[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE USE OF ARTIFICIAL INTELLIGENCE TO
IMPROVE THE U.S. DEPARTMENT OF VETERANS
AFFAIRS' CLAIMS PROCESSING SYSTEM
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JANUARY 29, 2008
__________
Serial No. 110-66
__________
Printed for the use of the Committee on Veterans' Affairs
----------
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
JOHN J. HALL, New York, Chairman
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado, Ranking
PHIL HARE, Illinois MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada GUS M. BILIRAKIS, Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
January 29, 2008
Page
The Use of Artificial Intelligence to Improve the U.S. Department
of Veterans Affairs' Claims Processing System.................. 1
OPENING STATEMENTS
Chairman John J. Hall............................................ 1
Prepared statement of Chairman Hall.......................... 44
Hon. Doug Lamborn, Ranking Republican Member..................... 4
Prepared statement of Congressman Lamborn.................... 45
WITNESSES
U.S. Department of Veterans Affairs:
Kim A. Graves, Director, Office of Business Process
Integration, Veterans Benefits Administration................ 33
Prepared statement of Ms. Graves........................... 78
Stephen W. Warren, Principal Deputy Assistant Secretary for
Information and Technology, Office of Information and
Technology................................................... 35
Prepared statement of Mr. Warren........................... 79
______
Christopherson, Gary A., University Park, MD (Former Senior
Advisor to the Under Secretary for Health, and Chief
Information Officer, Veterans Health Administration, U.S.
Department of Veterans Affairs, Former Principal Deputy
Assistant Secretary for Health Affairs, U.S. Department of
Defense)....................................................... 24
Prepared statement of Mr. Christopherson..................... 75
Cleveland, Gunnery Sergeant Tai, USMC (Ret.), Dumfries, VA....... 5
Prepared statement of Gunnery Sergeant Cleveland............. 45
Miller, Randolph A., M.D., Donald A.B. and Mary M. Lindberg
University Professor of Biomedical Informatics, Medicine, and
Nursing, Vanderbilt University School of Medicine, Nashville,
TN............................................................. 18
Prepared statement of Dr. Miller............................. 53
Mitchell, Tom M., Ph.D., E. Fredkin Professor and Chair, Machine
Learning Department, School of Computer Science, Carnegie
Mellon University, Pittsburgh, PA.............................. 16
Prepared statement of Mr. Mitchell........................... 49
QTC Management, Inc., Diamond Bar, CA, Marjie Shahani, M.D,
Senior Vice President, Operations.............................. 19
Prepared statement of Dr. Shahani............................ 58
Stratizon Corporation, Atlanta, GA, Ned M. Hunter, President and
Chief Executive Officer........................................ 21
Prepared statement of Mr. Hunter............................. 61
Unum, Portland, ME, John F. McGarry, Senior Vice President of
Benefits, Chief Risk Officer................................... 23
Prepared statement of Mr. McGarry............................ 64
Wounded Warrior Project, John Roberts, National Service Director. 8
Prepared statement of Mr. Roberts............................ 47
SUBMISSIONS FOR THE RECORD
American Veterans (AMVETS), Raymond C. Kelley, National
Legislative Director, statement................................ 80
American Legion, Steve Smithson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, statement............... 82
Disabled American Veterans, Kerry Baker, Associate National
Legislative Director, statement................................ 82
Paralyzed Veterans of America, statement......................... 83
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Tom Mitchell, Ph.D., School of Computer Science,
Machine Learning Department, Carnegie Mellon University,
Pittsburgh, PA, letter dated February 4, 2008, and April 2008
response from Mr. Mitchell..................................... 85
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Randolph Miller, Ph.D., Professor and Former Chair,
Department of Biomedical Informatics, Vanderbilt University
School of Medicine, Nashville, TN, letter dated February 4,
2008, and February 28, 2008, response from Dr. Miller.......... 87
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Marjie Shahani, M.D., QTC Management, Inc., Diamond
Bar, CA, letter dated February 4, 2008, and response letter
dated March 3, 2008............................................ 95
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Ned M. Hunter, President and Chief Executive
Officer, Stratizon Corporation, Atlanta, GA, letter dated
February 4, 2008, and March 6, 2008, response from Mr. Hunter.. 97
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Gary A. Christopherson, Strategic Management and
Performance, University Park, MD, letter dated February 4,
2008, and response from Mr. Christopherson..................... 98
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Hon. James B. Peake, M.D., Secretary, U.S.
Department of Veterans Affairs, letter dated February 4, 2008,
and VA responses............................................... 100
THE USE OF ARTIFICIAL INTELLIGENCE TO
IMPROVE THE U.S. DEPARTMENT OF
VETERANS AFFAIRS' CLAIMS
PROCESSING SYSTEM
----------
TUESDAY, JANUARY 29, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance and Memorial Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:06 p.m., in
Room 340, Cannon House Office Building, Hon. John J. Hall
[Chairman of the Subcommittee] presiding.
Present: Representatives Hall, Lamborn, Bilirakis.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. Hall. Good afternoon ladies and gentlemen. The
Committee on Veterans' Affairs, Subcommittee Disability
Assistance and Memorial Affairs, hearing on ``The Use of
Artificial Intelligence to Improve the U.S. Department of
Veterans Affairs' (VA's) Claims Processing System'' will come
to order.
Before I begin with my opening statement, I would like to
call attention to the fact that Raymond C. Kelley, National
Legislative Director for AMVETS and Kerry Baker, Associate
National Legislative Director for the Disabled American
Veterans have asked to submit written statements for the
hearing record.
If there is no objection, I ask unanimous consent that
these statements be entered into the record.
Hearing no objection, so entered.
[The statements of Mr. Kelly and Mr. Baker appear on p. 80
and p. 82.]
I would ask that we all rise for the Pledge of Allegiance.
The flag is in this corner of the room.
[Pledge of Allegiance.]
I would like, first of all, to thank the witnesses for
coming today to appear before the Subcommittee. I know I speak
for my colleagues when I say we are all extremely frustrated
and disappointed when we hear about 650,000 claims pending and
another 147,000 appeals with a delay of 183 days to process
those claims.
But looking at this photograph, which is up on the screen
right now, of an eight-inch paper record held together with
rubber bands and marked with post-it notes, it is hard to
imagine that things do not get lost or missed. This has got to
be cumbersome when processing our veterans' claims.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
There is no doubt that we need a better system than rubber
bands and post-it notes and must look beyond the current way VA
is doing business. There are best practices within the
scientific community and best practices in use in the private
sector.
I thank you for joining me and the Subcommittee today to
explore these solutions to broaden our understanding of what is
possible, realistic, and achievable in this technological age.
The current VA claims process is paper intensive, complex
to manage, difficult to understand, and takes years to learn.
Training a rater can take 2-3 years and many leave within 5
years. Experienced raters can adjudicate about 3 claims a day,
taking about 2-3 hours apiece.
This means that if there are 10 people who can rate a claim
and 800 claims are ready to rate, then it will take another 80
days to process those pending claims, which have already been
in the system for several months.
This is very labor intensive. And in the meantime, veterans
are waiting months without compensation while their completed
case sits on a shelf. I know the other Members of the Committee
and most Americans find that unacceptable.
Additionally, there have been reports by the U.S.
Government Accountability Office, the VA Inspector General, and
the Institute for Defense Analyses that explored the variances
in ratings between Regional Offices (ROs) and the lack of
inter-rater reliability.
The Veterans' Disability Benefits Commission also found a
great deal of subjectivity and inconsistency in the VA's
disability claims process.
So how do we solve this?
I have had a lifelong interest in science, was a three-time
National Science Foundation scholar, and a physics student
while at Notre Dame. I learned FORTRAN when I was a kid when my
father was teaching seminars when the computer would take up a
room this size that now fits into a laptop.
So I find the topic of artificial intelligence, or AI,
compelling since it requires the confluence of science,
technology, mathematics, engineering, and physics.
In general, the purpose of AI is to make computer programs
or machines that can solve problems and achieve goals. AI
software increases speed, improves accuracy and reduces costs
for many industries and agencies.
AI does not replace the human element, but rather
facilitates its availability. There are many examples of AI in
other areas, such as banking and medicine. For instance, the
Veterans Health Administration (VHA) relies on VistA to help
doctors with diagnosis and treatment. It sends alerts when a
patient needs a flu shot, cholesterol screening, or warns of
potential drug interactions.
AI can be a decision support tool for adjudicating claims
too. It could be used to organize and store data. It could
match key words from a veteran's record to the criteria in the
Rating Schedule. It could prioritize multiple disability
issues.
I envision a VA in which a veteran can apply online for
benefits, upload records, exams, and other certificates, which
are prioritized and classified by an expert system that can
match the data to the Rating Schedule criteria and thereby
shorten the time it takes to generate a claim.
The electronic template used by the examiner could be
associated with the Rating Schedule, which could also help
calculate ratings. Classifiers or key words could easily be
matched by the computer to the Rating Schedule, such as
``Arm,'' ``Amputation,'' then ``90 percent.''
This would free up the time for the RO employers to deal
with the more complicated issues, and assist veterans and their
families with their problems.
This Subcommittee has often heard that veterans do not know
about, or understand, their benefits and that transitioning
servicemembers are not getting all of the support that they
need from the Veterans Benefits Administration (VBA).
In this way, VBA staff could be providing more outreach and
ensuring that veterans understand their entitlements and
eligibility requirements for other programs, and benefits such
as vocational rehabilitation, insurance and special monthly
compensation.
I am eager to hear testimony today that will open up the
discussion on information technology (IT) and share ideas that
can improve rating efficiency, quality, and accuracy while
reducing inconsistencies and variances in decisions for our
disabled veterans who often have been waiting for a long time
for a claim determination.
I look forward to working with Ranking Member Lamborn and
the Members of this Subcommittee in finding real solutions that
will vastly improve the VA claims process. It is unconscionable
that our veterans are waiting as long as they are for their
earned benefits. And this situation must end.
I now recognize the distinguished Mr. Lamborn for any
opening remarks he may have.
[The prepared statement of Chairman Hall appears on p. 44.]
OPENING STATEMENT OF HON. DOUG LAMBORN
Mr. Lamborn. Thank you, Mr. Chairman for yielding. I would
like to welcome all of our witnesses to this Subcommittee's
first hearing of the Second Session.
I want to commend you, Mr. Chairman, for your leadership
and bipartisanship in the previous session. And I look forward
to working with you and your staff to find meaningful solutions
to improving the VBA claims processing system and reducing
VBA's disability claims backlog.
I am excited that our topic of discussion today is the Use
of Artificial Intelligence to Improve the Disability Claims
Process.
As you know, Mr. Chairman, this is an idea that my
colleagues and I on this side of the aisle have long supported.
Whether it was in our fiscal year 2008 views and estimates,
or two bills that I introduced last session, H.R. 1864 and H.R.
3047, we believe that one way to truly reduce the current
backlog and prevent future backlogs is to propel the VA beyond
a 20th century, paper-based processing system, as you so
eloquently showed us through a picture on the screen.
VA must create a system where all claims are electronically
scanned and rating board members have access to computerized
interactive tools to assist them in the adjudicative process.
Hopefully, the new system will lead to more accurate rating
decisions that are delivered to our Nation's veterans in a
timely manner.
While I envision an important role for artificial
intelligence in the decisionmaking process, I also concur with
our witnesses who will attest that this technology should not
and will not ever completely replace claims adjudicators.
A few weeks ago, staff from both sides of the aisle
attended a briefing where VBA laid out plans to move forward
with such a system. And I am excited to learn more about those
plans today.
The Subcommittee must ensure that this new initiative is
fully funded and completed with the speed and attentiveness
that our veterans deserve.
I am glad that we have representatives from both the
private and academic sectors here with us today. It is my hope
that they will be able to help VA develop some of the options
that are currently available in the private sector.
While I understand that VA has a very large and unique
disability claims system, there are similar systems out there.
And I would hope that VA would look at these systems before
they reinvent the wheel.
We must improve this system so heroes like Gunnery Sergeant
Cleveland do not have to wait several years to have their claim
adjudicated correctly.
Mr. Chairman, I extend my thanks to you and your staff for
holding this hearing this afternoon. And I look forward to
hearing the testimony of our witnesses. I yield back the
balance of my time.
[The prepared statement of Congressman Lamborn appears on
p. 45.]
Mr. Hall. Thank you, Congressman Lamborn.
Joining us on our first panel is Tai Cleveland from
Dumfries, Virginia. Mr. Cleveland is a medically-retired Marine
who sustained a devastating training injury in Kuwait in 2003.
With him is his wife, Robin.
And they are joined by John Roberts, the National Service
Director for Wounded Warrior Project (WWP), which is the
veterans service organization (VSO) that represents the
Clevelands. I would also like to recognize Mr. Roberts'
distinguished service as a Marine who was also severely injured
while serving this Nation in Somalia. I thank you all for being
here.
I would like to remind our panelists that your complete
written statements have been made a part of the hearing record.
Therefore, if you would, try to limit your remarks to 5
minutes so that we have sufficient time for follow-up
questions.
Mr. Cleveland, we will go ahead and begin with your
testimony. You are now recognized, sir.
STATEMENTS OF GUNNERY SERGEANT TAI CLEVELAND, USMC (RET.),
DUMFRIES, VA (DISABLED VETERAN); ACCOMPANIED BY ROBIN
CLEVELAND, DUMFRIES, VA; AND JOHN ROBERTS, NATIONAL SERVICE
DIRECTOR, WOUNDED WARRIOR PROJECT
STATEMENT OF GUNNERY SERGEANT TAI CLEVELAND, USMC (RET.)
Mr. Cleveland. Mr. Chairman, Ranking Member Lamborn,
distinguished Members of the Committee, thank you for the
opportunity to testify before you regarding my experience with
the Department of Veterans Affairs and claims process. My name
is Gunnery Sergeant Tai Cleveland, United States Marine Corps
Retired. With me today I have my wife, Robin. And I would like,
with your permission, Mr. Chairman, for my wife, who has dealt
often with the VA on our benefits claim, to discuss the issues.
Mr. Hall. Thank you, sir. And, Robin, you are now
recognized for 5 minutes.
Mrs. Cleveland. Thank you, Mr. Chairman. My husband served
his country proudly for 24 years as a United States Marine. And
although we had many issues with the U.S. Department of Defense
(DoD) following his injuries, due to the subject of this
hearing, I will limit my comments to our difficulties with the
VA claims processing system and its impact on our family. As I
am speaking, however, please keep in mind that a severely
injured servicemember must navigate multiple systems: the
Department of Defense, the Social Security Administration,
Medicare, and the VA. It is quite overwhelming to say the
least.
Tai was injured in August 2003 during a hand-to-hand combat
training accident in Kuwait, where he was flipped onto his
back, injuring his head and multiple vertebras. The resulting
damage has left my husband a paraplegic with chronic
neuropathic pain, spasticity, and what is classified as a mild-
to-moderate traumatic brain injury that has its own set of
challenges.
Since Tai's injury, I have had to learn the hard way how to
navigate the systems. Keeping meticulous records of documents,
recording dates and times of telephone calls, confirming
receipt of anything sent or hand delivered to Federal agencies.
As such, I thought the best way to convey our situation was
to share a timeline detailing our experiences with the VA.
In June 2005, we attended the Transition Assistance Program
class provided by the Marine Corps and the VA to learn about
the available options. We completed the VA's Benefits Delivery
at Discharge (BDD) process, including the benefits, specially
adaptive housing, and adaptive vehicle program applications,
and hand delivered it with medical records, MRI compact discs,
films, prescription reports, et cetera, in its totality to 1722
Eye Street, Washington, DC.
After having completed his compensation and pension exam,
we called the VA Benefits number in November of 2005 where we
were advised that the application was incomplete and medical
records from the military treatment facility (MTF) were needed.
I delivered a second copy of MTF medical records to the DC
Office.
A month later, I phoned again to see if the records were
received and was advised that no application was on file. I
copied and redelivered the original application to the DC
Office.
In January 2006, another call to VA Benefits advised me
that the claim was being reviewed, but that medical records
were required to make a final determination.
I again copied medical records and redelivered to the DC
Office. I was later told that the housing and vehicle grant
were denied.
When I called in February of 2006, I was told no
determination could be made because Tai was still on active
duty. Additionally, I was told that no claim was on file for
the housing or vehicle. We reapplied.
In March 2006, I met with a VA employee at Walter Reed
regarding benefits and our difficulty with the claims. She
introduced us to a VA social worker at Walter Reed who enrolled
Tai in the Adaptive Driving Program at Richmond.
We were told to reapply for benefits, because no
application was found. We resubmitted the original application
and completed a new application for Specially Adaptive Housing,
Home Improvement and Structural Alteration (HISA), and the
vehicle grant, but were informed on April 5th that the
applications were denied and advised to reapply.
In June 2006, we were informed by the VA social worker that
the approval for the vehicle application was in fact received.
But she was ``unable to locate the application, because the
clerk failed to separate the application and maintain an in-
house copy.''
In addition, our HISA and Adaptive Housing Grants were
denied. We reapplied.
Everything was quiet for the next 3 months until October
26, 2006, when we were advised to reapply for vehicle and
housing grants since no official notification of approval was
received.
Again, in November of 2006, we received verbal notification
from the VA representative at Walter Reed of the latest vehicle
and housing denial. And on December 13th, 2006, we were advised
to reapply for vehicle and housing grants, and were contacted
by VA to verify our address.
In January of 2007, Tai was medically retired from the
Marine Corps. After filing BDD, we assumed we would get his
disability check within a month or so.
In February of 2007, our housing and vehicle grants were
approved and supposedly had been approved since April of 2006.
But the hard copy was no longer on file. To date, we still have
not received the official vehicle approval.
In late May 2007, we received verbal notification from the
VSO, helping us at the time, that the VA was indicating that
there was not enough information on file to rate the claim.
And, therefore, additional information was necessary.
In June, we received notification from the VA of an 80
percent partial rating. We were advised that the rating was
temporary and additional information was necessary in order to
process the claim.
As we were scheduled to be in Richmond shortly to obtain an
adaptive cycle, we were advised to have Richmond perform the
necessary evaluations for submittal to the Roanoke Regional
Office.
While at Richmond, I also inquired about obtaining the
vehicle grant hard copy and contacted the VA to inquire about
Aid and Attendance. I was told that I was not eligible.
In July 2007, via express mail, Tai's medical records from
Richmond to Roanoke--I delivered Tai's records from Richmond to
Roanoke and sent the VA an email advising that we still had not
received a disability check approximately 6 months post-
discharge.
In August, I phoned and emailed VA Benefits again and told
them that despite the temporary rating, we still had no check.
I requested direct deposit information and requested to verify
our address.
After having been contacted about our problems by a non-
profit organization, a concerned representative from the VA's
Central Office called in September about the outstanding
checks. And we were told that a tracer would have to be placed
on the missing checks before replacements could be mailed. I
later received a call from the Roanoke office and was advised
that replacement checks were going to be issued.
On October 4th, 2007, a VA representative told us that the
claim was being expedited and should be completed by the 14th.
We were informed on the 14th and on the 30th that the updated
medical reports still had not been received. However, on the
29th we began to receive the replacement checks for the
temporary rating.
At this point in the timeline, it is important to note that
our family had now been without our full disability
compensation and benefits for almost 11 months. Our college-
aged children were forced to withdraw. The overall financial
strain, and frustration level, and emotional toll, in addition
to the actual injury, were crushing.
Finally, on January 7th, 2008, after the intervention of
Mr. Hall's Subcommittee and the Wounded Warrior Project, we
received a final rating and back payment totaling thousands of
dollars.
As you can see we filed and re-filed, submitted and
resubmitted medical records, claims forms, applications, and so
on. But no one seemed to be able to track anything, placing
additional burdens on an already overwhelmed family. In our
case, after the intervention of a Congressional office and a
non-profit organization, we were able to get the benefits Tai
has earned. This process should not be that hard.
Today, almost 4 years later, while we still have a few
things to resolve with our ratings and benefits, our family is
trying to move on.
Many people have stepped in to help us, from government
agencies, to Congressional offices, to non-profit
organizations. I am planning to return to work and school. Our
children are returning to school. And Tai is enrolled in a
media careers program for veterans in Chairman Filner's
district. He has been a noted leader in the program, and ever
the Gunny, and has even spoken to the Wounded Warrior Project
about being a peer mentor.
However, our purpose in coming here today is not only to
tell you our story, but also to let you know that we are not
alone. People we know have had similar problems. And we know
there are more out there.
We are hoping that our presence here will help you
understand the obstacles faced by wounded members and their
families and inspire everyone involved to work together to
improve the efficiency of this vital system for the benefit of
those who sacrificed so much for this country.
Thank you, and I look forward to any questions you may
have.
[The prepared statement of Gunnery Sergeant Cleveland
appears on p. 45.]
Mr. Hall. Thank you, Mrs. Cleveland, and thank you so much
Gunnery Sergeant Cleveland for your testimony. And--If your
case was expedited, I would hate to see one that was not
expedited.
Now we recognize John Roberts from the Wounded Warrior
Project. Mr. Roberts, you are recognized for 5 minutes.
STATEMENT OF JOHN ROBERTS
Mr. Roberts. Mr. Chairman, Ranking Member Lamborn,
distinguished Members of the Subcommittee, thank you for the
opportunity to testify before you today regarding the use of
technology to improve the efficiency of the Department of
Veterans Affairs' claims process.
My name is John Roberts. And I am the National Service
Director for the Wounded Warrior Project, a non-profit, non-
partisan organization dedicated to assisting the men and women
of the United States Armed Forces who have been injured during
the current conflicts around the world.
As a result of our direct, daily contact with these wounded
warriors, we have a unique perspective on their needs and the
obstacles they face as they attempt to transition and
reintegrate into their communities.
In addition to my experience with the Wounded Warrior
Project in general and the Clevelands' case specifically, I am
a service-connected veteran, a former veteran service officer,
and most recently a supervisor with the Houston VA Regional
Office where I had the opportunity to review claims and became
familiar with a number of significant deficiencies within the
system.
In order to fully appreciate the problem, it is important
to understand how the systems currently operate. Despite recent
advances in technology common to most businesses, the Veterans
Benefits Administration claims processing system is still
dependent on a paper system. Although the VBA can now view
electronic health records transmitted from the Veterans Health
Administration, the ratings team is still required to print the
records, place them in the veteran's claim folder, which are
then reviewed page by page by a Veteran or a Rating Veteran
Service Representative (RVSR).
The current model of the VBA claims processing system has a
total of six separate teams and often, but not always, includes
another team that is dedicated to the processing of the
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)
cases.
The six main teams are, of course, triage, which handles
the incoming claims, evidence, and is charged with maintaining
the outdated file cabinet system, which stores the hard copy
paper claims files.
Predetermination, is charged with the initial development
of all claims for Service-connected disabilities.
The rating team is responsible for reviewing all available
evidence and determining if the disabilities are service
related. If so, they also assign the disability percentage.
The post-determination team is responsible for inputting
awards and generating notification letters to the claimants.
The appeals team maintains all pending appeals submitted by
all claimants.
And the public contact team is charged with the general
phone calls, questions, and conducting one-on-one interviews
with the veterans, dependents, and survivors.
Files must be hand carried to each of the teams. And any
member of these teams has access to the records at any given
time.
Despite the number of people with access and the ease with
which files may be misplaced, VBA only has one way to locate
the files once it is removed from the filing cabinet.
