at www.chcradio.com . Dr. Vega, again,
thank you so much.

Dr. Ryan Vega: Yeah, thanks very much for having me.

[Musi c]

Mark Masselli: At Conversations on Health Care, we want our audience to be truly in the know when it comes to the facts about health care reform and policy. Lori Robertson is an award winning journalist and Managing Editor of FactCheck.org, a nonpartisa n, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U .S. politics.
Lori, what have you got for us this week?

Lori Robertson: With the U .S. experiencing a major dip in the number of daily deaths
as the Omicron variant wave runs its course President Joe Biden has
repeatedly boasted that his “ approach has brought down COVID
deaths by 90%. ” The figure is accurate, but experts say the dip is
largely attributable to a number of factors outside the P resident's
control. There has been a 92% drop in COVID - 19 deaths when
comparing the seven - day average since the day Biden took office with
the average as of June 20

th
. Virtually every country in the world has
recently experienced a steep decline in COVID - 19 deaths. In fact, since
the day of Biden's inauguration, the seven - day rolling average of daily
deaths per 100,000 residents worldwide has dropped 8 9.4%, which

Dr. Ryan Vega

suggests Biden's policy is not somehow unique. There have been
steep declines of at least 90% in COVID - 19 deaths in the Unite d
Kingdom, Germany, Italy and India over the same time period . Experts
say it is the disease, the emergence of variants, the rollout of
vaccines, and immunity gained from prior infection that are primarily
responsible for the peaks and valleys in the numbe r of deaths
worldwide . Upon taking office in January 2021 , Biden initiated an
effort to encourage Americans to get one of the newly authorized
COVID - 19 vaccines. He has promoted effective new treatments, and
he has been a consistent advocate for masking in appropriate
situations. Experts say those are all positive things. They say there's
no question the vaccines have reduced the number of deaths in the
U.S. , and Biden's promotion of vacci nation has helped.

According to a Commonwealth Fund Analysis, if not for vaccines,
there would have been more than 1 million more deaths in the U .S. by
November 2021. But Biden's vaccine efforts can't get all the credit.
Rachel Pi t lch - Lobe , a Researcher and Project Director at the Harvard
School of Public Health told us it' s “ near impossible ” to say a
particular policy has led to a sharp drop in the death rate. That's my
fat check for this week. I'm Lori Robertson, Managing Editor of
FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the cou ntry’s
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you’d
like check, email us at www.chc.radio.com . We’ll have FactCheck. org’s
Lori Robertson check it out for you here on Conversations on Health Care.

[Music]

Margaret Flinter: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. A significant
number of post 911 V eterans are suffering the long term effects of
post traumatic stress disorder, often associated with a traumatic brain
injury suffered in the field of battle. While these conditions manifest
in many ways, they often are accompanied by a common sympto m,
persistent and frequent headaches. A study published in JAMA
neuroscience shows that a newly developed non - drug intervention
holds significant promise in treating these headaches, which are a
leading cause of debilitation among betters. Cognitive behavi oral
therapy for headache deploys a targeted behavioral health
intervention designed to empower patients to control and manage
their symptoms without incurring any of the side effects that often
acc ompany drug based interventions.

Dr. Don McGeary : Self man agement through cognitive behavioral therapies has been
around for a long time. It's tried and true, and we just haven't really

Dr. Ryan Vega

developed any convincing evidence to support its use until now at
least for post traumatic headache. This is the first study to d o it.

Margaret Flinter: Dr. Don McGeary , Neuroscientist at the University of Texas Health
Science Center at San Antonio led the team of investigators . Clinicians
were trained in the delivery of the CBT intervention, a relatively
simple technique to teach a nd deploy , and the initial results a
significant percentage of the participants reported not just improved
headache control, but also reported more broadly realized benefits
often manifeste d and those suffering from PTSD.

Dr. Don McGeary: Insomnia or depre ssion or anxiety , these things usually come in
clusters. It's very rare that you'll see an individual who just is
experiencing one single trauma condition and when you start to put
these trauma conditions together when they co - occur, they change
and influe nce one another , and usually the direction of that influence
is one towards recalcitrance towards any frontline treatment. So,
there are great frontline treatments for primary headaches like
migraine. But when you add TBI and you add PTSD into that, those
frontline treatments start to fail.

Margaret Flinter: Dr. Mc Geary says that what is most exciting to the team is that this
intervention seems to improve these poly conditions which reduce
disability across the board and enhance quality of life.

Dr. Don McG eary: Post traumatic headache is a really great example of this because it
often shows up in the context of PTSD, it is a sequela of mild
traumatic brain injury. So it is the quintessential pain condition
associated with poly trauma and finding a treatment t hat actually
works for this is a major breakthrough because it represents not only
being able to address the headache, but somehow navigating all the
other stuff that's coming along with it that includes PTSD.

Margaret Flinter: The study is being expanded to multiple VA s around the country .
Cognitive Behavioral Therapy for headache, adapting and already
accepted behavioral intervention, targeting it to a specific
unaddressed health concern among millions of veterans achieving
successful outcomes while avoid ing side effects that often accompany
drug interventions. Now that's a bright idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and h ealth .

[Music]

Dr. Ryan Vega

Marianne O’Hare : Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, or wherever
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[Music]