An electronic system called COVERS, but this system is only
effective if utilized by the individual employee. Rather than
having access to the file through electronic means, COVERS
requires manual input to identify a specific location or
individual. If this is not done, it is very time consuming to
locate one file among all the files that are within the
processing system.
I'll give you an example. Within the Houston Regional
Office, there are approximately 200 employees. And each of
these employees could have up to 30 or more files at his or her
desk at any time.
Another challenge is the outdated filing system, which is
used to store thousands of active files warehoused either at or
near Regional Offices. If a file clerk or an employee for that
matter is not paying attention and misfiles a claim folder into
the wrong cabinet or drawer, it then becomes a very time
consuming and difficult task to check each and every drawer to
locate the missing file.
The Triage Team at each RO is responsible for the intake of
all new claims and evidence submitted by each and every
claimant. If the file is not easily located, the mail is placed
on search within the COVERS system until the file can be
located.
Because there are so many teams within the claims
processing system, a particular file could be located within
teams at any given time. This allows for--this allows for the
human error factor, which is often why the numerous pieces of
vital evidence are often lost or misplaced and cannot be
associated with the appropriate claim folder.
If a file cannot be located and all avenues have been
exhausted to locate the file, the Regional Office will take
action to rebuild the folder from scratch. This means that all
prior evidence, claims, and claims which are submitted by the
claimant are then lost. The responsibility to replace the
missing evidence or claims is placed on the claimant. The VA
will ask the claimant to submit any copies that he or she may
have in their possession.
In addition, due to the current war on terrorism, VBA is
faced with another challenge. The new challenge is trying to
obtain records from the National Guard and Reserve units.
Active duty forces obviously do not file a claim until released
from service. Once demobilized, a Reserve member or National
Guard component is eligible to file such a claim. If
reactivated, however, the Reservist's claim is halted and he or
she at that time will take their service medical records with
them into theater.
There is also the large backlog of records requests to the
Records Management Center, which houses not only claim folders,
but now receives all servicemember records for recently
discharged servicemen. Think of this as a large warehouse of
nothing but paper files and an inadequate staff to locate each
and every file or record that has been requested by Regional
Offices across the country.
Another significant issue, which can be identified at every
Regional Office around the country, is the varying levels of
experience of the Rating Veterans Service Representative. In
any given case, you could take five individual RVSRs and give
them the same file and come up with five different opinions on
how the case should be rated.
Although there have been improvements with the
implementation of Rating Board Automation (RBA) 2000, the
current electronic system utilized to rate compensation claims,
the system is far from perfect. The overall ratings decision,
including the service connection and actual percentage, is left
up to the interpretation of the individual RVSR.
The gap in varying decisions nationwide can also be
attributed to the local policy at each individual Regional
Office. While this has been the case for many years, the issue
has come to a head due to the increased frequency at which this
generation of veterans speak to each other and compare their
individual situations.
Mr. Chairman, unfortunately, there are--these are only a
few of the issues that surround a paper-based system. And
situations like the Clevelands' are not unique. Many working
groups, Government Accountability Office reports, and
commissions have made recommendations on this topic.
Most recently, the Veterans' Disability Benefits Commission
suggested that cycle times and accuracy could be improved by
``establishing a simplified and expedited process for well-
documented claims, using best business practices and maximum
feasible use of the information technology.''
While the availability of well-trained, customer-service-
minded employees cannot be overvalued, the implementation and
recommendations such as these can help to greatly reduce the
complexity of the claims processing system and result in a
timely--result in timely results.
WWP looks forward to working with you and the VA to try to
resolve these problems. Thank you again for the opportunity to
testify today. And I will be happy to answer any questions you
may have.
[The prepared statement of Mr. Roberts appears on p. 47.]
Mr. Hall. Mr. Roberts, thank you very much for your service
to our country, the Marines, VA, and also now with the Wounded
Warrior Project.
And, I would start, I guess by asking Sergeant and Mrs.
Cleveland what would you say were the biggest missteps in where
the VA communicated with you?
Mrs. Cleveland. That is just it--the lack of communication.
Mr. Hall. Okay. It is just a simple answer.
Mrs. Cleveland. Right. What happens is you just get a
general form letter that says ``your file is incomplete'' or
``medical records are necessary.''
But then when you contact someone or you finally are able
to get someone on the phone, they have no idea what it is that
you are talking about. And it becomes submit or resubmit the
entire package.
Mr. Hall. So you were initiating most of the
communications?
Mrs. Cleveland. Exactly.
Mr. Hall. Is this your file, by the way, on the table?
Mrs. Cleveland. This is a part of it.
Mr. Hall. It is----
Mrs. Cleveland. This is a snapshot of it. And I was in the
process. And I had it in one-inch binders is what it started
out in. And it has grown quite a bit.
Mr. Hall. The average we hear today is 183 days to process
a claim. And that is hard enough to imagine. But in your case,
it sounds like it went closer to 365 days.
Mrs. Cleveland. Probably a little bit further than that,
because we initially applied while he was still on active duty.
July 2005 was when his application went in, the BDD.
Mr. Hall. Well, somebody from this government ought to
apologize to you. So let me be the first--if nobody else has, I
apologize to you both on behalf of your government that you
weren't taken care of and your needs were not attended to more
quickly.
Mrs. Cleveland. Thank you.
Mr. Tai Cleveland. Thank you.
Mr. Hall. I am sorry that happened. And we are going to try
to make sure that it does not happen to future veterans
anymore. I am going to try to reduce the time and reduce the
number of repetitive requests, and stop making our veterans
jump through hoops and prove that something is service related
when it obviously is, and try to get people like you back
integrated into something approaching normalcy and going about
their lives in a much quicker way.
My understanding was it took a full year for the VA to get
you a check. And that was even after you underwent the BDD
process.
Mrs. Cleveland. Correct.
Mr. Hall. What would have helped make this a better
process, other than better communication? What would you list
as the things that would have made it a better process for you?
Mrs. Cleveland. If the process were fully automated, that
would make a huge difference, because then you would not have
to venture out on this paper chase.
Mr. Hall. Right.
Mrs. Cleveland. From my understanding, the file moves from
one person to the next person in the rating process. And if one
piece of paper ends up missing, the next person, it is
something that they need, they don't--it is not as simple as
going back and saying, excuse me, you just gave me this record.
And--page 20 is missing. Can you locate it?
Mr. Hall. Yeah.
Mrs. Cleveland. It becomes the claimant's, the veteran's
job to get that page 20 in there. Only they don't know it is
page 20, so it becomes resubmit.
Mr. Hall. Thank you very much.
Mrs. Cleveland. The automation.
Mr. Hall. Let me just ask Mr. Roberts, as a former Regional
Office supervisor, could you describe for us how you would
change this system to make it more effective and efficient for
veterans?
Mr. Roberts. Well in the Clevelands' case specifically, the
VA historically, until the War on Terrorism started, they
didn't--they were not used to taking active duty
servicemembers, and taking claims while they were still on
active duty, and establishing a claims folder.
In their case, I would imagine that because he was on
active duty, a claim folder was not established. Papers that
were submitted, claims that were submitted, were not tracked in
any way, shape, or form, and misplaced, lost. And that is why
they were resubmitting over and over.
The current claims processing system right now that--Mrs.
Cleveland is absolutely right. It goes from one hand to
another, from one team to another. And if the veteran has an
appeal pending, then it could be in any team within the
Regional Office at any given time.
Definitely having the electronic file back and forth with
DoD and VA would be the most beneficial system.
Mr. Hall. Do you believe it is really necessary for six
teams to handle one case?
Mr. Roberts. No. This is--CPI was put into place several
years ago. They used to have a team concept where files were
rated. Everything was done within the same team. And the file
stayed within that team.
The way they have it set up now, everybody is doing part of
the assembly line process. And they have their own specific
part. And then it is passed on to the next person to do theirs.
So it was a little bit easier years ago to do the claim,
because you have RVSRs. You had decision review officers. You
had veteran service representatives. You had all the components
to work the claim right there on one team.
Now responsibility gets passed along to whoever takes over
after they get done with their part. And they pass it on to
someone else. So it is hard to track.
Mr. Hall. Thank you, sir. My time has run out. So I just
want to ask very quickly--You mentioned that you can have more
than one RVSR rating a case. Five different ones that come up
with five different opinions----
Mr. Roberts. Right.
Mr. Hall [continuing]. Can VETSNET fix that problem?
Mr. Roberts. VETSNET has come out. And they are working in
it. Before I left the VA, it was just getting rolled out and
being utilized. It doesn't fix it.
And it is still the interpretation portion that the RVSR
actually does on their own. They look at it. They make a
judgment call based on the medical evidence. And based on their
background, their experience, they make their decision. So it
is still flawed in the current way it is rolled out.
Mr. Hall. Thank you, sir. Now I will turn to our Ranking
Member, Mr. Lamborn, for 5 minutes.
Mr. Lamborn. I thank you, Mr. Chairman. Ms. Cleveland--Mrs.
Cleveland, you mentioned that there are some unresolved issues.
And the Chairman may have asked you briefly about that.
Is there still anything as we sit here that needs to be
resolved that we can help you with? Briefly; if not, we might
have to talk separately or if you haven't already talked.
Mrs. Cleveland. Separately.
Mr. Lamborn. Okay.
Mrs. Cleveland. Thank you.
Mr. Lamborn. Okay, okay. Thank you.
Mr. Roberts, do you believe that several of the problems
that you laid out in your testimony to date could be solved
with the new and up-to-date system, electronic system, that
uses some form of artificial intelligence to adjudicate the
claims?
Mr. Roberts. Honestly, sir, I am just not that familiar
with it. I wouldn't even want to get involved with that. And I
will leave that up to the experts.
Mr. Lamborn. Okay. Well, thank you for your candidness
there.
Why does the VA have a policy to place the responsibility
to replace a lost file on the claimant?
Mr. Roberts. Well, once the file is lost, they have no
other option. And they are hoping that the claimants themselves
have copies, like the Clevelands, in their possession. And they
can resubmit and kind of rebuild the folder from the ground up
again.
You have to remember when the file is lost and they have to
go through this process, they lose all service medical records,
DD-214's, the initial claims, any medical evidence submitted
from private physicians or medical facilities. Everything is
gone. They have to start completely from scratch and rebuild
the file from the ground up.
Mr. Lamborn. Okay. And you said in your testimony that
numerous pieces of vital evidence are often lost or misplaced
and cannot be associated with the appropriate claim folder.
Could you give us a little more specificity on how often you
think this happens?
Mr. Roberts. Well, I imagine--and just for an example, I
used to use Houston, because I worked there. If the claim file
is not where it is supposed to be, if it is not in the filing
cabinet, or it is not at the person's desk that says it is
actually located with, the mail is just put on search. And it
is put in a bin in numerical order. And it sits there until
somebody COVERS in a file to themselves and sees, you know,
mail search pop up. And then they physically have to go get up
and go get the mail and then associate it with the file. If
they don't use the system, they never know the mail is there.
I have seen files go all the way through the processing
system, be adjudicated, be rated, be finalized, letter has gone
out to the veteran, the file goes back, gets covered into the
filing cabinet, and the little GS-4 file clerk goes, ``Oh,
there is mail for it.'' And the process starts all over again.
They have to go back and re-adjudicate and re-rate that claim
based on the new evidence.
The system they have now is the human error. If they don't
use it, it doesn't do you any good.
Mr. Lamborn. Now it sounds like some of the issues we are
talking about right this minute, and in response to earlier
questions from the Chairman, and based on the testimony from
the witnesses, has to do not so much with artificial
intelligence or how the claims are adjudicated, but how the
records are stored, and kept, and processed, and transferred.
So at a minimum, it sounds like we should be looking at
digitizing some of these records to hopefully reduce the
examples where things are lost and the time is lost trying to
retrieve them, if that can be done. Or multiple people can look
at them at the same time, if we have these six teams, more than
one of which might be looking at it at the same time.
Do you think that is a step that the VA, at a minimum,
should take?
Mr. Roberts. I think that is exactly what they should be
doing. I have seen--this is a small example of files I have
seen. I have seen two or three boxes just for one file, one
veteran, in large boxes. And I have seen boxes get lost that
belong with other boxes.
So I got--I have seen files from veterans filed--half of
the file in one side of the building and the other half of the
file on another side of the building. And it takes--I have seen
up to a month for them to actually connect the two of them
together.
So, yeah, I have actually seen people on the appeals team
working a claim with half a file. And people in
predetermination working on half a file. And I am not sure how
they did it. But I have seen it.
Mr. Lamborn. I thank you for your testimony. Mr. Chairman,
I yield back.
Mr. Hall. Thank you, Mr. Lamborn. It would be funny were it
not so serious. The Chair will now recognize Congressman
Bilirakis for 5 minutes of questioning.
Mr. Bilirakis. Thank you, Mr. Chairman. My question has
already been answered.
But I appreciate you holding this hearing. And we need to
solve this once and for all, because I know it has been going
on a long time. And the claims--the process is too long.
Thank you very much for testifying today. And thank you for
your service.
Mr. Hall. I would add my thanks to all of you, and just say
that, Mr. Roberts, the help that the Wounded Warrior Project
provided and you provided is very welcome I'm sure to the
Clevelands but also to all of us.
And, just knowing that this is not an isolated incident, I
hope that we can set up a system using as much digitizing,
electronic storage, and electronic motion, and shared files, as
the Ranking Member was saying, so that we can avoid this; what
looks like it is well over a foot high. If you piled those on
top of each other, a foot high, for what you are saying is a
relatively small case in terms of the amount of information.
But at any rate, thank you for your testimony.
And we have votes that are under way now. So we will recess
the hearing for as long as it takes for us to go across the
street and vote. When we come back, we will hear from our
second panel.
This Committee stands at recess until then.
[Recess.]
Mr. Hall. The Subcommittee will come to order. Thank you
for your patience. We now have joining us at the witness table
panel two.
Dr. Tom Mitchell, Chairman of the Machine Learning
Department, School of Computer Science at Carnegie Mellon
University; Dr. Randolph Miller, Chairman of the Department of
Biomedical Informatics at Vanderbilt University School of
Medicine; Dr. Marjie Shahani, Senior Vice President of
Operations at QTC Management, Inc.; Mr. Ned Hunter, Chief
Executive Officer from the Stratizon or is it Stratizon?
Mr. Hunter. Stratizon.
Mr. Hall. I am thinking of that other company that ends
with ``izon'' Corporation, to describe a pilot study in
Virginia. Mr. John F. McGarry, Senior Vice President of
Benefits and Chief Risk Officer at Unum; and Mr. Gary
Christopherson, the former Veterans Health Administration Chief
Information Officer, former Senior Advisor to the Under
Secretary for Health, and former Principal Deputy Assistant
Secretary for Health Affairs. A distinguished group indeed.
Ladies and gentlemen, welcome to this Subcommittee. Your full
written statements have been entered into the record. And so
feel free to cut corners if you wish so that we will have time
for questions.
We are expecting to have Ranking Member Lamborn back here
any time. But since the next round of votes is scheduled in
about 40 minutes, we are going to try to move this along so we
can hear from you and not interrupt the panel to have to go
vote.
Mr. Mitchell, you are now recognized for 5 minutes.
STATEMENTS OF TOM M. MITCHELL, PH.D., E. FREDKIN PROFESSOR AND
CHAIR, MACHINE LEARNING DEPARTMENT, SCHOOL OF COMPUTER SCIENCE,
CARNEGIE MELLON UNIVERSITY, PITTSBURGH, PA; RANDOLPH A. MILLER,
M.D., DONALD A.B. AND MARY M. LINDBERG UNIVERSITY PROFESSOR OF
BIOMEDICAL INFORMATICS, MEDICINE, AND NURSING, VANDERBILT
UNIVERSITY SCHOOL OF MEDICINE, NASHVILLE, TN; MARJIE SHAHANI,
M.D., SENIOR VICE PRESIDENT, OPERATIONS, QTC MANAGEMENT, INC.,
DIAMOND BAR, CA; NED M. HUNTER, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, STRATIZON CORPORATION, ATLANTA, GA (VA STATE PILOT
STUDY); JOHN F. MCGARRY, SENIOR VICE PRESIDENT OF BENEFITS,
CHIEF RISK OFFICER, UNUM, PORTLAND, ME; AND GARY A.
CHRISTOPHERSON, UNIVERSITY PARK, MD (FORMER SENIOR ADVISOR TO
THE UNDER SECRETARY FOR HEALTH, AND CHIEF INFORMATION OFFICER,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS, AND FORMER PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR
HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE)
STATEMENT OF TOM M. MITCHELL, PH.D.
Dr. Mitchell. Thank you Chairman Hall and distinguished
Members of the Committee.
It is an honor for me to be asked to testify here today,
and to try to help you help the members of our armed services
who have served.
Clearly, we face a significant problem and backlog in the
processing of benefits claims by the VA. In my opinion, we have
the technology needed to address and to eliminate this problem.
Think for a moment of the forms filling problem that we are all
familiar with, filling out forms for income taxes.
If we can develop computer software like TurboTax, which
helps us fill out very complex multiple page forms, guides us
through the steps to determine what kind of information to put
in which kind of field, and then can instantly apply very
complex tax regulation codes to calculate to the penny the
amount of income tax that we owe, then I don't see why we can't
develop software that performs an analogous function for the
people who have to fill out forms for VA benefits and the
people who have to apply the complex regulations to those.
To take a second example that is even more similar to the
problem faced by the VA, consider the current practices for
processing benefits claims in the medical insurance industry.
At Highmark Inc., which is a major provider of health
insurance in my home State of Pennsylvania, I am told that 90
percent, nine zero percent, of the claims that come in from
physician offices and from hospitals are automatically
processed without any human intervention.
How do they do this? They do it by using electronic forms
instead of paper. They do it by coding the treatments that the
patients have received using industry standard (International
Statistical Classification of Diseases and Related Health
Problems) ICD-9 codes. They do it by developing rule-based
software that captures the rules and regulations by which the
correct payment is calculated from the details of the treatment
received by the patient.
And after the decision is made automatically by the
software, the payment is issued automatically. So that process
happens in 90 percent of the cases automatically. And the other
cases require human intervention.
Can the VA do the same? While the type of benefits claims
processed by the VA may be somewhat different from those in the
medical insurance industry, it seems to me the problems are
similar enough that we ought to expect that the VA can also get
a great benefit out of this kind of automation.
In my opinion, it is useful to consider a three-stage
introduction of computer technology for claims processing in
the VA. First, we can shift from pencil and paper claims to
online claims. This alone would improve the accuracy,
efficiency, and as we heard in the previous panel, the ability
to hold onto and not lose claims.
Second, introducing computer software to help interpret
these online claims to apply the regulations about which
benefits are due would be a second step. We have well
understood technologies for encoding complex regulations in
software such as rule-based systems.
And for steps that require some human subjective judgment
along the way, we also have technologies such as case-based
reasoning, which allow the computer to pull up the two or three
most similar previous claims in the system for inspection by
the human as they are applying their judgment to this new case.
As the third step, once these claims are online and the
processing is automated, the resulting database of claims can
itself serve as a resource for data mining. Data mining methods
can be applied to the claims data.
For example, data mining can be used to predict and flag
new claims that are outliers that might require some
specialized expertise to evaluate them, or to identify
soldiers, veterans, who should be taking advantage of services
that they appear not to and alerting them.
So to summarize, in applications from insurance claims
processing to tax filing to customer help centers, there is a
growing and widespread use of computer-based tools for
capturing data in forms and for applying automatic rule-based
inference to those.
Much of this technology comes out of research previously
sponsored by Federal agencies such as the National Science
Foundation and Defense Advanced Research Projects Agency. But
the core technology is by now very well understood. This is not
bleeding-edge technology.
The VA should take advantage of this. And I recommend three
steps that can be carried on in parallel to get started.
One, conduct a detailed 3-month study of the workflow
process in the benefits office to determine the different steps
and to identify for each of those steps whether it can be
automated. If not, whether some computer support such as case-
based reasoning can be used to help in the human judgment.
Second, begin immediately to move all of the claims online.
Even without any additional processing, just having them online
will be a benefit.
And third, consult with large insurance companies and
others who process benefits claims more automatically to
understand what are the current best practices and to begin a
process of adopting those where appropriate.
Thank you, Mr. Chairman, for your attention and for the
opportunity to address the Committee.
[The prepared statement of Dr. Mitchell appears on p. 49.]
Mr. Hall. Thank you, Dr. Mitchell.
Dr. Miller, you are now recognized for your opening
statement.
STATEMENT OF RANDOLPH A. MILLER, M.D.
Dr. Miller. Thank you, Mr. Chairman, for the opportunity to
address the Subcommittee this afternoon.
My comments describe the applicability of biomedical
informatics to the processes determining veterans' eligibility
for disability compensation.
Clinical informatics involves application of computer-
assisted technology for information management and
decisionmaking during healthcare delivery.
If I could have my slide over here. Don't worry, I am not
going to read the whole slide. So the problem we have at hand
is first the criteria in CFR 38 part 4 are vague and ambiguous.
For example, in section 56, part C, muscle disability is
defined as ``loss of power, weakness, lower threshold of
fatigue, and fatigue pain.''
While I can't do as many push ups as I did when I was 20, I
can't run the mile like I used to, and they talk on Sundays in
the NFL broadcast about the athletes working through the pain
of fatigue, I do not consider myself or pro athletes disabled.
And so the criteria are very ambiguous.
So the first thing is for Congress to redefine what they
really mean in a way that is actionable. Otherwise, computers
won't be able to help.
Another key principle of informatics is that you need to
identify the most proper, correct, definitive source of
information, collect information from that source, once and
only once, and record it once in a place where everybody else
can access it without overriding it with incorrect information.
So in addition to the veteran himself or herself, there are
three places of major activity relative to disability
determination. During active duty, when somebody is injured or
wounded, they should collect disability information right
there--beginning at the time that the service man or woman
receives care, and collect it in a way that is relevant to
disability claims, so that doesn't have to be replicated later.
After discharge, the veterans are seen within the VA
healthcare system, and they should collect disability
information there. The Compensation and Pension Record
Interchange (CAPRI) system is the beginning of a good way to do
that. But it is only used on about 25 percent of disability
examinations now.
And then finally, as we have already seen in the previous
panel, there is more than ample opportunity to automate the
paper records system for VBA.
And in my written statement, I presented three different
layers, starting with simple collecting of information to more
complicated things like AI applications that can be used to
progressively refine the system.
And I would also like to point out, as Dr. Mitchell stated,
that once all of this information is automated, not just in
scanned records but in actionable form, then you can collect
information about which claims are more difficult to process or
take longer time, which Regional Offices are efficient and not,
which veterans need more attention because they haven't been
processed yet, and so on.
When everything is electronic, you can do quality
improvement much more effectively than you can with paper.
As I have stated, and the Chairman pointed out in his
opening comments, artificial intelligence and expert systems
cannot replace human intelligence and human compassion in
judging whether veterans qualify for disability benefits. But
they can speed up the process and help the VBA make it more
uniform and more accurate.
It is very important to realize that you can cause problems
by automating things as well as curing problems. So, for
example, if in the process of implementing improvements the VBA
raters had a half electronic system and half paper system, they
would never know whether information was in the paper side or
the electronic side. And they would have to go to both all of
the time.
So this needs to be done in a thoughtful way, where people
are helped at each step and the situation is not made more
chaotic or confusing. And it needs to be done in a
nondisruptive manner.
The way the VA has implemented the VistA system is
exemplary nationally in informatics. And that would be a good
basis on which to model future changes. Thank you.
[The prepared statement of Dr. Miller appears on p. 53.]
Mr. Hall. Thank you, Dr. Miller.
Dr. Shahani, you are now recognized for 5 minutes.
STATEMENT OF MARJIE SHAHANI, M.D.
Dr. Shahani. Mr. Chairman, Members of the Subcommittee,
thank you for the opportunity to testify before you today on
the important topic of processing veterans' claims.
QTC is a nationwide provider of medical examinations and
record review services to the medical and disability
communities. We actually support Federal, State, local
government agencies; property and casualty insurance carriers;
third-party administrators; employers and the claimants they
serve.
We have been a provider of compensation and pension medical
examinations services to the Veterans Benefits Administration
since 1998.
QTC provides the detailed medical examination for veterans
and then submits the exam report to the VA's claims
adjudicators or rating specialists who then, along with the
veterans C-file or claims file, rates the veteran's disability
claims.
To ensure a quality, timely, customer-focused, and cost-
effective process and medical report, QTC pioneered the use of
software and technology. In every step of our process, we have
created software to facilitate and improve our own efficiency.
Over our 9 years of experience working with the VA, we have
come to understand the unique and complex challenges of the VA
disability process. It is like no other disability program with
which we work.
In an attempt to provide value-added services to VBA and
for veterans, QTC applied its knowledge and experience
specifically to simplify and streamline the information
gathering process for VA's rating specialists.
QTC actually developed what we call an Evidence Organizer
prototype. It is an automated tool designed to assist VA's
rating specialists significantly reduce the time to determine a
rating decision.
The Evidence Organizer has great potential in helping
rating specialists search and find relevant medical information
critical to make that final rating decision.
How does it work? Basically it converts the cumbersome
paper-based c-file to create an electronic record or e-file. I
guess that is what everybody is saying. First we have to
convert the paper into something electronic.
This document management process begins with a technician
scanning in the entire c-file through the use of optical
character recognition. The software transforms each record into
a text searchable digital record.
At the heart of this process is QTC's core knowledge
database, which is built upon our extensive disability
examination experience supporting the VA's Compensation and
Pension exams.
The knowledge database identifies, highlights, and
electronically indexes all keywords. For example, claimed
conditions like diabetes, asthma, arthritis, as well as any
potential claimable conditions throughout each medical record.
Once the e-file has been established, each record is
reviewed, validating the software's indexing, highlighting the
records, and now actually linking the referenced medical
records and evidence in the c-file to VA's rating requirements
or rating codes.
Once all medical records have been reviewed and linked, the
e-file is now ready for VA's rating specialist. Right now as we
understand it, the c-file is organized or filed according to
the date reports or documents are received.
In addition, most rating specialists process a veteran's
case addressing and rating one claim condition at a time. Thus,
in addressing a veterans' case with four claim conditions, the
current average, the rater reviews the entire paper claims file
repeatedly, making notes, putting sticky notes, clipping files
together to organize the medical evidence.
The Evidence Organizer will not only organize the medical
evidence by claim conditions, but also link the available
evidence to the actual rating requirements, allowing the rating
specialist to still make that final determination and write the
rating decision.
Upon consultation with former VA rating specialists, we
estimate that turning this manual paper process into an
electronic process will actually improve productivity by 37
percent per decision. By applying technologies such as the
Evidence Organizer to this paper process, VBA could greatly
reduce routine and repetitive administrative tasks for rating
specialists, improve their efficiency, and ensure quality and
accuracy of each review.
Thank you again for the opportunity to testify this
afternoon.
[The prepared statement of Dr. Shahani appears on p. 58.]
Mr. Hall. Thank you, Dr. Shahani.
Mr. Hunter, you are now recognized for 5 minutes.
STATEMENT OF NED M. HUNTER
Mr. Hunter. Chairman Hall and distinguished Members of the
Subcommittee, thank you for the opportunity to appear before
you today.
Stratizon Corporation is a veteran-owned Software-as-a-
Service company, which has utilized the concepts of artificial
intelligence to successfully design a software platform and
application solely focused on improving the VA claims
processing system.
We have gained valuable insight into the underlying success
of using AI to solve the VA claims processing system. First,
the technology available is in the marketplace. It is
adaptable, flexible, scalable, proven, and cost effective.
Technology is not to be resisted but embraced.
Second, success will be highly dependent upon the
perspective in which AI solutions are constructed. A true
veteran-centric solution of the future must be constructed
through the eyes and the situation of the veteran to satisfy
the requirements of the State and Federal policies and VA
systems and not constructed through the eyes of the multiple
government entities to independently present the bureaucracy to
the veteran.
Stratizon applied this perspective in successfully piloting
for the United States Navy, three unique web-based intelligent
solutions that demonstrated how the quality of life for sailors
could be significantly improved by replacing confusing,
complicated, paper intensive, and manually driven enterprise
processes with web-based, easy-to-use, fully automated, and
complete self-service solutions, or what we define as
``intelligent user interfaces'' or ``IUIs.'' And our tool does
this without the use of any programs or hard coding.
IUIs can also be designed for numerous veteran events such
as transitions from active to veteran status or applications
and appeals for VA compensation and health benefits.
The Commonwealth of Virginia's Department of Veteran
Services, working with the Joint Leadership Council of Virginia
representing 32 veteran service organizations, is implementing
such a solution called TurboVetTM.
Building on a successful pilot in 2007, the Governor of
Virginia has included funds in his fiscal 2009 budget that
begins on July 1st, 2008, for full production.
TurboVetTM will provide Virginia veterans, or an
authorized representative, or survivor the ability to log
online at Virginia.gov, via a personal computer or device such
as this Apple IPhone, and select an event that they need
assistance with.
Initially a series of statements and questions regarding
their status or particular event will be presented. Their
personal data currently on file with the State will be
retrieved so they may confirm or validate that data, thus
improving data integrity and eliminating redundant data entry.
The system will use embedded decision logic to react
intelligently to their input to continually refresh and display
only the necessary event questions, thus eliminating the
frustration of redundant and unnecessary questions.
A list will be displayed of all State and Federal benefits
the veteran has earned with all corresponding documents
spanning multiple agencies required for the veteran to submit,
thus providing a peace of mind to the veteran their solution is
holistic.
Each document will then be progressively, simultaneously,
and perfectly auto-populated with the proper data, thus
eliminating data transcription errors and numerous processing
delays.
Finally, the veteran will have the option to save and print
each document locally and, at their discretion, electronically
submit their data securely to all participating authorities and
systems to be processed and tracked fully and completely.
Virginia's success in using an AI platform is dependent
upon the continued support and cooperation of all parties, both
political and technical. Decisionmakers need to remain
committed to this paradigm shift to the future and must always
provide their best institutional knowledge available to ensure
the TurboVetTM IUI not only becomes that benchmark
of service but also remains that benchmark.
We need technical cooperation between State agencies to
take advantage of TurboVetTM's ability to seamlessly
exchange data with disparate IT systems. We need cooperation
and support at the Federal level.
Federal supervisors in Roanoke have projected that a
minimum of 100 days of processing time will be eliminated when
the TurboVetTM system is implemented at only the
State level.
Stratizon foresees few problems in exchanging data between
TurboVetTM and VA systems such as VistA and VETSNET.
We fervently believe there could be significant process cycle
time improvement and extraordinary cost savings at the State
and Federal level if veteran's data at the State level could
first be pre-verified against recognized authoritative national
VA databases and then seamlessly exchanged upon claims
submission and during the claims management process. Virginia's
goal is to fulfill the vision of House Resolution 3047 and have
a claim prepared properly with attached medical evidence and
documentation for electronic submission to Federal adjudicators
for rating, and have those claims calculated fairly,
consistently, and automatically.
In summary, using a properly designed AI system would
dramatically improve the VA claims processing systems by
improving the access to customer solution and service for
veterans and their family members, reducing the costs to the
State in staff administration, training, and paperwork, and
improving the accuracy, throughput, and expediency of claim
submissions by the State for VA adjudication.
On behalf of the Stratizon Corporation, I would like to
thank the Chairman and all Subcommittee Members for this
opportunity to be here today.
[The prepared statement of Mr. Hunter appears on p. 61.]
Mr. Hall. Thank you, Mr. Hunter.
Mr. McGarry, you now are recognized for 5 minutes.
STATEMENT OF JOHN F. McGARRY
Mr. McGarry. Mr. Chairman, Members of the Subcommittee, I'd
like to thank you for the opportunity to testify before you
today.
My name is Jack McGarry. I am the Senior Vice President of
Benefits and Chief Risk Officer at Unum.
I have submitted written testimony, which has been made
available to you. But will briefly present an overview.
I am here today to discuss how our technology facilitates
claim management decisions at Unum. We process approximately
400,000 disability claims per year and pay about $4 billion in
benefits directly to our insureds and their families.
Most of Unum's claims are governed by the Employee
Retirement Income Security Act (ERISA), the Federal law which
generally requires insurance companies to make disability claim
decisions within 45 days.
Unum's experience shows that it is possible to manage high
volumes of claims in a timely and accurate manner while
achieving high levels of customer satisfaction.
Technology is an important component to the solution of
managing volumes, timeframes, and customer service. However,
the decision about a person's ability to work is also informed
by in-depth analysis of pertinent documents and discussions
with claimants, their employers, and their physicians in order
to assess their ability and motivation to work.
In the end, the disability determination is a judgment call
that needs to be made by a person.
In order to assure that the right people are reviewing the
right claims at the right time, a combination of Unum's
technology and people is necessary.
For example, a routine claim may be automatically sent by
the system to one person, while a complex claim with multiple
diagnoses may go to another based on a combination of systems
and management decisionmaking. As robust as our systems are, a
person does look at every claim we pay.
Our technology does the following. It manages documents,
facilitates workflow, ensures a complete administrative record,
and monitors and measures quality and service results.
First, our system manages documents. Our files can grow to
hundreds if not thousands of pages. With our image-based system
all files are paperless and multiple people can access the
claim same--same claim at the same time. Documents are
organized and stored in an efficient manner.
Second, our system facilitates workflow. All new documents
and other information are electronically scanned into our
system upon receipt. Our technology facilitates parallel claims
processing and ensures claims issues are promptly addressed.
The act of scanning the documents as they are received
creates an online activity for the claim payer to review. In
our system, every action a person completes creates another
action or follow-up activity.
The system can also trigger an action for someone to review
claims and/or contact customers at key times during the claims
management process.
Third, our system ensures a complete administrative record.
An administrative record is important for ERISA purposes as
well as sound claim management.
When a claim changes hands between claim payers, all of the
management activities associated with that claim, including
future activities, stay with the claim and are automatically
assigned to the new claim payer.
The technology keeps the file together in one place and
minimizes any disruption in service due to a personnel changes.
Fourth, our system monitors and measures quality and
service results. Management and our quality assurance process
require the ability to review files real time, at the same time
that the claim payers are working on the files. The system
automatically tracks and reports on service times and outcomes.
At the initial level, for the shorter terms claims, our
intake department reviews each new claim and assigns an ICD-9
diagnosis code. Our technology then separates the levels of
disability into those which have shorter durations and those
which may be longer term based on the assigned diagnosis code.
Simpler claims are triaged directly to a claim payer. For
the most complex claims, our technology triages the claims to a
manager who decides which claim payer to assign the claim based
on the experience of the individual.
After the initial assignment, our technology initiates
reports based on key measures, including diagnosis, generally
accepted medical condition guidelines, and our own Unum
database information. These reports can identify claims that
need additional work or follow up, and help each claim payer to
determine what steps to take next.
Disabilities present a complex management challenge,
because they are logistically difficult, judgment based, and
can be emotionally charged. Technology can help facilitate
judgment-based decisionmaking, but we don't see it as ever
being able to replace people in the claim management process.
I would like to end by extending an invitation to all of
you and for the VA staff to visit Unum and would welcome the
opportunity to continue to be a resource for sharing best
practices between the public and private sectors as you
continue to evaluate the disability adjudication/case
management process.
Thank you for the opportunity to testify before the
Subcommittee.
[The prepared statement of Mr. McGarry appears on p. 64.]
Mr. Hall. Thank you very much, Mr. McGarry. You and Dr.
Miller have helped set standards for efficiency by finishing in
under 5 minutes. Not that we will hold anybody else to that.
Mr. Christopherson, you are next, and are recognized for 5
minutes please.
STATEMENT OF GARY A. CHRISTOPHERSON
Mr. Christopherson. Chairman Hall, Mr. Lamborn, Members of
the Subcommittee, let me applaud you for holding these very
important hearings and for your opening remarks.
Today I am going to speak to the enabling role of
artificial intelligence, to the true obligation of duty to
assist, and to the honor bestowed on those who deliver on time
and on target.
When I served as Principal Deputy Assistant Secretary of
Defense for Health Affairs, I saw our servicemembers sacrifice
and our Nation incurred debt.
I saw our veterans' plight when serving as VHA Chief
Information Officer and Senior Advisor to the Under Secretary.
And I had the great privilege of getting to know
servicemembers, veterans, and their support organizations as
people providing a great service to our Nation.
All this taught me that everything VA does should be
centered around the veteran. It is not today. If we believe
that veterans are hurting, and that we have the duty to assist,
and that we should be on time and on target, we need a new
claims system. And we need it now.
When I was advising VBA in thinking about a new system
several years ago, I learned it takes 6 months to a year or
more to complete about 8 hours of actual work. Unacceptable.
When a veteran is hurting and needs healthcare, the VA
health system assists the veteran and provides care quickly.
When a veteran is hurting and needs financial benefits, the VA
benefits system does little to assist, forces the veteran to
navigate a large bureaucracy and massive paperwork, and
provides financial benefits only after months or years. Sadly
this all happened to Gunnery Sergeant Cleveland.
So what should happen? First place, VA staff should be
coming out and welcoming the veteran, not the way it is done
today. They should actively assist the veteran to get
everything processed quickly and correctly. Longer term, they
should assist as case managers.
Further, we need the continuing and valuable support and
assistance of the veterans' service organizations.
In my opinion, changing the process means giving a veteran
a temporary financial benefit at least as soon as the veteran
files a claim with basic supporting evidence.
For the permanent decision, real time would mean the VA
could receive the claim with supporting evidence and make the
decision on the same day or at least within a couple of weeks.
Further, let us start paying the veteran within 30 days.
In my colleagues' testimony, we heard that technology
exists today to greatly improve the speed and accuracy of
benefit decisions.
For those who argue claims processing is a much more
complicated and difficult process, I counter that it is not.
Healthcare, much more complicated and difficult, is figuring
out how to provide care in real time without technology and
even better with technology.
When I rescued the VistA health information system and
moved it to a brighter future, we also made that information
available to VBA electronically and in real time.
Now artificial and human intelligence together can help. VA
healthcare providers have the decision support to care well for
a person in real time. For claims processing, we do not have to
wait for the technology. We can start reducing the misery today
and even better when the technology arrives. However, getting
to a new, veteran-centric, effective claims processing system
with the necessary enabling technology will only happen if VA
leadership is fully committed to achieving that vision.
Further, VA leadership will need effective management and
staff to make all this happen.
Yes, this is all affordable and doable. First, it could be
well built into the $150 billion economic stimulus package
moving at this very moment through the Congress.
Secondly, we have to understand that we handle the budget
when we send our servicemembers to war. We should do no less
when they come home and need our help. This is a part of real
cost of preventing or conducting war.
Today, there is a failure to understand and appreciate the
veteran's plight. Feel what it is like for a veteran to live in
uncertainty and without support for months, or a year, or more.
If we did that for healthcare, that would be totally
unacceptable.
Bottom line, change the assumptions. Change the process.
Use the best technology. Change the attitude. Care for the
veteran. On time and on target is what we expected of our
veterans and what we should expect of VA. The duty to assist is
an obligation that VA with regards to benefits has yet to
honorably discharge.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Christopherson appears on
p. 75.]
Mr. Hall. Thank you, Mr. Christopherson.
Eloquent, powerful testimony all. The question I wanted to
ask, first of all, Mr. Christopherson, you talked about
starting paying veterans once they filed a complete claim
within 30 days. First you said immediately. And then you said
at least within 30 days. This is something that many of us have
been advocating for.
Do you have a figure in mind or a percentage disability
rating in mind that would be your best guess average or, you
know, baseline to start while the process goes forward?
Mr. Christopherson. Not really. I think what you have to
look at the situation of the person's need, the veteran's need
at that time.
Secondly, there is obviously a political process you have
to go through with budgetary decisions. And what I may ask for
and what I think should happen, my sense of right now is if a
veteran has a disability, whatever degree is appropriate at
that time, that we have some degree of confidence in, grant it.
And start paying it within 30 days in terms of that.
Second part is, and by the way, that starts to shift the
burden onto the VA rather than onto the veteran. Right now we
have a backward, upside down system. Where we sort of say if
you can figure out how to navigate the system, maybe we will
let you get benefits. And Lord knows how long it is going to
take.
If we start the reverse and say we are going to start
paying some benefits, and we will make some mistakes, but by
the way, they served. We didn't essentially ask them a lot of
questions at that time. They didn't demand a lot of answers at
that time. We should be doing the same here.
So I think essentially what you really have now is give as
much as you can with a certain reasonable amount of risk. If we
do it for a temporary basis and for a relatively short period
of time, the government is not at great risk in doing that.
If you couple that with all the things we have talked about
here at this table about moving the whole time process down,
the risk to the taxpayer goes down very substantially as well.
Mr. Hall. Thank you. Mr. Mitchell, your work in artificial
intelligence covers a broad area from computer learning to
advanced robotics.
I was wondering what level of technology are we talking
about for transforming the VA claims processing system?
Mr. Mitchell. Well I think the example of Highmark is a
good one. They automate the claims processing. And, in fact,
TurboTax is another good example. Both of these are systems
that essentially are very well understood. These are not
bleeding-edge technology. They are based on very well
understood techniques that come out of artificial intelligence.
But essentially they are ways of encoding in software a
large collection of rules like the one that you mentioned in
your own opening remarks that say ``if, the form has this kind
of data, then this is an appropriate kind of disability
rating.''
And so that technology for rule-based processing is very
well understood. It is something we could do today and is
widely done today.
Mr. Hall. How long would you guess it would take, Mr.
Mitchell, for such a system to be created?
Mr. Mitchell. I believe if--so I looked in preparation for
this meeting at some of the rules that are used for assigning
disability benefits based on these conditions. To take a
standard rule-based engine and to input those kind of rules is
months. It is well under a year.
Now I can't estimate the additional sort of organizational
and bureaucratic adjustments that would be needed--that would
have to be done to go along with that. But from a purely
technical standpoint, we are talking about months.
Mr. Hall. First to you, and then to anybody else on the
panel, how important would it be that we get a digital handoff
from the DoD to the VA? I heard when I was in Landstuhl,
Germany, in October on my way back from Iraq. The commander who
is in charge of the hospital in Landstuhl says that they are
bringing back the servicemembers who are injured with an
electronic record, which is like an onion. They keep adding
another layer to the onion at each place to what they added in
theater.
And then they added in, the treatment they are getting
while they are being flown, and then when they get to
Landstuhl, they add more records about the medications, or the
therapies, or the treatments, or surgeries, whatever is
happening to that veteran.
When they return to Walter Reed or Bethesda, then another
layer is added to the onion. They told me that in December,
last month, they were going to be able to start handing this
off to the VA. Well, I am not sure if--I haven't gotten a clear
answer as to whether this is actually happening yet. But
assuming that happens, how important is that to being able to
start this process?
Mr. Mitchell. Yes. You know, I would leave that to people
who know more about the detailed decision--the detailed policy
for assigning benefits. But it is clearly the case that these
rule-based systems can apply only to data that has already been
captured online.
And so if that part of the electronic record is relevant,
then it would have to be online, either by being passed off or
by being transcribed from paper in some other way.
Mr. Hall. Dr. Miller.
Dr. Miller. The CAPRI system that the VA has developed for
examiners to record the disability exams within VHA to pass
along to VBA, I believe it was already in pilot that you are
referring to. So the problem is the DoD records are in
different format computationally than the VA records are. And
that is one of the logjams in the disability determination.
But for the BDD process that Dr. Christopherson referred to
it, if in active service they use CAPRI forms to do the quick
and dirty disability determination, that is an existing system
the VA developed. And they could probably use that as the basis
fairly quickly for the initial short-term disability ranking
and payment while more electronic work is done.
Mr. Hall. And----
Mr. Christopherson. Mr. Chairman, if I may.
Mr. Hall. Yes?
Mr. Christopherson. Let me fill in. It started when I was
at DoD and then continued when I was at VA, which was the idea
of doing exactly what you are describing. Which is to make the
information that DoD generates electronically available to VA
both for healthcare and for benefits determination there.
Much of that information is now available. If it is
electronic, it is available to VA both sides of the equation
there. What you have to look at, what will slow things down is
for older veterans who didn't have much care electronically in
DoD. It has to go through the paper route.
The later era, you have a mixed bag of that. You have to
sort of deal with the mixed bag of that. But again, digitalize
that and then essentially move it across.
The next generation coming through should be heavily
digitized. And the data should be standardized, which means you
really can feed it into the rules engines that these folks are
talking about here.
Mr. Hall. So the most time-consuming task that we face is
entering all of the old data that is in boxes and files, like
the ones we saw earlier, into the system. And then starting
from whatever point the system is online, hopefully it will be
expedited and more or less instantaneous.
Mr. Christopherson. I would suggest, Mr. Chairman, that is
not a staff issue. That is more likely going to be a contract
issue. You can make that happen as far as you are willing to
spend money to make it happen.
Mr. Hall. It always comes down to money, doesn't it? Dr.
Miller, I have one more question for you. I have often heard
that doctors use a technique called differential diagnosis
where they have a hypothesis about a patient's illness and then
ask questions to rule out conditions until they come up with a
diagnosis.
Can a computer using a rule-based expert system as you
described, assist with assigning disability ratings that cover
the VA's 700 codes and its zero to 100 percent range of
severity that often includes multiple conditions? How long
would it take a computer to do that?
Dr. Miller. I worked on diagnostic systems of the type you
are referring to for a quarter century. There are probably
seven or eight techniques in addition to rule based that can be
used to do what you have asked.
Essentially the idea has already been stated. But you would
use electronic means to identify findings in the veterans
records or an active service person's records. And that could
cue the practitioner taking care of them that this patient is
potentially eligible for disability and hone down into the
specific categories of the 700 that the veteran might be
eligible for.
In the end, it still should be a decision by a human. But
reminding people when they might not be thinking about
disability in the heat of battle or whatever that is an
important component of the care is something that such tools
would be able to do.
Mr. Hall. Thank you very much. Dr. Shahani, we have often
heard that claims have become more complex with over eight
conditions per claim instead of just one or two.
Could a system such as QTC's rate all of those conditions
given that the claim is already in a ``ready to rate'' format
such as the one described by Mr. Hunter? How long would that
take?
Dr. Shahani. Just to paraphrase your question again, are
you asking then for the time it would take to code all the 700
codes, the multiple conditions?
Mr. Hall. Yes.
Dr. Shahani. Right. Basically like, you know, what Mr.
Mitchell said, anywhere from 6-9 months to come up with that
system.
Mr. Hall. Can you tell us more about the knowledge library?
Though you did not mention it in your testimony, what would its
use be once the exams are stored?
Dr. Shahani. Basically the knowledge library that we are
talking about or the knowledge database contains, you know, the
rating codes that are in 38 CFR part 4. The claim conditions
that we have encountered throughout the 9 years, and all the
potentially claim conditions, and all other keywords that are
within the rating code, because each rating diagnostic code
actually has descriptions. So they will say range of motion
limited by 30 degrees or 40 degrees. All of that is within that
knowledge database.
So when it actually scans the records, it identifies and
highlights those key words. And then later links, through the
rule-based technology or artificial intelligence, links that
medical evidence to the rating code.
So what the rating specialist will see is actually medical
evidence already showing them what rating codes they need to
consider. But they need to make the final decision.
Mr. Hall. Thank you, Doctor. Mr. Hunter, I want to ask you
if you could describe a little bit more about the system that
you developed for the Navy, that you referred to during your
testimony.
Mr. Hunter. Well we took the approach that we have--we have
developed what has been discussed today would take another 6-9
months. Over the course of last 5 years, we used open standard
technologies, realizing that no matter what software tool we
developed would have to work with a multiple set of disparate
systems and communicate with that data.
So we--when you put yourself in the seat of the veteran and
as the bureaucracy, the IUI will reflect the Boolean logic that
is the knowledge library. It actually is that the pages refresh
reflecting that knowledge library to say okay, based on what
you have told us, this is the paperwork, what you need to do.
Maybe the medical records that need to be attached. And we can
do it without programmers. That was a real key, because you
don't want to get--when we worked in the Navy with PeopleSoft
and you had to write hard code APIs, you get bogged down. And
we just do it now in drop-down menus so you can select from a
drop-down menu that knowledge library in which to inject into
the question.
So we have accelerated. And the technology is not unique or
patentable. It is just the way we presented that tool in order
to have the institutional knowledge get transferred into that
IUI. That is what is critical.
Virginia refers to it as the unlucky or lucky vet. It does
take 3-5 years to scale up a Federal adjudicator or veterans
service representative. So if the veteran is lucky to call in
and get someone who has just been there 2 months, well they
don't know all the questions to ask or the right questions. And
that is the key.
If we don't catch this problem at the tip of the spear, it
just rolls through the entire system. And that is what we are
finding. They want to get the person who has had 35 years. It
is just critical that they have a consistency of every veteran
with the access to be asked the right questions and all the
questions, because that starts the claim bill process.
So some of the other companies here today can take a claims
management process forward. And we have done that unique and
successful--successfully.
Mr. Hall. So how long should it take to rate a claim in
your opinion?
Mr. Hunter. Well in our opinion it should take less than 48
hours, depending if the right Boolean logic is put in.
Now I also agree it will never take the place of a human.
All we are doing is shifting the job focus from those people
from this data entry and doing what they really are set out to
do, which is the human interaction.
I also believe that the technology will never solve 100
percent of the problems. What we found is it is more of an 80-
20, 90-10 rule. That you do not want to take the time or the
money to put in this logic for the person with the extreme
case. That person needs to be immediately put to personal
attention, because they need that.
But for the bulk of the people, the frustration of going
through the same questions and same paper, it is ridiculous.
And we take a position it is more about the data than the
document. You need some documents by mandate. But documents to
us are online receipts, box and lines around the data. It is
the data that is really the back-end systems need, which was to
close. We put that in standard, native XML so we can very
confidently talk with any back-end system without trying to
change that system. That just seemed--that really lengthens the
time.
They just need good data to do what they do well.
Mr. Hall. Thank you. Mr. McGarry, I just wanted to ask
you--well first of all, thank you for being here again. You
have been a help to the VA system in the past. And I appreciate
you being here again.
It is curious, you mentioned that you can process some
claims within 3 days but must process them within 45 days in
order to be ERISA compliant. Should VA be required to meet the
same standard for processing a claim?
Mr. McGarry. I think it is certainly possible for the VA to
meet the same standard for processing a claim. You know, my
view of it is that the processing part isn't the only piece.
There is the definition of disability as well as the resources
applied.
And so my only recommendation is in addressing this
problem. You address all three of them to get a holistic and
consistent solution to it.
Mr. Hall. Does----
Mr. McGarry. Mandating one or the other I think is going to
be--fall short of the total solution.
Mr. Hall. Right. Does Unum have a backlog of claims?
Mr. McGarry. We do not.
Mr. Hall. Do you see a lot of fraud?
Mr. McGarry. We see--you know, fraud is a high standard
requiring intent. We do see misrepresentation or people----
Mr. Hall. Misunderstanding?
Mr. McGarry. Misunderstanding. And so there is a reasonable
amount of that. You know, we discover a fair amount of claims
through investigation and surveillance for instance.
Mr. Hall. Do you think that if the VA used a triage system
similar to Unum's where the claims got sent to a subject matter
specialist, it would improve their success?
Mr. McGarry. Our actual triaging is less around subject
matter specialists and more around the duration and complexity
of the claim.
I think one of the biggest drivers of our success is
quickly separating claims into those that can be solved readily
and quickly versus those that need more in-depth analysis and
investigation.
Mr. Hall. The 80-20 or 90-10.
Mr. McGarry. And the thing is, you know, is don't mingle
those two. Don't have the same people doing the 90 and the 10,
because the 90 are quick hits that you can do in 10-15 minutes
all day long. It is a processing work. Whereas the 10 is more
of an investigative work that takes real expertise to do. And
so one of our successes is separating those right up front.
Mr. Hunter. And, Mr. Hall, may I add that quickly, we have
found in Virginia's pilot that less than 95 percent of the
claims are ready to rate when they are submitted by the
hardworking VSOs in the State, only 5 percent. So if they are
not ready to rate, the claims management process can't proceed
properly.
Mr. Hall. Thank you. We are going to have--since Mr.
Lamborn is not here, we will have the Minority Counsel ask a
few questions. And then we will move along to the next panel.
Mr. Lawrence. Thank you, Mr. Chairman. Many of your
questions were similar to Ranking Member Lamborn's, so I just
have a couple.
For Mr. McGarry and Dr. Shahani, in your testimony you
mentioned that your systems have the capability of managing and
organizing multiple documents.
Veterans claims files, as you know, can be rather
voluminous. They can submit anything they feel is pertinent as
evidence. Would that be problematic to your systems?
Dr. Shahani. When we ran the prototype basically and
scanned c-files, we are able to separate duplicates. We are
also able to separate non-medical from medical records. And so
we don't see that to be a problem. We can build in rules again
to separate out all those different records.
Mr. McGarry. We have files too that stand 6 feet tall
stacked one on top of the other, which is why it is such a must
to have a document--a document management system is such a big
piece of the file so that you can footnote and identify those
documents that are germane to the decision.
Mr. Lawrence. Thank you. And, Mr. McGarry, how long did it
take Unum to establish your system?
Mr. McGarry. It took approximately 3 years.
Mr. Lawrence. And for Mr. Mitchell, you had mentioned
additional benefits that may accrue from more advanced
technologies that can be adopted once the claims are captured
and managed online. Could you elaborate on that just briefly
please?
Mr. Mitchell. Sure. I was primarily thinking of data mining
that collection of benefits claims and how they were ruled on
finally. So if you had that kind of data, you could data mine
that for example to detect the features of the claim that
indicate, for example, that this is likely to require a
particular type of special processing. And to do the kind of,
you know, initial sorting that these gentleman were talking
about.
You could do data mining to detect the features of the
claim that suggest perhaps this should be looked at as a
potential case of fraud or misunderstanding. That is very
common in the insurance industry.
So primarily I was thinking of the--of the uses of that
data in a data mining.
Mr. Lawrence. Thank you.
Mr. Hall. I would like to thank our panel. It is very, very
interesting. You have exceeded my expectations. I don't know
about anybody else, but I trust that these are very exciting
possibilities that you raise. So thank you again for your
testimony, and for your responses to our questions.
This panel is dismissed, And we will ask our third panel to
come forward.
Kim Graves, the Director of the Office of Business Process
Integration of the Veterans Benefits Administration, U.S.
Department of Veterans Affairs, and Stephen W. Warren,
Principle Deputy Assistant Secretary of the Office of
Information and Technology, U.S. Department of Veterans
Affairs.
And if we are lucky, the votes will be held off until after
we hear from our two panelists and ask a couple of questions.
While you are getting settled, I will tell you that within
the last couple of months, our office up in New York's 19th
District resolved a claim for a Navy vet from World War II
which was the most extreme case that I have come across yet.
A man who had two ships blown out from under him in the
Pacific, one by a kamikaze pilot, one by a torpedo. Twice was
floating in the ocean with sharks and body parts floating by
him. Had to be pulled back off the ship by his buddies, because
he kept on trying to rescue more of his shipmates and get them
in the lifeboat.
He has a drawer full of medals for it. He is 84 years old
now, and had been diagnosed as schizophrenic, which of course
is not a service-related diagnosis. With the help of his friend
who happens to be the local Veterans of Foreign Wars commander
of the post that he belongs to, and my staff, and working with
the local VA, and the VSOs in our area, and so on, we corrected
it.
And Sailor Ken McDonald had a happy Christmas with $100,000
of back disability pay, and $2,400 a month, and 100 percent
Post Traumatic Stress Disorder rating, which is evident when
one talks to him about--even all these years after. He was 20
when these incidents happened. Yet today he still shakes and
has a hard time, when you bring it up and ask him about it.
But we can prevent worst case scenarios. I guess the worst
case is, if he didn't live to have the resolution. But
hopefully we can move this all toward a quicker, more efficient
resolution.
And Director Graves, we have your statement--your written
statement is in the record. So you have 5 minutes give or take.
And you are now recognized.
STATEMENTS OF KIM A. GRAVES, DIRECTOR, OFFICE OF BUSINESS
PROCESS INTEGRATION, VETERANS BENEFITS ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; AND STEPHEN W. WARREN,
PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR INFORMATION AND
TECHNOLOGY, OFFICE OF INFORMATION AND TECHNOLOGY, U.S.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF KIM A. GRAVES
Ms. Graves. Mr. Chairman and Members of the Subcommittee,
it is a privilege to be here today to talk about the use of
information technology to enhance claims processing within the
Veterans Benefits Administration.
VBA has made significant strides in the use of information
technology to improve claims processing in all of our benefit
programs.
Our current focus is the development of a comprehensive
strategy to integrate the various initiatives already underway
and leveraging successes already accomplished. VBA is
collaborating with the Office of Information and Technology in
developing this strategy to ensure our mission needs are met
and that the appropriate enterprise architecture is employed.
At the core of our strategy is the implementation of a
business model for compensation and pension processing that is
less reliant on paper documents. The use of imaging technology
and computable data to support claims processing in our
insurance, education and loan guaranty programs has been
successful for many years.
Initial pilot efforts in our compensation and pension
business line have demonstrated the feasibility of using this
type of technology for these benefit programs as well.
Our comprehensive strategy, the Paperless Delivery of
Veterans Benefits initiative, is envisioned to employ a variety
of enhanced technologies to support end-to-end claims
processing.
In addition to imaging and computable data, we will also
incorporate enhanced electronic workflow capabilities,
enterprise content, and correspondence management services, and
integration with our modernized payment system, VETSNET. In
addition, we are also exploring the utility of business rules
engine software for workflow--for both workflow management and
to potentially support improved decisionmaking by claims
processing personnel. A recent request for information (RFI) to
industry yielded a variety of products that may be useful in
our end-state vision.
As part of our strategy for improving the claims processing
business model, VBA recently contracted with IBM to conduct a
study of the current process and suggest improvements. We
expect their report shortly and will assess their findings as
we move forward with documenting our information technology
strategy.
As noted previously, two pilot programs are currently
underway and have demonstrated the utility of imaging
technology in our compensation and pension business line. Both
projects utilize our Virtual VA imaging platform and related
applications. Virtual VA is a document and electronic claims
folder repository.
The first pilot supports our income-based pension program.
It involves imaging documents received in conjunction with the
annual income reporting process.
Imaging allows the three Pension Maintenance Centers to
make the necessary claims adjustments without need for
retrieval and review of the paper claims file.
The second pilot supports the compensation program at our
centralized rating activity sites for our Benefits Delivery at
Discharge program. The separating servicemember's medical
records and supporting claim information are imaged at the
outset of the claims process. This allows rating veteran
service representatives to make decisions based solely upon
review of the imaged records rather than reliance on the paper
claims file.
Further refinements of the business process are now
underway and will be factored in as we evaluate options for
expanding use of this technology.
An additional pilot project is also under development. This
project will examine issues such as user authentication and
using online forms to provide the capability for the initial
``electronic'' filing of benefit claims. This is a first step
in implementing online self-service to allow veterans to manage
some of their interactions with VA electronically.
Integration with VETSNET is also a critical success factor
in our overall strategy. We have made significant progress in
the implementation of VETSNET over the past 2 years.
Approximately 98 percent of all original compensation
claims are now being processed end-to-end in VETSNET. And we
are now paying monthly compensation benefits to more than
850,000 veterans or approximately one of every three
compensation recipients using our modernized platform.
With our next conversion of records from the legacy
Benefits Delivery Network scheduled for April, VETSNET will
become the primary payment system for compensation benefits.
Integration and data exchange with the Department of
Defense are also essential, as is our continued expansion of
exchange of healthcare information with the Veterans Health
Administration.
As we continue to move forward with the efforts described
here, we are focused on developing an integrated project plan,
ensuring the needs of our veterans and their families are
documented and attainable. Demonstrable milestones and
performance metrics will be incorporated so that we and our
stakeholders are able to assess our progress in achieving our
vision.
To assist in developing this plan, we are working closely
with our Office of Information and Technology partners to
develop a request for proposals to engage the services of a
lead systems integration contractor.
The integrator will provide support in documenting both the
business and technical requirements for implementation of our
long-term strategy.
I assure you that the Under Secretary for Benefits is
committed to implementation of the Paperless Delivery of
Veterans Benefits initiative.
Together with our partners in the Office of Information
Technology, we believe this goal is not only attainable, but is
imperative to ensure the best possible service to our Nation's
veterans.
We thank you for the opportunity to address these important
issues and would be happy to address any questions that you may
have. Thank you, Mr. Chairman.
[The prepared statement of Ms. Graves appears on p. 78.]
Mr. Hall. Thank you, Ms. Graves.
Mr. Warren, you are now recognized for 5 minutes.
STATEMENT OF STEPHEN W. WARREN
Mr. Warren. Mr. Chairman and Members of the Subcommittee, I
would like to thank you for the opportunity to testify today on
the use of information technology to enhance claims processing,
within the Department of Veterans Affairs, as well as utilize
data from the Veterans Health Information Systems and
Technology Architecture or VistA system to assist in the
processing of disability claims. These are very important
issues that affect the life of every veteran and their just
compensation for disabling injuries received while serving our
Country.
I would like to begin by addressing VA's efforts at
leveraging information technology to improve the timely
delivery of veterans' benefits. The Office of Information and
Technology has been collaborating with the Veterans Benefits
Administration in the development of a comprehensive strategy
to achieve their target business model.
The operational concept of the Paperless Delivery of
Veterans Benefits initiative is to employ enhanced technology
platforms to include imaging, computable data, electronic
workflow capabilities, and enterprise content and
correspondence management services. Some of the same
technologies you heard from earlier panelists.
The initiative will integrate with the Veterans Benefits
Administration's core business application and modernized
payment system, the Veterans Service Network known as VETSNET.
My office also supports the Veterans Benefits
Administration's market research of business rules engine
software and other decision support technologies, which can be
leveraged to improve and expedite decisionmaking by claims
processing personnel.
We recently released a Request for Information from
industry or RFI. This request for information resulted in the
demonstration of technologies that may be appropriate for the
Veterans Benefits Administration's target business strategy.
The request for information process helps us gain a better
understanding of how private industry and other government
agencies have employed these types of technologies to support
their specific business models.
We also have conducted an analysis of technical
architectures, business applications, and Commercial Off-The-
Shelf products, utilized to support the business processes of
the Social Security Administration, as well as the Veterans
Affairs Organization of Australia and Canada.
A Statement of Work is currently being prepared to engage
the services of a Lead Systems Integration Contractor. The
purpose of this contract is to assist with the development of
the overarching strategy and business requirements for the
Paperless Delivery of Veterans Benefits initiative.
These key deliverables will enable us to begin specifying
the supporting technical architecture and business
applications.
Mr. Chairman, I would like--now to highlight how the
utilization of data from the VistA system, the one used by the
Veterans Health Administration, assists in the processing of
disability claims.
The business application used by the Veterans Benefits
Administration to navigate and retrieve clinical data within
the VistA system, is called the Compensation and Pension Record
Interchange or CAPRI. Online access to medical data, housed in
the Veterans Health Administration VistA system, supports the
disability benefits determination.
CAPRI also provides access to some Department of Defense
medical records through integration with the Federal Health
Information Exchange framework. CAPRI was nationally deployed
during fiscal year 2001, and delivered cutting edge ``point and
click'' technology to the users' desktop at that time.
Since its deployment, the application has been repeatedly
enhanced as new categories of clinical data in the Veterans
Health Administration and Department of Defense became
available.
Mr. Chairman, in closing I want to assure you that we
remain steadfast in our efforts to continuously optimize any
and all information technology improvements, as we strive to
improve our veterans' benefits IT environment.
Our goal is that these efforts, coupled with the support of
the Veterans Benefits Administration and our partners in the
private sector, will greatly improve the business processes,
which will significantly enhance the disability claims process
that our Nation's heroes undergo.
Thank you for your time and opportunity to address these
issues. I would be happy to answer any questions you may have.
[The prepared statement of Mr. Warren appears on p. 79.]
Mr. Hall. Thank you, sir.
Ms. Graves, I just wanted to ask you, in November of 2007,
VA testified that it has received $20 million in a supplemental
appropriation for electronic processing initiatives.
When this Subcommittee asked about IT expenses, we were
given an analysis that showed that VA spent approximately $300
million on VETSNET since 1986. With all that time and money,
how is it that we still do not have a system that satisfies
veterans' claims processing needs?
Ms. Graves. Thank you, Mr. Chairman. Moving to the VETSNET
environment, off of our antiquated and outdated payment system
has been a paramount concern to the Veterans Benefits
Administration.
The actual software development component of VETSNET began
in 1996. And it has taken us a significant amount of time to
make these accomplishments.
Over the past 2 years, Under Secretary Cooper instituted a
variety of changes to include restructuring the overall
management of the VETSNET project. We believe that the progress
that we have made demonstrates that we have learned some very
significant lessons in how to better manage the business
process of IT development.
We hope to bring to bear these lessons learned as we move
forward with our next initiative, which is that next step in
bringing a paperless environment to the Veterans Benefits
Administration.
Mr. Hall. It sounds like your current plan to make the
system paperless means that the rater does the same things with
the screen that they did with the paper record unless I am
mistaken.
What is the plan to make an electronic record computable so
that data can be mined, matched, and manipulated?
Ms. Graves. There are a number of efforts that we will have
to address with our information technology partners.
I think as you heard in the prior panel, some of the issues
that we must contend with deal with the records of veterans who
may have exited the service many years ago. Many of these
documents are handwritten.
This presents a number of challenges in turning that into
computable data. We will be looking at all of our opportunities
for moving forward from a paper environment, whether it is
images, computable data, all along the spectrum, to enable us
to better utilize the data in support of claims processing.
I think as you heard from the panels before, the rating
process in and of itself is significantly difficult. There is
much human judgment that must be applied. It is not only a
matter of determining a level of disability, but making a
judgment as to whether the disability itself was incurred in or
aggravated by service.
So there are a number of factors that must be brought to
bear. And as we work with our IT partners, we will be looking
for all of the opportunities that we can utilize to facilitate
bringing this to a more streamlined process.
As we mentioned in the testimony, IBM Global Services has
been with us for the past number of months conducting a study
of the claims process. We are anxiously awaiting their findings
to help us look at the business model itself and match that up
with technologies that are available to improve the claims
process.
Mr. Hall. Thank you. The VA already has Veterans Online
Application (VONAPP) so that veterans can file online. So, I am
wondering what would be the purpose of an additional pilot
project you mentioned to study this capability if the capacity
already exists, or are they dissimilar?
Ms. Graves. The current VONAPP process that we have is an
online application. The veteran can fill in the application, by
typing in their information in the application. They can either
email that document, that application into us, or mail it in
hard copy.
In either case, we accept the application. We must also go
out and get a physical signature from the veteran. Regardless
of whether they have submitted it online, we must have the
signature.
And also in its current form, the information that we
receive on the veteran's application is re-keyed into the
claims processing system.
The pilot that we are working with our IT partners on will
take the next step, and hopefully begin to utilize fillable
forms, computable data, and also explore our ability to accept
an electronic signature as we move forward with the appropriate
business process that will allow us to accept that online
signature.
Mr. Hall. Thank you, Ms. Graves. Mr. Warren, what is the
Under Secretary for Benefits' commitment to fully instituting
an automatic claims processing system? What has he done in 6
years, in your opinion, to get to this goal, and why has it
taken so long with so few results?
Mr. Warren. Mr. Chairman, I probably should caveat my
remarks with stating that I have only been at the VA for the
last 9 months. So I can only give you my observations for the
last 9 months.
Mr. Hall. That is good.
Mr. Warren. The commitment that I have seen by our partners
in the Veterans Benefits Administration is a commitment to make
the dramatic changes necessary to go forward.
And I think one of the things that it is good to keep in
mind as we talk about how do you take an old paper-based system
and move it into the nirvana, if you will, or at the punch of a
button it makes a determination, there are many steps you need
to go through. And some of them were touched upon.
It is moving from paper data to electronic data. It is
moving to electronic data that is computable. It is utilizing
workflow tools or technologies that allow you to move the
information to the appropriate folks.
Then there is the need for tools that assist in the
determinations up to the point where maybe you can have a
tentative determination. And then somebody having to look at
it. Each one of those things take time, especially with a
consideration for what are the rules that the organization has
to follow?
And the Department, through the Veterans Benefits
Administration, is looking at those rules and trying to
understand what does it take to automate those rules and are
there limitations in the rules themselves?
As an example, our colleagues in the Australian Veterans
Administration went through this process themselves. And
working with their legislature, it took them 4 years from going
to ``we want to do this'' to, ``how do we need to change the
rules?'' How do we need to make the rules actionable, so we
actually can use automated tools to make the determinations?
So I would love as a veteran for it to be easy. However, we
have complex rules and complex systems that need to be taken
forward through a deliberative process so we don't mess it up
along the way, sir.
Mr. Hall. Some of our previous panelists suggested, coming
from their private sector positions, their view was that a
system like this could be developed in 6-9 months. Do you think
that is accurate? I don't mean completely dialed in and have
all the data entered into it, but to have the actual system.
Mr. Warren. And to give you a sense in terms of how quickly
you can do things, prior to the Department of Veterans Affairs,
I was the Chief Information Officer at the Federal Trade
Commission. And we brought on the Do Not Call Registry in 100
days. So you can do complex things quickly. But the National Do
Not Call Registry is actually a trivial effort in comparison to
what it will take to make the system, and the processes, and
the rules that the folks need to use into an automated system.
I wish it was 6-9 months, because then we could get it
done. But it actually is going to take longer once you look at
the complexity of the rules and the ambiguity in some of the
rules. And we will need your assistance and the assistance of
this body as we identify what rules might be too ambiguous for
the utilization of advanced technology to make the
determination.
Mr. Hall. There used to be a VA Office of Seamless
Transition, which has now become a VHA/DoD Outreach
Coordination Office. How has VBA been dropped from the process?
How are veterans, who seem to have a difficult enough time in
getting claims processed, supposed to navigate the system
without this level of support? I guess that could be to either
of you. But----
Ms. Graves. Mr. Chairman, I apologize. But I am not aware
of the change that you have stated.
Mr. Hall. Referred to?
Ms. Graves. Referred to. We can certainly take that
question back and get you a response on that. I apologize for
not having that information.
[The response was provided by VA in the answer to Question
3 from the post hearing questions for the record, which appears
on p. 101.]
Mr. Hall. Well, I will just ask one more. And then turn it
over to Mr. Lamborn for his questions. But I am just wondering
why the Clevelands, Gunnery Sergeant and Mrs. Cleveland, even
though they went through the BDD process and--well, you--were
you here for their testimony?
Ms. Graves. Yes, sir.
Mr. Hall. Do you--would you hazard a guess as to why it
would take a year to rate and compensate Mr. Cleveland? Or is
this just one of those stories that you hear about where things
fell through the cracks repeatedly?
Ms. Graves. Mr. Chairman, first and foremost, I want to
apologize and did apologize to Mr. and Mrs. Cleveland for the
difficulty that they endured moving through the claims process.
I do not have the specifics on the timeline that Mrs.
Cleveland so eloquently went through. I give you my assurance
that we will be doing that when we go back to the office to
make sure that we have not only addressed any issues that still
may be outstanding. Unfortunately, when we become aware of
cases that in falling through the cracks is such a--it doesn't
do justice obviously to what the family endured.
But certainly as we become aware of these types of
circumstances, we do look at these. And try to make adjustments
where we can to ensure that we put procedures in place to try
to prevent these from occurring in the future.
Mr. Hall. I would guess that maybe we were talking about
the 80-20 or 90-10. And this might be in the 10 or the 20. In
other words, it is the more dramatic instances of evident
disability. Like I have had a couple that my office has dealt
with like the sailor with the two ships blown out from under
him for instance. If one had 80 or 90 percent of the cases
being processed with the computerized, automated system
primarily, and then have the ones that need special care being
diverted to human resources, you would hope that would solve
the problem.
I am just curious it would seem that an automated registry,
a record, right from the word go, would eliminate the many
times they were asked to resubmit, the many times they were
told the record couldn't be found, that there was no ``this or
that'' form or medical report.
So let us all hope that we are after the holy grail here. I
guess my last question to either or both of you is are the
systems that you already have in place and that you are--that
the VA is developing, going to be, or are the people who have
put those in place going to be, open to changing them or adding
things like some of the previous panelists talked about?
Ms. Graves. If I may, certainly one of the lessons that we
have learned in the last couple of years with the VETSNET
initiative that there is a pull from our employees for the
types of technologies that we have been delivering and that we
will continue to deliver.
Our paperless rating process and the benefits delivery at
discharge pilot has also demonstrated from our ratings
specialist, our rating veterans service representatives, that
not only can they rate a claim in a paperless environment, but
they prefer it, at least the ones who have gone through that
process.
That has given us a demonstrated capability that this is
something that can be accepted and will be accepted by at least
a group of our employees.
So we are looking at that process right now on how we can
expand that. And that would certainly, in taking Mr.
Cleveland's case, if, as we expand the BDD process and the
paperless BDD process, when Mr. Cleveland--coming through now,
were in that population, we would have received his paper
records at the time of his discharge. And then imaged them
immediately into the system. So at least that opportunity for a
loss of a record would be certainly greatly mitigated or
diminished.
So we believe that our employees are open. And would
welcome the advanced technologies that are available. And we
are very anxious to set a course that is achievable and to move
forward to a better system for our veterans.
Mr. Hall. Thank you very much, Ms. Graves.
The Chair will now recognize Ranking Member Lamborn.
Mr. Lamborn. Thank you, Mr. Chairman. And this is for
either one of you. Can you give some examples of some of the
types of questions that you expect the IBM study to be able to
answer?
Ms. Graves. Thank you. We have just received a very
preliminary report from IBM. But we are hopeful that the IBM
group will be able to point us in a direction of where we may
be able to improve the process.
I certainly expect that we will hear from IBM some of the
things that we have heard today on the panel. That our reliance
on a paper-based system is detrimental to the overall
efficiency of the process. I am speculating on that. But
certainly we would expect to derive great benefit from IBM's
observations as they have gone and looked at our claims
process.
Mr. Lamborn. Now apart from the rules-making ability or
excuse me the claims adjudicating ability that hopefully will
eventually be realized as a goal. Just in the meantime, it
seems that document management would be a huge benefit. You
know seeing the picture that the Chairman showed of an eight-
inch stack of paper, or we saw something like that on the table
in front of us today.
Is the IBM study looking at that only, or are they going
beyond that? Or what are they looking at again?
Ms. Graves. The IBM study was designed as a comprehensive
review of the compensation claims process. I believe their
charge was to come back with any suggestions that they would
have, whether it is regulatory, legislative, or information
technology that might be brought to bear to improve the claims
process.
The pictures that were shown today and the look, the
physical look at Mr. Cleveland's--the portion of Mr.
Cleveland's records, again, certainly demonstrates that as we
become better able to turn that paper into something that is
easier to manager, easier to keep control of, we can only
speculate that will improve our ability to manage that
workflow.
Some of the technologies that we have been exploring with
our partners in the Office of Information and Technology, we
are looking forward to evaluating how those types of workflow
management and document management tools will enable us to not
only take those paper records and turn them into an image or
some type of computable data, but also to manage the flow of
that information throughout the claims process.
Mr. Lamborn. Now I take it that they are not looking at the
ability to come up with decisions through artificial
intelligence or anything like that. They are not going that far
on the cutting edge, are they?
Ms. Graves. Sir, I would presume that if IBM, in their
review of the process, believes that is a viable opportunity
that they will present that. Their charge was relatively open
to come in and review the claims process and provide
recommendations for improvement. And they were not constrained
on the types of the improvements that they can provide to us.
Mr. Lamborn. And you have seen a preliminary version of
that?
Ms. Graves. Very preliminary. Just a couple of pieces of
it. I have not had a chance to go through it. And it has not
been formally released to the Veterans Benefits Administration
yet.
The only look I got at it was to ask so they could ask a
couple of clarifying questions as they were putting some
touches on their draft.
Mr. Lamborn. Okay. Well I look forward to helping or
learning with you some of their recommendations and helping the
VA as we go forward to make this a better process. Whether it
is just document management or even beyond that into the
processing of claims.
So thank you for what you are doing. And thank you for your
testimony today.
I yield back, Mr. Chairman.
Mr. Hall. Thank you Mr. Lamborn. Ms. Graves and Mr. Warren,
thank you for your testimony and for the work that you are
doing. And I echo the Ranking Member's comments that we are
here to help, and to nudge, and to stir the pot.
And we would love to see a copy of the report as soon as it
is in a presentable enough form that you can share it with us.
The sooner the better. It couldn't happen too fast for us.
We all have veterans in our own districts that we deal with
on a day-to-day basis and our staffs deal with on a day-to-day
basis. And we see, as with the Clevelands here, the cases I
think that get to a Congressional office are the ones that have
had trouble. So we don't necessarily see a scientific sample.
But what we see are the ones where the system failed to
come through in an adequate or in a timely fashion. And that
is, for me, what motivates me, and I think all of us to, want
to cover and take care of our veterans without these problems
arising, and to give them the service that is commensurate with
that they gave to our country.
So thank you for your comments. Thank you for your
conversation with the Clevelands', which I also had. I think
that it is the best thing that we can do as a tribute to them
and to others like them is to continue and speed up this
process of modernizing a system that, as one of the previous
witnesses said, we would not tolerate if it were our own health
insurance.
In private business we have grown accustomed to a higher
standard or quicker standard of technological resolution of
these issues.
So institutional momentum being what it is, we are going to
work together and move into the 21st century with both feet.
So if there are no further statements, no further
questions, I thank you and all the panels. And this hearing
stands adjourned.
[Whereupon, at 4:54 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. John J. Hall, Chairman,
Subcommittee on Disability Assistance and Memorial Affairs
I would ask everyone to rise for the Pledge of Allegiance--flags
are located in the front and in the rear of the room.
I would first like to thank the witnesses for coming today to
appear before the Subcommittee. I know I speak for my colleagues when I
say that we are all extremely frustrated and disappointed when we hear
about 650,000 claims pending and another 147,000 appeals with a delay
of 183 days to process those claims. But looking at this photograph of
an 8 inch paper record held together with rubber bands and marked with
post-it notes, it's hard to imagine that things don't get lost or
missed. This has got to be cumbersome to process.
There is no doubt that we need a better system than rubber bands
and post-it notes and must look beyond the current way VA is doing
business. There are best practices within the scientific community and
in use in the private sector. I thank you for joining me today to
explore those solutions and to broaden our understanding of what is
possible, realistic, and achievable in this technological age.
The current VA claims process is paper intensive, complex to
understand, difficult to manage, and takes years to learn. Training a
rater can take 2-3 years and many leave within 5 years. Experienced
raters can adjudicate about three claims a day taking about 2-3 hours
apiece. This means that if there are 10 people who can rate a claim and
800 claims are ready to rate, then it will take another 80 days to
process those pending claims, which have already been in the system for
several months. This is very labor intensive and in the meantime
veterans are waiting months without compensation while their completed
case sits on a shelf. I find that unacceptable.
Additionally, there have been reports by the GAO, the VA Inspector
General, and the Institute for Defense Analyses (IDA) that explored the
variances in ratings between the Regional Offices and the lack of
inter-rater reliability. The Veterans' Disability Benefits Commission
also found a great deal of subjectivity and inconsistency in the VA
disability claims process.
So how do we solve this?
I've had a lifelong interest in science and was a three-time
National Science Foundation scholar in High School and studied physics
at Notre Dame. So, I find the topic of Artificial Intelligence--or AI--
compelling since it requires the confluence of science, mathematics,
engineering, and physics. In general, the purpose of AI is to make
computer programs--or machines--that can solve problems and achieve
goals. AI software increases speed, improves accuracy, and reduces
costs for many industries and agencies. AI does not replace the human
element, but rather facilitates its availability. There are great
examples of AI in other areas, such as banking and medicine. For
instance, the Veterans Health Administration relies on VistA to help
doctors with diagnosis and treatment. It sends alerts when a patient
needs a flu shot, cholesterol screening, or warns of potential drug
interactions.
AI can be a decision support tool for adjudicating claims too. It
could be used to organize and store data. It could match key words from
a veteran's record to the criteria in the Rating Schedule. It could
prioritize multiple disability issues.
I envision a VA in which a veteran can apply online for benefits,
upload records, exams, and other certificates, which are prioritized
and classified by an expert system that can match the data to the
Rating Schedule criteria and shorten the time it takes to generate a
claim. The electronic template used by the examiner could be associated
with the Rating Schedule, which could also calculate ratings.
Classifiers or key words could easily be matched by the computer to the
Rating Schedule, such as if ``Arm,'' ``Amputation,'' then ``90
percent.''
This would free up the time for Regional Office employees to deal
with the more complicated issues and assist veterans and their families
with their problems. This Subcommittee has often heard that veterans
don't know about or understand their benefits, and that transitioning
servicemembers are not getting all of the support that they need from
the VBA. In this way, VBA staff could be providing more outreach and
ensuring that veterans understand their entitlements and eligibility
requirements for other such programs as Vocational Rehabilitation,
insurance, and special monthly compensation.
I am eager to hear testimony today that will open up the discussion
on information technology and share ideas that can improve rating
efficiency, quality, and accuracy while reducing inconsistencies and
variances in decisions for our disabled veterans who are waiting on a
claim determination.
I look forward to working with Ranking Member Lamborn and the
Members of this Subcommittee in finding real solutions that will vastly
improve the VA claims process. It is unconscionable that veterans are
waiting as long as they are for their earned benefits and that must
end.
Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
Subcommittee on Disability Assistance and Memorial Affairs
Thank you Mr. Chairman for yielding. I would like to welcome all of
our witnesses to the Subcommittee's first hearing of the second
session.
I want to commend you Mr. Chairman for your leadership and
bipartisanship in the previous session and I look forward to working
with you and your staff to find meaningful solutions to improving the
VBA claims processing system and reducing VBA's disability claims
backlog.
I am excited that our topic of discussion today is the use of
artificial intelligence to improve the disability claims process.
As you know Mr. Chairman, this is an idea that my colleagues and I
on this side of the aisle have long supported.
Whether it was in our FY08 views and estimates, or two bills that I
introduced last session, H.R. 1864 and H.R. 3047, we believe that one
way to truly reduce the current backlog and prevent future backlogs is
to propel VA beyond a 20th century paper-based processing system.
VA must create a system where all claims are electronically scanned
and rating board members have access to computerized interactive tools
to assist them in the adjudicative process.
Hopefully the new system will lead to more accurate rating
decisions that are delivered to our Nation's veterans in a timely
manner.
While I envision an important role for artificial intelligence in
the decisionmaking process, I also concur with our witnesses who will
attest that this technology should not, and will not, ever completely
replace claims adjudicators.
A few weeks ago, staff from both sides of the aisle attended a
briefing where VBA laid out plans to move forward with such a system
and I am excited to learn more about those plans today.
This Subcommittee must ensure that this new initiative is fully
funded and completed with the speed and attentiveness that our veterans
deserve.
I am glad that we have representatives from both the private and
academic sectors here with us today.
It is my hope that they will be able to help VA develop some of the
options that are currently available in the private sector.
While I understand that VA has a very large and unique disability
claim system, there are similar systems out there and I would hope that
VA would look at these systems before they re-invent the wheel.
We must improve this system so heroes like Gunnery Sergeant
Cleveland do not have to wait several years to have their claim
adjudicated correctly.
Mr. Chairman I extend my thanks to you and your staff for holding
this hearing this afternoon and I look forward to hearing the testimony
of our witnesses. I yield back the balance of my time.
Prepared Statement of Gunnery Sergeant Tai Cleveland, USMC (Ret.),
Dumfries, VA (Disabled Veteran)
TAI: Mr. Chairman, Ranking Member Lamborn, distinguished Members of
the Committee, thank you for the opportunity to testify before you
today regarding my experiences with the Department of Veterans Affairs
(VA) claims process. My name is Gunnery Sergeant Tai Cleveland (USMC,
Ret.). With me today are my wife Robin and my children, Brittiney and
Rudi. My other son, Tai Jr. could not be with us today. With your
permission, as Robin has most often dealt with the VA on our benefits
and claims issues, I have asked her to deliver our testimony.
ROBIN: Thank you, Mr. Chairman. My husband served his country
proudly for 24 years as a United States Marine, and although we had
many issues with the Department of Defense following his injuries, due
to the subject of the hearing, I will limit my comments to our
difficulties with the VA claims processing system and its impact on our
family. As I am speaking, however, please keep in mind, that a severely
injured servicemember must navigate multiple systems, the Department of
Defense, the Social Security Administration, Medicare and the VA. It is
quite overwhelming to say the least.
Tai was injured in August 2003 during a hand to hand combat
training accident in Kuwait where he was flipped onto his back injuring
his head and multiple vertebras. The resulting damage has left my
husband a paraplegic with chronic neuropathic pain, spasticity and what
is classified as a mild to moderate Traumatic Brain Injury that has its
own set of challenges.
Since Tai's injury I have had to learn the hard way how to navigate
the systems; keeping meticulous records of documents, recording dates
and times of telephone calls, and confirming receipt of anything sent
or hand delivered to Federal agencies. As such, I thought the best way
to convey our situation was to share a timeline detailing our
experiences with the VA.
In June 2005 we attended the Transition Assistance Program (TAP)
class, provided by the Marine Corps and the VA to learn about the
available options. We completed the VA's Benefits Delivery at Discharge
(BDD) process--including the benefits, specially adaptive housing, and
adaptive vehicle program applications--and hand-delivered it with
medical records, MRI compact discs, films, prescription reports, etc.,
to 1722 I Street, Washington, DC.
After having completed his compensation and pension exam, we called
the VA Benefits number at 1-800-827-1000 in November of 2005 and were
advised that the application was incomplete and medical records from
the Military Treatment Facility were needed. I delivered a second copy
of MTF medical records to the DC Office.
A month later, I again phoned VA Benefits to see if the records
were received and was advised that no application was on file. I copied
and redelivered the original application to DC Office.
In January 2006, I made another call to VA Benefits and was advised
that the claim was being reviewed but that medical records were
required to make a final determination. I AGAIN copied medical records
and redelivered to DC Office. I was later told that the housing and
vehicle grant were denied.
When I called in February of 2006, I was told that no determination
could be made because Tai was still on active duty. Additionally, I was
told that no claim was on file for housing or vehicle which are allowed
while on active duty. We reapplied.
In March of 2006, I met with a VA employee at Walter Reed regarding
benefits and our difficulty with the claim. She introduced us to a VA
social worker at Walter Reed who enrolled Tai in the Adaptive Driving
Program at the Richmond VA. We were told to reapply for benefits
because no applications were found. We resubmitted the original
application and completed a new application for Specially Adaptive
Housing, HISA, and Vehicle Grant, but were informed on April 5 that the
applications were denied and advised to reapply yet again.
In June 2006 we were informed by the VA social worker that approval
for the vehicle application was received but she was, ``unable to
locate our application because the clerk failed to separate application
and keep an in-house copy.'' In addition our HISA and Adaptive housing
grants were denied. We reapplied.
Everything was quiet for the next 3 months until October 26, 2006
when we were advised to reapply for vehicle/housing grants since no
official notification of approval was received.
Again in November of 2006 we received verbal notification from the
VA Rep at WRAMC of the latest vehicle and housing denial, and on
December 13, 2006, we were advised to reapply for vehicle and housing
grants and were contacted by VA to verify our address.
In January of 2007, Tai was medically retired from the Marine Corps
and after filing BDD, we assumed we would get his disability check
within a month or so.
In February of 2007, our housing and vehicle grants were approved,
and had supposedly been approved since April of 2006, but the hardcopy
was no longer on file. To date, we have still not received an official
vehicle approval.
In late May 2007 we received verbal notification from the VSO
helping us at the time that the VA was indicating that there was not
enough information on file to rate the claim, and, therefore,
additional information was necessary.
In June, we received notification from the VA of an 80% partial
rating. We were advised that the rating was temporary and additional
information was necessary in order to process the claim. As we were
scheduled to be in Richmond shortly to obtain an adaptive cycle, we
were advised to have Richmond perform the necessary evaluation for
submittal to the Roanoke Regional Office. While at Richmond, I also
inquired about obtaining a vehicle grant hardcopy and contacted the VA
to inquire about Aid & Attendance. I was told that I was not eligible.
In July 2007 we delivered, via express mail, Tai's medical records
from Richmond to Roanoke and sent the VA an email advising that we
still had not received a disability check approximately 6 months post-
discharge.
In August I phoned and emailed VA Benefits again and told them that
despite the temporary rating, we still had no check. I requested direct
deposit information and requested to verify our address.
After having been contacted about our problems by a non-profit
organization, a concerned representative from the VA's Central Office
called in September about the outstanding checks and we were told that
a tracer would have to be placed on the missing checks before
replacements could be issued. I later received a call from the Roanoke
office and was advised that replacement checks were going to be issued.
On October 4, 2007, a VA Representative told us that claim was
being expedited and should be completed by the 14th. We were informed
on the 14th and the 30th that the updated medical report still had not
been received. However, on October 29 we began to receive the
replacement checks for the temporary rating.
At this point in the timeline it is important to note that our
family had now been without our full disability compensation and
benefits for almost 11 months. Our college-aged children were forced to
withdraw from school, and the overall financial strain, frustration
level and emotional toll--in addition to the actual injury--were
crushing.
Finally, on January 7, 2008, after the intervention of Mr. Hall's
Subcommittee and the Wounded Warrior Project, we received a final
rating and back payment totaling thousands of dollars.
As you can see we filed and re-filed, submitted and resubmitted,
medical records, claims forms, applications, and so on, but no one
seemed to be able to track anything, placing additional burdens on an
already overwhelmed family. In our case, only after the intervention of
a Congressional Office and a non-profit organization were we able to
get the benefits Tai had earned. This process should not be this hard.
Today, almost four years later, while we still have a few things to
resolve with our rating and benefits, our family is trying to move on.
Many people have stepped in to help from government agencies to
Congressional offices to non-profit organizations. I am planning to
return to work and school. Our children are returning to school, and
Tai is enrolled in a media careers program for veterans in Chairman
Filner's district. He has been a noted leader in the program and, ever
the Gunny, has even spoken to the Wounded Warrior Project about being a
peer mentor.
However, our purpose in coming here is not only to tell you our
story, but also to let you know that we are not alone. People we know
have had similar problems, and we know there are more out there. We are
hoping that our presence here will help you understand the obstacles
faced by the wounded and their families and inspire all involved to
work together to improve the efficiency of this vital system for the
benefit of those who sacrificed so much for their country.
Thank you and I look forward to answering any questions you may
have.
Prepared Statement of John Roberts, National Service Director,
Wounded Warrior Project
Mr. Chairman, Ranking Member Lamborn, distinguished Members of the
Committee, thank you for the opportunity to testify before you today
regarding the use of technology to improve the efficiency of the
Department of Veterans Affairs claims process. My name is John Roberts,
and I am the National Service Director for the Wounded Warrior Project
(WWP), a non-profit, non-partisan organization dedicated to assisting
the men and women of the United States Armed Forces who have been
injured during the current conflicts around the world. As a result of
our direct, daily contact with these wounded warriors, we have a unique
perspective on their needs and the obstacles they face as they attempt
to transition and reintegrate into their communities.
In addition to my experience with WWP in general and the
Cleveland's specifically, I am a service-connected veteran, a former
veterans service officer, and was most recently a supervisor with the
Houston VA Regional Office where I reviewed claims and became familiar
with a number of significant deficiencies within the system.
In order to fully appreciate the problem, it is important to
understand how the system currently operates. Despite recent advances
in technology common to most businesses, the Veterans Benefits
Administration (VBA) claims processing system is still dependent on a
paper system. Although the VBA can now view electronic health records
transmitted from the Veterans Health Administration (VHA), the ratings
team is still required to print the records and place them in the
veteran claims folder, which are then reviewed page by page by a Rating
Veterans Service Representative.
The current model of the VBA claims processing system has a total
of six separate teams and often, but not always, includes another team
that is dedicated to processing only the OIF/OEF cases. The six main
teams are as follows:
Triage which handles the incoming claims, evidence, and
is charged with maintaining the outdated file cabinet system, which
stores the hard copy paper claims files
Pre-Determination which is charged with the initial
development of all claims for service connected disability.
Rating is responsible for reviewing all available
evidence and determining if disabilities are service related. If so,
the percentage of disability assigned.
Post Determination is responsible for inputting awards
and generating notification letters to the claimants.
Appeals maintains all pending appeals submitted by the
claimants.
Public Contact is charged with the general phone calls
and questions and conducting one-on-one interviews with the veterans,
dependents and survivors.
Files must be hand carried to each of the teams, and any member of
these teams has access to the records at any given time.
Despite the number of people with access and the ease with which a
file may be misplaced, VBA has only one way to locate a claim file once
it is removed from the filing cabinet. An electronic system called
COVERS is available, but is only effective if utilized by the
individual employee. Rather than having access to the file through
electronic means, COVERS requires manual input to identify a specific
location or individual. If this is not done, it is a very time
consuming task to locate one file among all the files that are in the
processing system. For example, in the Houston Regional Office (RO),
there are approximately 200 employees and each person could have up to
30 files or more on his/her desk.
Another challenge is the outdated filing system used to store the
thousands of active files warehoused either at or near each Regional
Office. If a File Clerk or any employee for that matter is not paying
attention and misfiles a claims folder into the wrong cabinet or
drawer, it again becomes a very time consuming and difficult task to
check each and every drawer to locate the missing file.
The Triage team at each RO is also responsible for the intake of
all new claims and all evidence submitted by each and every claimant.
If the file is not easily located, it is placed on search within the
COVERS system, until the file can be located. Because there are so many
teams within the claims processing system, a particular file could be
located within any of the teams at given time. This allows for the
human error factor, which is often why the numerous pieces of vital
evidence are often lost or misplaced and cannot be associated with the
appropriate claim folder.
If a file cannot be located and all avenues have been exhausted to
locate the file, the RO will then take action to rebuild the folder
from scratch. This means that all prior evidence and claims submitted
by the claimant are also lost. The responsibility to replace the
missing evidence or claims is placed on the claimant. The VA will ask
the claimant to submit any copies that he/she may have in their
possession.
In addition, due to the current war on terrorism, VBA is faced with
another challenge. The new challenge is trying to obtain records from
National Guard and Reserve units. Active duty forces obviously do not
file a claim until released from service. Once demobilized a member of
the Reserve or National Guard component is eligible to file such a
claim. If reactivated, however, the Reservist's claim is halted and he/
she takes the medical file with them to the theater.
There is also the large backlog of records requests to the Records
Management Center which houses not only claim folders, but now receives
all service medical records for recently discharged servicemen. Think
of this as a large warehouse of nothing but paper files and an
inadequate staff to locate each and every file or record that has been
requested by Regional Offices across the country.
Another significant issue which can be identified at every Regional
Office around the country is the varying levels of experience with the
Rating Veterans Service Representatives (RVSR). In any given case, you
could take five individual RVSRs and give them the same file and come
up with five different opinions on how the case should be rated.
Although there have been improvements with the implementation of RBA
2000, the current electronic system utilized to rate compensation
claims, the system is far from perfect. The overall ratings decision
including service connection and actual percentage is left up to the
interpretation of the individual RVSR. The gap in varying decisions
nationwide can also be attributed to local policy at each individual
Regional Office. While this has been the case for many years, the issue
has come to a head due to the increased frequency with which this
generation of veterans speak to each other and compare their individual
situations.
Mr. Chairman, unfortunately, these are only a few of the issues
that surround a paper-based system, and situations like that of the
Cleveland's are not unique. Many working groups, Government
Accountability Office reports, and commissions have made
recommendations on this topic. Most recently, the Veterans Disability
Benefits Commission suggested that claims cycle times and accuracy
could be improved by ``establishing a simplified and expedited process
for well-documented claims, using best business practices and maximum
feasible use of information technology.'' While the availability of
well-trained, customer service minded employees cannot be overvalued,
the implementation of recommendations such as these can help to greatly
reduce the complexity of the claims processing system and result in
timely results.
WWP looks forward to working with you and the VA to try to resolve
these problems. Thank you again for the opportunity to testify today,
and I will be happy to answer any questions you may have.
Prepared Statement of Tom M. Mitchell, Ph.D., E. Fredkin Professor and
Chair, Machine Learning Department, School of Computer Science,
Carnegie Mellon University, Pittsburgh, PA
Executive Summary
Claims processing at the Veterans Benefits Administration appears
to be amenable to a variety of improvements through the introduction of
more computerized operations, including the adoption of artificial
intelligence (AI) technologies for rule-based processing, case-based
reasoning, and data mining.
In the commercial sector, insurance claims are routinely processed
online and automatically--Highmark, for example, processes over 90% of
its insurance claims for hospital and physician services automatically,
with no human intervention.
To pick an example familiar to many, commercial software for filing
income taxes (e.g., TurboTax) illustrates how computerization can
improve accuracy, convenience and adherence to regulations when filling
out complex forms and applying complex regulations automatically.
The VA should be able to obtain similar benefits by computerizing
its processing of claims. Much of this benefit can be achieved by
applying well-understood computerized decision-support technologies
that are already in widespread use in the commercial sector. Additional
benefits may accrue from more advanced technologies that can be adopted
once claims are captured and managed online.
More specifically, three types of improvements to VA claims
processing can be expected to follow from the adoption of online claims
processing:
1. Shifting from pencil and paper claims to online claims can
improve the accuracy, efficiency and convenience to veterans in filing
and tracking their claims.
2. Introducing computer software to help interpret these online
claims can improve the productivity of human claims processors, and the
consistency and fairness of benefits awarded by (a) automating the more
mundane and tedious steps in claims processing, and (b) informing human
claims processors of benefits guidelines, typical awards, and similar
past cases relevant to the claim they are evaluating.
3. Capturing the claims and their processing online provides
additional opportunities for continuous and ongoing improvements to
benefits processing, including (a) the use of data mining methods to
predict and to flag new claims that are ``outliers'' likely to require
collecting additional information, require specialized expertise for
processing, etc., (b) the use of data mining methods to identify
veterans who are not filing for benefits they should take advantage of
given their condition, and to encourage them to seek these benefits,
and (c) the use of historical claims and their disposition to help
train newly hired claims processors.
Full Testimony
Chairman Hall, and distinguished members of the committee:
It is an honor to be asked to testify today, and to try to help you
improve the situation faced by the brave men and women of our armed
forces who have given so much on behalf of us all.
My name is Tom M. Mitchell. I have been involved in the field of
artificial intelligence for over 30 years, and am currently a Professor
in the School of Computer Science at Carnegie Mellon University, and
Chairman of the Machine Learning Department. While I can be considered
an expert in computer science and artificial intelligence, I have no
direct experience with the processing of veterans' benefits by the VA.
Therefore, my comments should be interpreted as those of a technology
expert who is not intimately familiar with the VA's claims processing
system.
The Problem and the Opportunity
That said, it is my understanding that we face a problem in the
processing of benefits claims by the VA. I am told that the process of
collecting and processing claims is primarily a manual, paper-based
process in which 19 page claims forms are hand-written, and evaluated
manually by claims processors. I am aware that there is an optional web
interface at the Department of Veterans Affairs website for entering
claims online, but that claims processing nevertheless remains
primarily manual. I understand that in some cases delays of many months
have occurred while veterans await the decision of the VA, and that
recent increases in the number of claims have caused serious backlogs
in processing, leading to undue hardships for our veterans.
In my opinion, we have the technology we need to address and
eliminate this problem.
If we can develop computer software such as TurboTax, which guides
taxpayers as they fill out complex tax forms online, and which then
provides them with instant, computer based application of complex tax
regulations to calculate to the penny the taxes they owe, then I see no
reason why we cannot develop similar software to automate online filing
of VA benefits claims and to automate a substantial fraction of the
processing of these claims.
To get even closer to the nature of the problem faced by the VA,
consider current practices for processing medical claims in the
insurance industry. The Senior Vice President for Health Plan
Operations at Highmark Inc., which is a major provider of health care
insurance in my own state of Pennsylvania, informs me that over 90% of
the insurance claims they receive for hospital and physician services
are processed fully by computer, with no human intervention.
How do they do it? The insurance claim form is received
electronically, and uses industry standard ICD9 codes to describe the
hospital and physician services performed for the patient. The
patient's eligibility is first checked automatically, by consulting a
database describing which patients carry which benefits plans, and
determining which policy was in force on the date the service was
performed. The claim is then processed to determine the payment due,
based on a combination of medical policy requirements, benefits already
received by this patient, the specifics of their insurance plan, and
the detailed information in the online claim form. In essence, the
software is able to decide on the payment due because it contains a
large collection of rules, each one specifying the payment to be made
in some very specific case, defined by the details of the patient's
policy, treatment, and history. The complex policy for determining what
payment is due under which condition is encoded in these rules inside
the computer. Once the software determines the payment due, the payment
is issued automatically, and a record is added to the database to
record this new bit of patient history--both the claim that was filed,
and the outcome of the claim processing. Later, this database is used
in a number of ways that further assist the patient and the insurance
company. For example, by data mining the database, it is possible to
detect that certain patients with chronic medical problems are not
filing claims for medical treatments they should be receiving. In this
case, Highmark can contact the patient to encourage them to seek this
medical care. Highmark and other insurance companies have achieved
great improvements in efficiency and effectiveness of claims processing
by capturing the claims and the benefits policies online, and by
automating the process of applying the policy to the claim.
Can the VA do the same? While the type of benefits claims processed
by the VA might not be identical to those processed at Highmark and
other medical insurers, the two are sufficiently similar that one must
conclude online processing will be of considerable value to the VA. A
thorough analysis is needed to determine exactly which aspects of the
VA claims processing are, in fact, amenable to computer automation, and
which aspects require human judgment. I recommend that this analysis be
performed immediately, and that a report be written that describes each
step in the VA processing workflow, assessing the feasibility of
automating or semi-automating each step. For those steps where human
decision making is required, it may be the case that computer support
for human claims processors could improve their effectiveness and
efficiency, and this should also be examined in the report.
Relevant Computational and Artificial Intelligence Technologies
Processing of online benefits claims may be improved by adopting a
variety of well-tested computer technologies, including several
artificial intelligence technologies that are routinely used today to
support human decision makers. These technologies have been used, for
example, to improve efficiency and effectiveness of medical claims
processing in industry, to provide interactive support to workers in
call centers who must gather information from customers and guide them
to a solution, and to improve efficiency of filing and processing
income taxes. All of these applications, like processing of VA
benefits, involve collecting information from an individual and then
making a decision based on a complex, predefined policy. Some of the
key technologies used in practice in these and similar systems include:
1. Rule based decision aids. Rule-based software systems are
widely used to encode expertise so that computers can apply this
expertise automatically to assist in decision making. Rules are written
in an ``IF-THEN'' format. For example, one fragment of the VA policy
for evaluating claims can be captured in the following rule: ``IF there
has been more than one episode of acute congestive heart failure in the
past year, AND no chronic congestive heart failure THEN assign a
disability rating of 60.'' Although described here in English, such
rules are easily encoded in a computer language, then automatically
applied to data on a benefits form. The VA benefits processing policy
described in its ``Schedule for Rating Disabilities'' is described
primarily as a very large collection of such rules.
2. Case-based reasoning systems. Case-based reasoning systems
provide help to human decision makers such as call center personnel, by
providing them rapidly with historical cases similar to the one they
are currently processing, to help guide them as they process this new
case. In the portion of benefits processing that requires human
subjective judgments to evaluate the level of disability, it may well
be helpful to the claims officer to examine the most similar past
claims, as well as the judgments made in those cases. Case based
reasoning is a technology that can quickly locate and deliver the
relevant past cases from a database containing hundreds of thousands of
historical cases, allowing it to act as an automated assistant to the
human decision maker.
3. Machine learning and data mining. Machine learning algorithms
and data mining systems that apply them to large databases are often
able to discover important statistical regularities in the data that
may not be apparent to a person. For example, large historical
databases of credit card transactions are routinely mined to determine
the features that indicate which future credit card transactions are
likely to be fraudulent. In the VA claims database, data mining might
be used to discover the pattern of features that indicate a claim will
require additional information from the filer of the claim, or that a
particular type of medical expertise will be required to evaluate it,
or too, that the person filing the claim should also seek a particular
additional preventative treatment. Data mining methods are widely used
for applications where large numbers of historical records are
available for computer analysis, from medical outcomes analysis, to
telephone fraud detection, to targeted marketing to customers.
4. Methods for analyzing text and other unstructured data.
Automated processing of information in forms is easiest if the fields
in the form contain well-structured values (e.g., gender is either male
or female, age is always a number). When a field in a form contains
unstructured text (e.g., the description of how you were injured),
automated processing is much more difficult because computers obviously
cannot understand arbitrary sentences. Nevertheless, computer
algorithms are able to extract some structured information from text,
such as identifying names, dates, and locations that appear in the
text. In some cases, this ability to extract certain types of
structured data from text can transform the data into a form more
amenable to automated processing.
Technically, one can envision developing an approach for the VA in
a sequence of stages. The first stage is to get claims online, so that
they can be easily tracked and accessed. The second is to use well-
understood approaches to automating the easy steps in decision making
(e.g., rule-based methods), and to provide interactive decision support
to human claims processors when they must be involved (e.g., using case
based methods to suggest relevant past cases for comparison and
guidance). A third stage is to data mine the claims databases to
analyze to improve claims processing, and to provide better service to
veterans filing claims.
Conclusions and Recommendations
In applications from insurance claims processing to tax filing to
customer help centers, there is a growing and widespread use of
computer-based tools to capture forms online, and to automate some or
all aspects of processing these forms. The VA should take advantage of
this well-developed computer technology, to move its own benefits
processing online, in order to gain a number of likely benefits
including:
1. Shifting from pencil and paper claims to online claims can
improve the accuracy, efficiency and convenience to veterans as they
file and track the processing of their claims.
2. Introducing computer software to help interpret these online
claims can improve the productivity of human claims processors, and the
consistency and fairness of benefits awarded by (a) automating the more
mundane and tedious steps in claims processing, and (b) presenting
claims processors with the past claims that are most similar to the one
they are currently processing, to help guide their analysis.
3. Capturing the claims and their processing online provides
additional opportunities for continuous and ongoing improvements to
benefits processing, including (a) the use of data mining methods to
predict and to flag new claims that are ``outliers'' likely to require
collecting additional information, require specialized expertise for
processing, etc., (b) the use of data mining methods to identify
veterans who are not filing for benefits they should take advantage of
given their condition, and to encourage them to seek these benefits,
and (c) the use of historical claims and their disposition to help
train newly hired claims processors.
Given the urgency of addressing current backlogs in processing VA
benefits claims, the VA should mount an aggressive effort to move its
benefits processing online. Three specific steps can be performed in
parallel to move rapidly toward this goal:
1. Begin immediately a process to move all VA benefits claims
forms into an online database, and to maintain the status of claims
processing and its final disposition. This will be useful for managing
and tracking claims even before processing of claims is automated.
2. Conduct a detailed study of the workflow process used by the VA
to evaluate benefits claims, producing a report that describes each
step in the workflow, and whether and how this step can be automated.
For workflow steps that require human subjective judgments, the study
should describe how computer decision aids can provide support to the
human.
3. Consult with large insurance companies and others who process
benefits claims to understand current best practices and to begin a
process of adopting them where appropriate.
Mr. Chairman, addressing the problem of effective and efficient
processing of benefits claims does not require new technological
breakthroughs--it requires the adoption of current best practices that
are based on well-understood technologies. I hope my remarks are useful
to your deliberations, and I thank you for the opportunity to present
my views here today.
References
1. TurboTax software for automatic completion of tax forms.
Available free online at http://turbotax.intuit.com/
2. Department of Veterans Affairs, Book C Schedule for Rating
Disabilities, available online at http://www.warms.vba.va.gov/
bookc.html#f
Prepared Statement of Randolph A. Miller, M.D., Donald A.B. and
Mary M. Lindberg University Professor of Biomedical Informatics,
Medicine, and Nursing, Vanderbilt University School of Medicine,
Nashville, TN
Overview
1. My comments describe the applicability of Biomedical
Informatics to improving the processes for determining Veterans'
eligibility for disability compensation.
2. Clinical informatics involves information management and
decision making during healthcare delivery. Expert systems, which
utilize artificial intelligence techniques, represent a subset of the
more general decision support techniques and electronic health record
approaches that clinical informatics provides.
3. I generally endorse the findings of the June, 2007 Institute of
Medicine Report, ``A 21st Century System for Evaluating Veterans for
Disability Benefits''. That report lacks adequate detail in some areas
pertinent to clinical informatics. I clarify below how informatics can
make a difference.
4. Clinical informatics can improve both the speed and quality of
disability determinations for U.S. Veterans. The highly acclaimed VistA
and CAPRI systems developed by the Veterans Health Administration (VHA)
and Veterans Benefits Administration (VBA) provide excellent examples
of relevant clinical informatics applications. Future informatics
efforts can help in five important areas by:
a. converting paper-dependent processes to electronic processes
for all stages of disability determination and designating VistA as the
definitive repository for such information, with supporting software
tools such as CAPRI available in whatever venues are appropriate;
b. creating electronic definitions for each of the approximately
700 disability conditions, based on current CFR 38 definitions and
amendments, that utilize standardized terminology for concepts and
findings (e.g., the SNOMED-CT, LOINC, DSM, and ICD terminologies);
c. creating a tracking system that captures electronically all
information relevant to each Veteran's disability determination. The
system would provide VBA raters with a checklist to determine what
documents they require, a method to order necessary tests and
procedures, and a dashboard to indicate the status of each document
needed to complete a review. These would help raters to locate and
retrieve the information efficiently, as well as to determine what
information was incomplete or missing, and limit unnecessary duplicate/
repeated testing that delays disability determinations and increases
costs;
d. creating decision support tools to identify and display
disability-specific patient information to VBA raters in a manner that
allows them to determine easily which disability criteria have been met
or not met, and to recommend appropriate next actions electronically;
and,
e. creating a quality feedback loop using current information to
evolve future practices through ongoing continuous improvement.
5. In matters as important as Veterans' disability determination,
computer-based tools, including ``expert systems'', can serve as
adjuncts to help humans to collect and manage information, but the
tools cannot in any way replace the most important aspects of human
judgment. Present and future computer-based tools will not displace the
talented, experienced people who comprise the present VHA and VBA.
Informatics can help people to work ``smarter'', in order to benefit
Veterans.
6. A key lesson from clinical informatics is that while change can
be beneficial, it can also be disruptive if employees must dramatically
and abruptly alter their work processes. Whatever plan of action the
government adopts to move from current state to a more ideal future,
the plan must be pragmatic, and coordinated to proceed in concrete,
non-disruptive steps. Each step must convey benefits and lay the
foundation for subsequent steps with greater benefits. Changes must be
gradual and familiar to already overburdened employees. This document
describes such scenarios.
Figure 1 illustrates applicability of the above ideas and
principles to various stages of disability determination: definition of
disability, documenting conditions during active military duty,
documentation of health and disability data within the Veterans Health
Administration system; and, determination of disability status by VBA
raters.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
I will describe the applicability of biomedical informatics to the
task of improving the processes and workflows used to determine
Veterans' eligibility for disability compensation. Clinical informatics
involves information management and decisionmaking during healthcare
delivery. Expert systems, which utilize artificial intelligence
techniques, are a subset of the more general decision support
techniques and electronic health record approaches that clinical
informatics provides.
I would first like to place the role of computer-based decision
support tools in proper perspective. As I detailed in 1990 in an
article in the Journal of Medicine and Philosophy,1 for
matters as important as Veterans' disability determination, computer-
based tools, including ``expert systems'', can serve as adjuncts to
help humans to collect and manage information, but the tools cannot in
any way replace the most important aspects of human judgment. If a
patient grimaces and winces while struggling to walk across a room, and
then claims, ``I'm OK, doc'', a compassionate human can correctly
categorize the patient's condition, but an expert system is far less
likely to do so if it only has ``I'm OK, doc'' as the patient
description. Present and future computer-based tools will not displace
the talented, experienced people who comprise the present VHA system.
Nevertheless, the VHA system can achieve significant progress and
efficiency through greater application of electronic information
systems in determining and tracking Veterans' disability benefits. I
generally endorse the findings of the June, 2007 Institute of Medicine
Report, ``A 21st Century System for Evaluating Veterans for Disability
Benefits''. That report lacks adequate detail in some areas pertinent
to clinical informatics. I clarify below how informatics can make a
difference. Clinical informatics can improve both the speed and quality
of disability determinations for U.S. Veterans. The highly acclaimed
VistA and CAPRI systems developed by the VHA provide excellent examples
of relevant clinical informatics applications. I will refer to the
principles and recommendations listed in Figure 1 and explain each.
PHASE ONE--BUILD INFRASTRUCTURE TO AUTOMATE STEPS OF EXISTING
DISABILITY DETERMINATION SYSTEM, TO GAIN EFFICIENCY
The first task is to identify disability-related records and
documents that exist now in paper format and to convert them, whenever
possible, into a standardized, electronically processable format. As
noted in Figure 1, Recommendation 1.2, this involves creating
standardized names for all document types used in disability
determination (there is already a history of being able to do so within
certain segments of the VHA system--see, for example).2 A
review of a sufficient number of existing disability records (paper and
electronic) used to establish (or deny) each disability category for
hundreds to thousands of Veterans would help to create a complete list.
Having specific names for each type of document makes it easier for VBA
raters to find and manipulate them.
In changing to a more electronic disability determination system,
one must be careful to convert almost all routine activities of VHA
raters to being electronically based, with actions analogous to what
they now do with paper. It would potentially be worse--more cumbersome
and slower for disability determinations--if VBA raters had to use both
paper and electronic record systems in processing a Veteran's
application, than to use only one or the other system. If both paper
and electronic systems were in active use, a VBA rater would always
have to check both systems to see if ``missing'' items in one system
are actually not ``missing'', but present in the second system.
The most straightforward way to begin conversion to electronic
processing is to identify where paper records are currently generated,
and where existing VHA software is applicable to creation of electronic
versions of that paper-based information. For all other paper records
that cannot be easily converted in this manner, the document naming
system should be used to label them, and then they should be
electronically scanned to create electronically retrievable records.
Such record types should be scheduled for subsequent projects to
capture them at their source--at time of generation--using future
electronic capture tools analogous to CAPRI. The award-winning CAPRI
system developed by the VHA provides templates that prompt physicians
and other clinicians as they examine a patient for disability
determination, and stores the information in a standard form within the
VHA's VistA electronic medical record system. Recommendations 2.1, 2.2,
3.1, and 4.1 suggest that the DoD, the VHA healthcare providers, and
the VHA disability raters rapidly move toward 100% utilization of the
current version of CAPRI to capture disability-related information as
it is generated, in all situations where CAPRI is applicable.
The next stage of utility for automated systems to enhance VBA
raters' processing of disability claims would be, per Recommendation
1.1, to categorize the criteria required to establish each of the
approximately 700 disability conditions specified in CFR 38 and its
amendments.
To develop electronic criteria for each disability condition would
require human review of the latest version of CFR 38 and amendments for
each condition, and creating: (a) a list of findings, coded in SNOMED-
CT or LOINC, required to be present to establish the disability, (b) a
list of findings, coded in SNOMED-CT or LOINC required to be absent to
establish the disability, (c) a list of findings that help to support
the presence of the condition but which are not required to establish
the condition, coded in SNOMED-CT or LOINC, (d) a list of the document
types (using the standardized document names per Recommendation 1.2)
that are relevant to determination of the specific disability
condition, (e) the list of CAPRI frame identifiers that are relevant to
determination of this specific disability, (f) names for each of the
700 conditions coded wherever possible in ICD, DSM, or SNOMED-CT, and
(g) narrative text that describes the remaining criteria for the
establishment of the specific disability condition that could not be
coded in steps (a) through (c).
Once the electronic identifiers exist for information relevant to
disability determination, including the CFR 38 definitions, the
document names, the finding names, and the CAPRI template IDs, it is
possible to create an electronic tracking system, per Recommendation
4.2, that can indicate for VBA raters which documents and findings are
required to establish the disability, and what the status of each is
for a given Veteran applying for disability. An electronic dashboard
that displays the status and availability of each item of information
could then be constructed. It is possible that aspects of the dashboard
might be shared with the Veterans who apply for disability through the
``my HealtheVet'' web portal created by the VHA.
An adjunct to the above system would expand CAPRI to assist VBA
raters in ordering the best tests and procedures to complete disability
determination efficiently, and to record the reasoning and conclusions
the VBA raters used to establish or deny the specific disability claim.
The recent Institute of Medicine report, ``A 21st Century System
for Evaluating Veterans for Disability Benefits'' (National Academies
of Science Press, 2007; Copyright National Academy of Sciences.
http://www.nap.edu/catalog/11885.html) recommends: ``Recommendation 6-
1. VA and the Department of Defense should conduct a comprehensive
multidisciplinary medical, psychosocial, and vocational evaluation of
each veteran applying for disability compensation at the time of
service separation.'' This should initially be done using the CAPRI
system in its current state, recording the results in a VistA
compatible format for future reference at VHA and VBA.
The above-described steps are somewhat straightforward, and are
within the reach of existing technology, although they require
substantial effort in terms of system development, security and
confidentiality assurance, application testing, training of end users,
and ongoing technical support. The steps essentially comprise a basic
level of automation of the current disability determination process in
a manner that will assist VBA raters in carrying out their work more
efficiently. Once such an infrastructure is established, substantial
enhancements could be made, some of which would involve simple decision
support techniques, and others of which would involve machine learning
and expert system approaches.
PHASE TWO--ENHANCE AUTOMATED INFRASTRUCTURE FOR DISABILITY
DETERMINATION WITH DECISION SUPPORT FEATURES
A number of techniques developed over the past three decades for
clinical decision support 3-10 are relevant to future
enhancements to a VHA/VBA disability determination and documentation
system. At the national level, the VHA has been a major contributor to
clinical decision support through its evolution of the VistA electronic
medical record system. In addition, many talented individuals working
within the VHA and VBA have also made contributions.
One important technological approach is clinical diagnostic
decision support systems,3-6 which can be probabilistic
(Bayesian), criterion-based, or heuristic (``artificial intelligence''
expert systems) 3 in nature. In general, such systems take
as input standardized vocabulary descriptors describing a patient's
condition (such as history, physical examination, or laboratory
findings) and produce as output a ranked list of possible diagnoses and
a suggested approach to determining which diagnoses are present.
A second important ``expert system'' technique relevant to clinical
informatics is natural language text processing.8-10 Using a
target vocabulary of defined clinical terms or concepts, such as
provided by the U.S. National Library of Medicine's Unified Medical
Language System Metathesaurus, or by the SNOMED-CT terminology system
officially endorsed by the U.S. Government, such programs can scan a
``free text'' document, such as a clinical note, and identify which of
the target concepts are present in the document.9 The
utility of such an approach for VBA disability determination has
already been demonstrated by a pilot project to identify spinal injury
related findings from free text disability exam records, and to
correlate those findings with an electronic representation of the
criteria used by VBA to determine disability.10
Finally, ad hoc or heuristic approaches can combine manual
techniques with semi-automated approaches to characterize clinical
domains or conditions.11-12 Such approaches have been used
to derive a standardized vocabulary for patients' problem lists from a
large set of examples in free text,11 and to attempt to
convert information stored in disparate DoD and VHA clinical record
systems from one representation format to the other.12
The recent Institute of Medicine report, ``A 21st century System
for Evaluating Veterans for Disability Benefits'' (National Academies
of Science Press, 2007; Copyright National Academy of Sciences.
http://www.nap.edu/catalog/11885.html) contained the following
recommendations:
``Recommendation 3-1. The purpose of the current veterans
disability compensation program as stated in statute currently
is to compensate for average impairment in earning capacity,
that is, work disability. This is an unduly restrictive
rationale for the program and is inconsistent with current
models of disability. The veterans disability compensation
program should compensate for three consequences of service-
connected injuries and diseases: work disability, loss of
ability to engage in usual life activities other than work, and
loss in quality of life.''
``Recommendation 4-1. VA should immediately update the
current Rating Schedule, beginning with those body systems that
have gone the longest without a comprehensive update, and
devise a system for keeping it up to date. VA should
reestablish a disability advisory Committee to advise on
changes in the Rating Schedule.''
``Recommendation 4-6. VA should determine the feasibility of
compensating for loss of quality of life by developing a tool
for measuring quality of life validly and reliably in the
veteran population, conducting research on the extent to which
the Rating Schedule already accounts for loss in quality of
life, and if it does not, developing a procedure for evaluating
and rating loss of quality of life of veterans with
disabilities.''
The effort to redefine the conditions for which disability
compensation is appropriate should be standards-based (ICD, DSM,
SNOMED-CT, LOINC) as described above. Text-mining and natural language
processing methods could be used to determine which coded terms are
currently used in disability determinations through review of the
thousands of existing electronic disabilty-related VistA and CAPRI
records, and from samples of paper records converted by OCR or direct
typing into electronic format. This review, coupled with the effort to
extend disability criteria as recommended by the IOM Report, could
result in computer-processable ``criteria table'' definitions for each
disability condition that would maximize the objective representations
of each condition (while still retaining free text if necessary to
describe the aspects of human judgment required in each determination).
As previously recommended, the list of document types and procedures
relevant to determination of each disability category, as well as the
orders required to carry out the procedures in VistA, could be added to
an expanded revision of CAPRI.
Once the above representation scheme for each disability condition
was in place, an expert system using the ``criteria table'' approach
could be developed to assist VBA raters in determining the completion
status of each disability determination, and added to a more advanced
version of the previously mentioned dashboard system. The AI-RHEUM
expert diagnostic system,6 developed in part at the U.S.
National Library of Medicine, might be used as a starting point for the
proposed VHA/VBA expert system.
A similar system could be developed for use within the DoD
electronic medical record system, which would employ natural language
processing and expert criteria table methods to identify portions of an
active duty service individual's record that would suggest eligibility
for disability evaluations before discharge from active duty, per the
IOM Report recommendation, ``Recommendation 6-1. VA and the Department
of Defense should conduct a comprehensive multidisciplinary medical,
psychosocial, and vocational evaluation of each veteran applying for
disability compensation at the time of service separation.''
PHASE THREE--CREATE A QUALITY FEEDBACK PROCESS TO ENHANCE AND EVOLVE
THE DISABILITY RATING PROCESS OVER TIME
The recent Institute of Medicine report, ``A 21st Century System
for Evaluating Veterans for Disability Benefits'' (National Academies
of Science Press; Copyright National Academy of Sciences. http://
www.nap.edu/catalog/11885.html) contained the following
recommendations:
``Recommendation 4-2. VA should regularly conduct research on
the ability of the Rating Schedule to predict actual loss in
earnings. The accuracy of the Rating Schedule to predict such
losses should be evaluated using the criteria of horizontal and
vertical equity.''
``Recommendation 4-3. VA should conduct research to determine
if inclusion of factors in addition to medical impairment, such
as age, education, and work experience, improves the ability of
the Rating Schedule to predict actual losses in earnings.''
``Recommendation 4-4. VA should regularly use the results
from research on the ability of the Rating Schedule to predict
actual losses in earnings to revise the rating system, either
by changing the rating criteria in the Rating Schedule or by
adjusting the amounts of compensation associated with each
rating degree.''
``Recommendation 5-1. VA should develop a process for
periodic updating of the disability examination worksheets.
This process should be part of, or closely linked to, the
process recommended above for updating and revising the
Schedule for Rating Disabilities. There should be input from
the disability advisory committee recommended above (see
Recommendation 4-1).''
``Recommendation 5-3. VA should establish a recurring
assessment of the substantive quality and consistency, or
inter-rater reliability, of examinations performed with the
templates and, if the assessment ends problems, take steps to
improve quality and consistency, for example, by revising the
templates, changing the training, or adjusting the performance
standards for examiners.''
Once a fully electronic system was available that both represented
criteria for disability determination electronically, and which
recorded individual Veteran's records in standardized terminologies,
text mining and machine learning techniques could be used to accomplish
the above-mentioned IOM objectives, and to provide feedback for
quality-based evolution of the proposed systems.
BACKGROUND INFORMATION
My own background is that I trained and became Board-certified in
Internal Medicine during the 1970s. For over a quarter century, I cared
for inpatients and outpatients in academic settings, including in
several VHA Hospitals and Clinics. My research over the past three
decades has been in the area of clinical informatics. I was the
founding Chief of the Section of Medical Informatics at the University
of Pittsburgh, and the founding Chair of the Department of Biomedical
Informatics at Vanderbilt. For more than two decades, I helped to
develop and evaluate expert systems for medical diagnosis at the
University of Pittsburgh. After moving to Vanderbilt in 1994, I helped
to develop clinical decision support tools implemented within
Vanderbilt's homegrown care provider order entry (CPOE) system. That
CPOE system improves quality of care, safety, and cost-effectiveness by
giving advice to physicians in real-time as they care for patients.
During my career, I have been Principal Investigator on over $20
million of Federal grants and contracts related to biomedical
informatics. I am currently a member of the Institute of Medicine of
the National Academies of Science. I am a Past President of the
American Medical Informatics Association (AMIA) and a Past President of
the American College of Medical Informatics (ACMI). I currently serve
as Editor-in-Chief of the Journal of the American Medical Informatics
Association (JAMIA). Two of the clinical informatics systems that I
helped to design and build have been disseminated commercially. My
comments above have no direct relationship to those commercialization
efforts, and I have no conflicts of interest in that regard.
REFERENCES
1. Miller RA. Why the Standard View is Standard: People, not
Machines, Understand Patients' Problems. J Med Philosophy. 1990;
15:581591.
2. Brown SH, Lincoln M, Hardenbrook S, Petukhova ON, Rosenbloom
ST, Carpenter P, Elkin P. Derivation and Evaluation of a Document-
naming Nomenclature. J Am Med Inform Assoc. 2001;8(4):379-390.
3. Duda RO, Shortliffe EH. Expert Systems Research. Science. 1983
Apr 15;220(4594):261-268.
4. Miller RA, Pople HE Jr, Myers JD. INTERNIST1, An Experimental
Computerbased Diagnostic Consultant for General Internal Medicine. N
Engl J Med. 1982; 307:46876.
5. Bankowitz RA, McNeil MA, Challinor SM, Parker RC, Kapoor WN,
Miller RA. A computer-assisted medical diagnostic consultation service:
implementation and prospective evaluation of a prototype. Ann Intern
Med. 1989; 110:82432.
6. Miller RA. Medical diagnostic decision support systems--past,
present, and future: a threaded bibliography and brief commentary. J Am
Med Inform Assoc. 1994;1(1):8-27.
7. Aliferis CF, Miller RA. On the heuristic nature of medical
decision-support systems. Meth Inform Med. 1995 Mar;34(1-2):5-14.
8. Tom Mitchell. Machine Learning, McGraw-Hill: New York, NY.
1997.
9. Uzuner O, Goldstein I, Luo Y, Kohane I. Patient Smoking Status
from Medical Discharge Records. J Am Med Inform Assoc. 2008; 15: 14-24.
10. Brown SH, Speroff T, Fielstein EM, Bauer BA, Wahner-Roedler
DL, Greevy R, Elkin PL. eQuality: Electronic quality assessment from
narrative clinical reports. Mayo Clin Proc. 2006; 81(11):1472-1481.
11. Brown S, Miller RA, Camp H, Giuse D, Walker H. Empirical
Derivation of an Electronic Clinically Useful Problem Statement System.
Ann Intern Med. 1999; 131(2):117-126.
12. Bouhaddou O, Warnekar P, Parrish F, Do N, Mandel J, Kilbourne
J, Lincoln MJ. Exchange of Computable Patient Data Between the
Department of Veterans Affairs (VA) and the Department of Defense
(DoD): Terminology Standards Strategy. J Am Med Inform Assoc. e-
published Dec 20, 2007 doi:10.1197/jamia.M2498
Prepared Statement of Marjie Shahani, M.D., Senior Vice President,
Operations, QTC Management, Inc., Diamond Bar, CA
Mr. Chairman, Members of the Subcommittee, thank you for the
opportunity to testify before you today on this important topic of
claims processing. QTC is a nationwide, private provider of medical
examination and medical record services to the medical and disability
communities, including Federal, state and local government agencies;
property and casualty insurance carriers; third-party administrators;
employers--and the claimants they serve. With 580 highly trained
employees located at five strategically placed regional administrative
offices, 35 owned and operated medical facilities in seven states, and
more than 12,000 pre-screened medical professionals, QTC has produced
more than 2.5 million quality medical exams and reports over the past
ten years and pioneered software and technology to ensure quality,
timely, customer-focused and cost effective services for our clients
throughout our 25 years of experience.
QTC Experience with VBA C&P Process
QTC has been a provider of C&P examinations to the Veterans
Benefits Administration (VBA) since 1998. QTC provides medical
examinations to veterans and active duty servicemembers seeking
compensation from the VBA in 12 VA Regional Offices (VAROs) and 40
Department of Defense (DoD) Benefits Discharge Determination (BDD)
sites around the country. After completing the medical exam, QTC
provides a detailed narrative report according to the guidelines of the
VA's Automated Medical Information Exchange (AMIE) worksheets. VA's
rating specialists then use this information along with the veteran's
claim file, or c-file, to adjudicate the veteran's claims. Supporting
the VBA for the past nine years has provided QTC with an in-depth
understanding of the complexity of the activities, nuances and
uniqueness of the VA medical disability examination process, as well as
its challenges.
QTC Developed Software Applications to Support the C&P Process
QTC has applied its experience and expertise in developing
knowledge-based tools and technology, not as the company's primary
purpose, but to facilitate and streamline the work of QTC's medical
professionals and support staff.
Specifically for veterans' C&P medical examinations, QTC has
developed:
A Client Portal--an Internet-based application
specifically designed and written for VA Central Office, VAROs, and
DoD. This application provides VA and DoD with online access to the
status of each case and appointment details along with the exam
results, including the narrative report and diagnostic test results,
and provides the ability to review the progress of any case, review
management reports, case summaries and perform a batch report download
from a secured Internet connection.
A Protocol Engine--A medical exam protocol engine, or
software, that synthesizes multiple VA required AMIE worksheets with
portions of the VA rating schedule (38 CFR, Part 4) into one veteran
specific medical examination form, thereby providing examiners with a
single head-to-toe examination. It organizes the VA requirements into a
form that assures the physician will address each and every medically
claimed condition for each veteran. This software generates a specific
exam protocol based on VA AMIE worksheets and the veteran's claimed
conditions, and it allows for immediate updating to conform to VA
statutory, regulatory and medical changes and quick dissemination to
all providers nationwide.
A Logical Next Step--Organize the Evidence
Secondary to our nine years of experience working with VA, we
acknowledge the complex challenges of the VA medical disability
process--it is like no other disability program we have worked with
previously. In an attempt to provide value-added services, QTC applied
its knowledge and experience to the next step in the C&P process--
specifically simplifying and streamlining the information gathering
process for the rating specialists so that they are able to rate the
veteran's claim in a quality, timely, customer-focused and cost-
effective manner.
QTC developed an Evidence Organizer (patent-pending)--a working
prototype that is an automated rating tool designed to assist the VA
rating specialist and significantly reduce the time to determine a
rating decision. The Evidence Organizer has great potential to help
rating specialists search and find relevant information needed to
determine and rate claims and thus help the VBA facilitate the process
of adjudicating each claim.
Current Rating Process Productivity and Challenges
The rating process begins when a veteran files a claim. The VA
Triage Team identifies the type of disability claim. Then the VA Pre-
Determination Team determines the need for additional information, such
as a medical examination, and gathers the additional records. Once all
the evidence is gathered, the Rating Team reviews the entire contents
of the c-file and rates the veteran's claim, determining entitlement to
benefits and the degree of disability. The Evidence Organizer was
designed to assist the rating specialist in their process of reviewing
the entire contents of the c-file and to assist them in making that
final decision.
Currently, the VA goal for each rating specialist is to rate an
average of 3-4 cases per day. In 2006, QTC interviewed experienced
claims examiners and asked them to break down the process and allocate
time for each step in the rating process, assuming seven claimed
conditions. The four steps of the rating process and allotted times
were:
1. Initial review of the c-file: 20 minutes.
2. Linking the evidence in the file to the claimed conditions: 85
minutes.
3. Determining the severity of the condition and if each is
service connected: 40 minutes.
4. Writing the rating decision: 65 minutes.
The total time to examine a veteran's claim is 210 minutes or 3.5
hours. It becomes evident that a rating specialist cannot meet a target
of 3-4 cases per day in one 8-hour workday. In fact, the actual average
number of cases a rating specialist can process in one day is 2-3
cases.
In 2007, based on QTC's data, the average number of conditions
claimed per veteran was four for C&P cases and eight for BDD cases.
Examples of multiple-claimed conditions include left knee pain, asthma,
low back strain, foot fungus, hearing loss, and depression.
Additionally, reopened claims now account for 54% of all open cases,
and cases are being reopened with additional unclaimed secondary
conditions, such as hypertension, headaches, or scars.\1\
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\1\ Statement of Mr. Ronald R. Aument before the House Committee on
Veterans' Affairs, March 13, 2007.
---------------------------------------------------------------------------
The biggest challenge the rating specialist faces is finding the
medical evidence in the veteran's paper files supporting the claimed
conditions and linking the evidence to the appropriate rating code as
listed in the 38 CFR, Part 4. QTC's Evidence Organizer would eliminate
this challenge, allowing the rating specialist to more efficiently make
the rating determinations. The Evidence Organizer accomplishes this by
creating an organized electronic c-file, providing the rating
specialist the ability to quickly search and review all available
evidence at the click of a mouse. The rating specialist no longer needs
to review the entire c-file over and over again for each claim they are
rating as the Evidence Organizer has organized all the available
evidence for them.
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Potential Impact
The Evidence Organizer decreases the decision time to rate veterans
claims from 3.5 hours to 2.2 hours, a time savings of 37% per decision,
increasing the number of veterans' cases rated from 2 per day to 3 per
day. On an annual basis this would increase the number of claims
decisions per rating specialist to 711 from the current 533, an
increase of 178 decisions per rating specialist or a 33% increase.
Evidence Organizer Process
The Evidence Organizer can be applied to all four steps in the
rating process, decreasing time spent per case file by organizing and
highlighting all medically related information. The Evidence Organizer
works by converting the cumbersome paper-based claim file (c-file) to
create an electronic record or file (e-file). This document management
process begins with a Technician scanning in the c-file and other hand
written documents through the use of Optical Character Recognition. The
software transforms each record into a text searchable digital record.
As additional records become available they are also integrated into
the e-file. At the heart of this process is QTC's core knowledge
database, which is built upon our extensive disability examination
experience supporting the VBA C&P examinations.
The knowledge database identifies, highlights and electronically
indexes all keywords and claimed conditions, for example: diabetes,
asthma, arthritis, as well as any potential claimable conditions
throughout each record, thereby providing the rating specialist with
all possible claimable conditions. Once the e-file has been
established, each record is reviewed to validate the software's
indexing, creating an initial table of contents for the e-file.
The next step involves a Reviewer validating the highlighted
records and linking the referenced medical evidence to the VA rating
requirements in 38 CFR, Part 4. PDF scanned records not compatible with
electronic screening methods (handwritten records) are reviewed page-
by-page by the Reviewer and relevant information is highlighted,
extracted, and digitally indexed and linked to the rating criteria
appropriate for the claimed condition or potentially claimable
condition. Once all the records have been reviewed the software creates
a full and complete e-file with a table of contents listing all claimed
conditions.
Finally, the complete annotated e-file is electronically available
for the VA rating specialist to review and assist in their rating
decision process. The software suite allows the VA rating specialist
to:
Review and search each and every document at the click of
a mouse.
Review all tagged, annotated and associated data.
Add the rating specialist's determination of relevance
with rationale electronically.
Identify, tag and index additional information as
desired.
Document the rating decision made with the referenced
evidence.
Review any additional potentially claimable conditions
Summary
By applying new technologies such as the Evidence Organizer, the
VBA could:
Organize medical evidence.
Reduce routine and repetitive tasks.
Increase accuracy by facilitating cross-referencing.
Link the rating criteria with the clinical annotation.
Scan, index and review all medical records.
Also, The Evidence Organizer will potentially complement RBA-200 or
other existing VBA software and serve as a training tool. With the
current challenges the VBA is experiencing in claims processing, the
application of this technology is essential to improving performance
and efficiently providing veterans with accurate ratings.
Prepared Statement of Ned M. Hunter,
President and Chief Executive Officer, Stratizon Corporation,
Atlanta, GA, (VA State Pilot Study)
Chairman Hall, Ranking Member Lamborn, and distinguished Members of
the Committee, thank you for the opportunity to appear before you
today.
Stratizon Corporation is a veteran owned Software-as-a-Service
company, which has utilized the concepts of artificial intelligence to
successfully design a software platform and application solely focused
on improving the VA's claims processing system.
We have gained valuable insight into the underlying success of
using AI to solve the VA's claims processing system. First, the
technology available in the marketplace is adaptable, flexible,
scalable, proven, and cost-effective. Technology is not to be resisted
but embraced. Second, success will be highly dependent upon the
perspective in which AI solutions are constructed. A true veteran-
centric solution must be constructed through the eyes and situation of
the veteran to satisfy the requirements of the state and Federal
policies and VA systems and not constructed through the eyes of the
multiple government entities to independently present the bureaucracy
to the veteran.
Stratizon applied this perspective in successfully piloting for the
U.S. Navy, three unique web-based ``intelligent'' solutions that
demonstrated how the quality of life for sailors could be significantly
improved by replacing confusing, complicated, paper intensive, and
manually driven enterprise processes with web-based, easy-to-use,
automated, and complete self-service solutions, or what we define as
``intelligent user interfaces'' or ``IUIs''. ``IUIs'' can also be
designed for numerous veteran events such as transitions from active to
veteran status or applications and appeals for VA compensation and
health benefits.
The Commonwealth of Virginia's Department of Veteran Services,
working with the Joint Leadership Council of Virginia representing 32
veteran service organizations, is implementing such a solution called
TurboVetTM. Building on a successful pilot in 2007, the
Governor of Virginia has included funds in his FY 09 budget that begins
on July 1, 2008, for full production. TurboVetTM will
provide Virginia veterans, or an authorized representative, the ability
to log online at Virginia.gov, via a personal computer or device such
as this Apple IPhone, and select an event they need assistance with.
Initially a series of statements and questions regarding their status
or particular event will be presented. Their personal data currently on
file with the state will be retrieved so they may confirm or validate
their data, thus improving data integrity and eliminating redundant
data entry. The system will use embedded decision logic to react
intelligently to their input to continually refresh and display only
the necessary event questions, thus eliminating the frustration of
redundant and unnecessary questions. A list will be displayed of all
state and Federal benefits the veteran has earned with all
corresponding documents spanning multiple agencies required for the
veteran to submit, thus providing a peace of mind to the veteran their
solution is holistic. Each document will then be progressively,
simultaneously, and perfectly auto-populated with the proper data, thus
eliminating data transcriptions errors and numerous processing delays.
Finally, the veteran will have the option to save and print each
document locally and, at their discretion, electronically submit their
data securely to all participating authorities and systems to be
processed and tracked fully and completely.
Virginia's success in using an AI platform is dependent upon the
continued support and cooperation of all parties, both political and
technical. Decisionmakers need to remain committed to this paradigm
shift to the future and must always provide the best institutional
knowledge available to ensure the TurboVetTM
IUITM not only becomes that benchmark of service but also
remains the benchmark. We need technical cooperation between state
agencies to take advantage of TurboVetTM's ability to
seamlessly exchange data with disparate IT systems. We need cooperation
and support at the Federal level. Federal supervisors in Roanoke have
projected that a minimum of 100 days of processing time will be
eliminated when the TurboVet system is implemented at only the state
level. Stratizon foresees few problems in exchanging data between
TurboVetTM and VA systems such as VistA and VetsNet. We
fervently believe there could be significant process cycle time
improvement and extraordinary cost savings at the state and Federal
level if veteran's data at the state level could first be ``pre-
verified'' against recognized ``authoritative'' national VA databases
and then seamlessly exchanged upon claims submission and during the
claims management process. Virginia's goal is to fulfill the vision of
H.R. 3047 and have a claim prepared properly with attached medical
evidence and documentation for electronic submission to Federal
adjudicators for rating, and have those claims calculated fairly,
consistently, and automatically.
In summary, using a properly designed AI system would dramatically
improve the VA claims processing systems by improving the access to
customer solution and service for veterans and their family members,
reducing the costs to the state in staff administration, training, and
paperwork, and improving the accuracy, throughput, and expediency of
claim submissions by the state for VA adjudication.
On behalf of the Stratizon Corporation, I would like to thank the
Chairman and all committee members for this opportunity to be here
today.
__________
In today's world the gathering, administration and management of
employee data has become a serious issue for corporate America. In
particular, when an employee is confronted with a business or personal
life event, the employee is required to provide sensitive personal data
to his or her employer or to corroborate the data the employer already
has on file for the employee. The employer, on the other hand, is under
great pressure and exposure to liability to process the event and the
data surrounding it swiftly, correctly, confidentially and completely.
In most cases, the individual providing the data and the organization
processing the data waste an extraordinary amount of time and energy
ensuring all personal data associated with the event is properly,
accurately and securely processed.
For the individual, incorrect data processing can mean endless
hours of wasted time, frustration, and even financial loss. For the
organization, incorrect data processing means significant and
unnecessary overhead expense due to decreased business productivity and
additional time and materials to correct data errors and to account for
lost data. Ultimately, the corporate liability for improperly or poorly
managing the business or personal life event for the employee is an
unacceptable business risk which can harm the employee/employer
relationship and damage the reputation of the organization.
The solution for this challenge is for enterprises to migrate from
enterprise employer centric solutions to customer employee centric
solutions through the use of open-standards web-based XML technology
and artificial intelligence concepts. Stratizon Corporation has engaged
this vision and has developed an open-standards J2EE technology
platform that creates software applications to display on-screen an
Intelligent User Interface (IUITM).
An Intelligent User Interface (IUITM) is an online
series of questions, consolidated from all the questions from a variety
and multitude of forms and applications pertaining to a specific
business or life event, and embedded with decision logic encapsulating
the major life event, to manage the event for the user by intelligently
responding to that user's input. In conjunction with accessing and
utilizing the user's data stored in the enterprise in multiple and
disparate systems, a complete picture materializes for the use and a
total solution is rendered.
The process begins when a user logs onto a website or access device
such as an Apple IPhone and selects a button that describes the
personal event they are confronted with. The IUITM firsts
presents the data the organization has on file for the user and allows
the user to confirm or change the information. The IUITM
then presents a series of questions regarding the event to gather the
required missing data the organization needs from the user so the
organization can process the event for the user and the organization
This allows the IUITM to quickly complete all steps of
the event process, auto-populate all required documents with the option
to print or digitally sign, and send the data to the enterprise in the
proper format to process the event. The result is a life event
processed simply, correctly and completely. The benefits are the
reduction in human frustration, elimination of paper, event processing
time and administrative data management costs for both the user and the
organization.
These customized intelligent user interfaces become the ``edge of
the enterprise,'' presenting a less bureaucratic image, providing a
less bureaucratic process to match, and providing several advantages.
First, there is a remarked improvement in end user satisfaction and
customer service because solutions have been engineered with a focus on
intelligence event solutions and not just intelligent document
solutions. It is more about the data than the document. This innovative
approach to user-centric design significantly reduces user frustration
and costs by more efficiently and cost effectively integrating,
delivering and managing the entire process and the requisite data,
forms and documents required from end users.
Second, an AI platform delivers better collective ``time to value''
for end users and organizations because it is sophisticated yet simple
in its presentation. By designing a solution from an end user's
``holistic event'' perspective versus an enterprise's ``silo-driven''
perspective, we ensure an event is managed with 100% completeness for
the user and the enterprise.
Third, an open standards XML platform has better flexibility in
working with existing corporate systems. Today's data systems need to
integrate with multiple web servers, application servers and database
server architectures and seamlessly integrate into an organization's
portal strategy. For the enterprise, this means lower cost, easier
scalability, and faster development and delivery of a solution.
In summary, an open standards XML artificial intelligent platform
provides a powerful development environment for rapidly developing and
deploying electronically enabled intelligent user interface
applications to provide the following benefits:
Consumer/Family Benefits
Improves end user productivity and morale
Reduces the pain associated with life-event related
paperwork
Eliminates difficult searches across multiple Web sites
and departments
Reduces need for forms
Ensures the proper data is completed and submitted
accurately and timely
Improves end user satisfaction with organization service
and support
Organization Benefits
Streamlines data and forms processing via the web
Establishes a consistent interface for all forms-based
events
Reduces administrative costs of providing service
Reduces training costs of customer support and service
personnel
Reduces personnel time to manage forms inventory and life
event packets
Reduces redundant data entry by customer support and
service personnel
Improves data integrity for the organization information
technology systems
Reduces process cycle-times
Reduces process re-work through increased data integrity
Provides workflow capabilities
Reduces cost of maintaining and handling supply of paper
forms
Prepared Statement of John F. McGarry, Senior Vice President of
Benefits,
Chief Risk Officer, Unum, Portland, ME
Mr. Chairman, members of the Committee, I'd like to thank you for
the opportunity to testify before you today. My name is Jack McGarry
and I am the Senior Vice President of Benefits and Chief Risk Officer
at Unum.
I am here today to discuss how our technology facilitates claim
management (case management) decisions at Unum.
We process approximately 400,000 disability claims per year and pay
about $4 billion in benefits directly to our insureds and their
families. Most of Unum's claims are governed by ERISA, the Federal law
which generally requires insurance companies to make disability claim
decisions within 45 days. Unum's experience shows that it is possible
to manage high volumes of claims in a timely and accurate manner while
achieving high levels of customer satisfaction. In fact, 93% of our
customers report that they are satisfied with the overall quality of
contact with Unum. Ninety-six percent are satisfied with our timeliness
and ability to respond to their questions. And 97% find us courteous
and respectful.
Technology is an important component of the solution to managing
the volumes and timeframes, as well as our customer service. However,
the decision about a person's ability to work is also informed by in-
depth analysis of pertinent documents and discussions with claimants,
their employers and their physicians in order to assess their ability
and motivation to work.
In the end, the disability determination is a judgment call that
needs to be made by people.
In order to assure that the right people are reviewing the right
claims at the right time, a combination of Unum's technology and people
is necessary. For example, a routine claim may be automatically sent by
the system to one person while a complex claim with multiple diagnoses
may go to another based on a combination of systems and management
decisionmaking. As robust as our systems are, a person does look at
every claim we pay.
Our technology, operated by our people, does the following:
Manages documents
Facilitates workflow
Ensures a complete administrative record, and
Monitors and measures quality and service results
1. First, our system manages documents. Our files can grow to
hundreds--if not thousands--of pages. With our image-based system: All
files are paperless, multiple people can access the same claim at the
same time, and documents are organized and stored in an efficient
manner. This reduces redundancies in workload management. For example a
nurse, a claim payer and a vocational rehabilitation specialist can all
be working on the same file at the same time--even if these people are
located in different parts of the country.
Another efficiency of the system is that our paperless files
can be viewed all at once or electronically ``tabbed'' in different
ways--for example, all the medical data can be viewed using a medical
view of the file. This creates efficiency in that if a doctor needs to
review a file, she is able to view the relevant medical data, and does
not have to review data unrelated to the medical condition unless
necessary. The file can be viewed using multiple other tabs--for
example, the letters can be viewed, financial data, or vocational
information. Thus, the technology frees our people to view only the
data pertaining to the issue they are working on--allowing each claim
payer to focus on critical case management activities.
2. Second, our system facilitates workflow. All information is
electronically scanned into our system upon receipt. The act of
scanning documents as they are received creates an online activity for
the claim payer to review. In our system, every action a person
completes creates another action or follow-up activity. The system can
also trigger an action for someone to review claims and/or contact
customers at key times during the claim management process.
This technology allows for activities and discussion to be
focused on ongoing claim management. With real time access to
information, our team focuses on the document review and discussion
needed to facilitate next steps on the claim instead of recapping
redundant data or gathering additional information that may not add
value to the process. Real time access involves multiple users being
able to access and update the claim file at the same time (parallel
claim processing). It also means that as documents are received via
mail or fax and scanned into the system, they are immediately viewable
by all involved in the claim. For example, a doctor may be writing a
report at the same time a claim payer is checking whether the claimant
is contractually eligible for benefits--the moment the doctor completes
her report, the claim payer would be able to see it in the image based
system and begin working on the medical case as well.
The image based claim management system also contains a
letter-writing function and a letter library so that a claim payer can
write to claimants and their doctors. Addresses populate automatically,
saving the claim payer time. Also, the claim payer can set follow-up
activities so the claims stay on track. An example of a follow-up
activity may be that the claim payer sets an automatic reminder for the
system to let the claim payer know whether requested data has arrived
after a certain number of days.
3. Third, our system ensures a complete administrative record. An
administrative record is important for ERISA purposes as well as sound
claim management. When a claim changes hands between claim payers, all
of the management activities associated with that claim--including
future activities--stay with the claim and are automatically assigned
to the new claim payer. The technology keeps the file together in one
place and minimizes any disruption in service due to a personnel
change. Thus, if a file does change hands, many redundant steps in
getting a new person up to speed on the file and setting direction are
eliminated.
4. Fourth, our system enables us to monitor and measure quality
and service results. Management and our Quality Assurance process
require the ability to review files ``real time''--at the same time
that the claim payer is working on the files. The system automatically
tracks and reports our service times and outcomes.
Because each one of the activities the claim payer does is
scheduled and tracked, we can ensure that the right resources are
applied to the right claims at the right time. Thus, our management and
Quality Assurance teams can provide feedback as the claims are being
managed--as opposed to days, weeks or months later.
We separate levels of disability into those which have shorter
durations--what we call Short Term Disability (STD--6 months or less in
duration)--and those which may be longer term--what we call Long Term
Disability (LTD--may last greater than 6 months)--based on a number of
factors--including experience of the claim payer and diagnosis.
At the initial level, for the shorter terms claims: Our in-take
department reviews each new claim and assigns an ICD-9 (International
Code of Diagnostics 9) diagnosis code. We use the ICD-9 system because
it is a standardized system within the medical community. Using a
standardized system avoids confusion and makes it easy and efficient to
communicate with the claimant's medical team about the condition and
treatment recommendations.
Thus, when a claim is filed, we use a quick assessment--a triage-
type process--to assess the case based on the employee's diagnosis and
other relevant criteria. Our operating standard for short term claims
is that at least 95% of our claims have been paid, denied or pended--
with the status and reason communicated to the claimant--within 5 days
of our receipt of a complete claim.
Long term claims are more complex and as a result require more
extensive investigation and skilled resources. Most of these claims
take longer than 5 days to assess. Thus, the system assigns claims to a
manager based on certain criteria and the manager gives different
numbers of claims to people based on data elements including diagnosis
and the expertise of the claim payer.
For all claims, we may gather information from multiple sources
including the claimant, the employer, the claimant's medical team and
our own medical and vocational resources. There is continuous
communication throughout this process.
After the initial assignment, our technology initiates reports
based on key measures--including diagnosis, generally accepted medical
duration guidelines, and our Unum database information. These reports
can identify claims that need additional work or follow-up, and help
each claim payer to determine what steps to take next.
Let's take a look at how a hypothetical claim may work through the
process. As news reports have widely documented that many veterans
suffer from behavioral health issues, I will use an example involving a
claimant with depression.
In the behavioral health context, our experience shows it is
critical for the well-being of the insured that the benefit specialist/
case manager be proactive and get involved in helping the claimant
return to functionality quickly. Speed, accuracy and quality are
critical, not only for the health and well-being of the claimant, but,
as previously mentioned, because most of our claims are governed by
ERISA, which among other things requires private sector insurance
companies to make disability claim decisions within 45 days. While
there are some provisions which do grant additional time under specific
circumstances, generally speaking we must make our decisions within 45
days.
On the complex behavioral health claim example, on Day One our
Intake Department would set up the claim on the image based system and
scan the documents into the electronic file.
On Day Two the system assigns the claim to a claim payer based on
the ICD-9 code and other criteria.
On days three through five, having access to the file, the claim
payer reviews the specific facts of the claim, including checking
contractual eligibility and determining whether a decision can be made.
A decision to pay could be made, for example, if the person is
hospitalized in an in-patient setting.
If more data is needed, the claim is pended and the claimant is
kept informed of the status. A claim may be pended if relevant medical
information has not been received yet. When that information is
received, a decision is reached by the claim payer or by the claim
payer working with the appropriate clinician or resources through what
we call our ``roundtable process,'' which would include physicians,
managers, and vocational rehabilitation consultants.
In our example, after payment has begun, our system is designed to
proactively identify claims for further attention based on a number of
triggers. If the system identifies these triggers--for example it may
identify a claimant with depression that is either approaching or
passing the timeframe in which recovery would be expected--it schedules
a claim management activity so the right person reviews the file on the
date specified and can initiate or delegate the appropriate activity.
The triggers may be identified based on this claimant's diagnosis and
our own duration management database. The activity may be for a Unum
nurse to call and work with the claimant, for example, ensuring the
claimant is getting the appropriate treatment needed for recovery.
If the claimant's symptoms are still acute at the six week mark, we
would continue to pay and work with the claimant and the insured's
medical team. On an ongoing basis we would stay in regular contact with
the insured and make sure we understand the continued nature and
severity of the condition.
At around the 60-day mark, the claim would be transitioned to a
different claim payer with more in-depth expertise and training in
managing complex claims. This claim payer would again keep in regular
contact with the insured, and would continue to work closely with
medical and vocational resources. If the claimant were hospitalized or
had suffered a severe injury--the claim may be sent to an extended
duration unit, where follow up would be less frequent.
During this phase the following steps could occur:
continued evaluation of the claimant's functional
ability, which could include setting up an independent medical
examination;
in depth assessment of the physical and cognitive
occupational demands of the insured's occupation or other occupations
they may be suited to perform;
vocational assistance, determining any possible
accommodations that could be made so the person can return to work; and
continued partnership with in-house medical, vocational
and management resources as needed.
In summary, the critical data elements associated with specific
claims are identified in short and long term situations and our benefit
specialists and/or nurses are able to focus on the right activity at
the critical time.
Ultimately, technology can facilitate claims handling processes and
decisionmaking by helping ensure that the documents are being reviewed
by the right people at the right time. It can also provide cost
savings. We estimate that since we implemented this system we have
saved 10-20 per cent over the previous system. More importantly, it has
increased claim management effectiveness and allowed us to pay claims
more accurately.
In the end, however, it is the skill of the management and the
people handling the claims, supported by those working with them, who
are responsible for the claim and service to our customers. Through the
time savings and other efficiencies created by technology, each claim
handler is freed to devote more time to interact directly with
claimants and their physicians in building a plan and assessing a
person's ability to return to work.
Disabilities present a complex management challenge because they
are logistically difficult, judgment based and can be emotionally
charged. Technology can help facilitate judgment based decisionmaking
but we don't see it as ever being able to replace people in the claim
management process.
I would like to end by extending an invitation to all of you and
for VA staff to visit Unum and would welcome the opportunity to
continue to be a resource for sharing best practices between the public
and private sectors as you continue to evaluate the disability
adjudication/case management process. Thank you for the opportunity to
testify before the Committee.
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Prepared Statement of Gary A. Christopherson, University Park, MD
(Former Senior Advisor to the Under Secretary for Health and Chief
Information Officer, Veterans Health Administration, U.S. Department of
Veterans Affairs, and Former Principal Deputy Assistant Secretary for
Health Affairs, U.S. Department of Defense)
Chairman Hall and Mr. Lamborn, let me applaud you for holding these
hearings on substantially improving the claims processing systems and
greatly improving how we care for our Nation's veterans. Today's
hearing, ``The Use of Artificial Intelligence to Improve the VA's
Claims Processing System'' is very important in its own right but more
so in how it supports the overall effort toward a truly caring, timely
and effective processing of our veterans' disability claims.
In my testimony today, I will be speaking both to the true meaning
and obligation of ``the duty to assist'' and to the strong enabling
role that artificial intelligence and other decision support tools can
and should play. I will point to the fact that, in the military where
our veterans served, great honor is given to those who deliver ``on
time and on target''.
Why do I believe this is so important? I saw the sacrifice of our
servicemembers and the incurred debt by our Nation when I had the honor
of serving as the Principal Deputy Assistant Secretary of Defense for
Health Affairs. I saw and helped achieve the great potential that the
Military Health System has for truly caring for our servicemembers, our
retirees and their families.
Subsequently, I saw the plight of many of our veterans and the
great obligation of our Nation when I had the honor of serving as the
Veterans Health Administration Chief Information Officer and Senior
Advisor to the Under Secretary for Health. I saw and helped achieve the
great potential that the Veterans Health System has for truly caring
for our veterans. In this latter role, I also had the opportunity to
work with the Veterans Benefits Administration as they explored the
potential for a much better claims processing system.
Most importantly, I had the great privilege of getting to know both
servicemembers and veterans as people providing a great service to our
Nation. I had the opportunity to work closely with organizations
supporting active servicemembers, the Guard, the Reserve, retirees,
veterans and their families.
All this taught me that what the Department of Veterans Affairs can
and should be doing is about the veteran and that everything VA does
should be centered around the veteran. VA should be a truly veteran-
centric system, including its claims processing system. This is not
about claims per se, it is about a veteran who needs the support of the
Nation that he or she served.
This is about strong leadership. This is about effective management
end-to-end. This is about deploying effective technology. Most
importantly, this is about a new process that honorably discharges more
of our obligation and delivers benefits on time and on target to our
veterans.
A New Claims Processing System
Let me start with the claims processing system. If we believe that
veterans are hurting, that we have ``the duty to assist'', and that we
should meet the expectation of being ``on time and on target'', then we
need a new process now. My suggestions for one such proposal and its
rationale are detailed in the footnote at the end of my statement.\1\
Several years ago, I had the opportunity to help advise the
veterans benefits system in its thinking about a new system. I asked
them how many hours of work it takes to process a claim. They said
about eight hours on average. Sadly, this means it takes six months to
a year or more to complete eight hours actual work. That makes no
sense.
What does make sense is a new system operating in real time like we
do with the health care system. When a veteran is hurting and needs
health care, the veterans' health system assists the veteran and
provides care quickly. When a veteran is hurting and needs financial
benefits, the veterans' benefits system does little to assist, forces
the veteran to navigate a large bureaucracy and massive paperwork, and
provides financial benefits only after months or years.
VA staff should come out and welcome the veteran. They should
actively assist the veteran to get everything processed quickly and
correctly. They should be working with the veteran on an ongoing basis
as case managers.
But we also need the continuing support and assistance of the
Veterans Service Organizations. They have played an invaluable role
over the years in trying to support the veteran in a broken system.
Changing the process means giving a veteran the financial benefit
at least as soon as the veteran files a claim with basic evidence
supporting that claim. Real time would mean that VA would receive the
claim and supporting evidence and make the decision on the same day.
That is achievable if we really want to make it happen.
Let's change the assumptions. Let's have VA presume that a veteran
filing a claim with basic evidence supporting that claim is entitled to
the associated benefit a) for the period of one year or b) until VA
completes the processing of that claim [no more than one year],
whichever is shorter. Further, let's have VA begin payments to a
veteran within 30 days of that veteran filing a claim with the
supporting evidence.
But let's also have the VA claims processing system function
better. Within six months, let's have VA institute a new claims
processing system that proactively assists a veteran with his/her
claim. Let's have them produce a temporary or permanent decision
(preferred) within two weeks of a veteran filing a claim with basic
evidence supporting that claim. And, let's begin payments to a veteran
within 30 days of that veteran filing a claim with the supporting
evidence. Further, preferably within six months, let's have VA deliver
the permanent decision within two weeks.
This can be done. It should be done.
Enabling Technology
In my colleagues' testimony, we have heard that the technology
exists today to greatly improve the speed and accuracy of benefits
decisions. Using artificial intelligence or electronic decision support
tools is nothing new. Both government and the private sector use them
every day.
For those who argue benefit claims processing is a much more
complicated and difficult process, I counter that it is not. If you
want to go to the most complicated and difficult process that exists
today, it is arguably health care. Yet, somehow health care has figured
out how to provide care in real time without technology and even better
with technology.
One doesn't even have to go outside the VA system to find real time
systems. The veterans' health care system is just that. Much praise has
been given to the veterans' health system for its responsiveness,
quality and effective use of technology. Today, the veterans' health
care system can access any electronic information in any VA health care
site in real time. With due diligence, this will be even better in the
future. One of my honors was to have both rescued the VistA health
information system and to have set it on the path to an even brighter
future.
To help improve the claims processing system, we even went one step
further. We made the veterans health care information available to the
claims processing system electronically and in real time.
Unfortunately, it doesn't seemed to have sped up claims processing.
Artificial intelligence and human intelligence together can make a
difference. Using health care as an example, we have some of the most
highly trained people in the world providing health care. More and more
we are using less highly trained people as well. More and more, these
talented people rely upon many kinds of decision support tools to help
them be effective. They have real time access to virtually everything
there is to know about a person that can help improve health. More and
more, they have real time access to the most current knowledge on any
particular condition and on caring for the whole person. They are
supported by guidelines and advice on what best will help a person get
healthier.
Sometimes they treat even without full information if that is what
it takes to reduce the misery now. Sometimes they have to gather
information from other physicians across town or across the country.
Sometimes, more often now than in the past, they have all the
information they need to treat within their own health information
system. VA's VistA and the future HealtheVet VistA do just that. Many
public and private sector health care providers' health information
systems do just that.
These health care providers have the decision support necessary to
care for a person in real time. They don't have to wait months or years
to make decisions on how to treat the person in misery today. The
person doesn't have to wait months or years to get help with their
misery.
But, keep in mind that health care did not wait for technology; it
just got better with technology as an enabler. Technology can greatly
enable the claims processing system, but it is only an enabler. For
better claims processing, we don't have to wait for the technology. We
can start reducing the misery today and then do it even better when the
technology arrives.
Leadership and Management
However, getting to a new, veteran-centric, effective claims
processing system with the necessary enabling technology will only
happen if VA leadership is fully committed. This is not going to be
easy, but it is doable.
VA leadership will have to adopt the vision of a system that gets
needed and appropriate support to the veteran in real time, meaning
days and not months or years. They need to lead a claims processing
system that welcomes the veteran at the door (preferably reaches out to
them earlier) and treats the veteran as one who has earned that
welcome. They need to lead a system where the intent is to have the
veteran file a claim and get approval (if appropriate) on the same day.
They need to lead the current staff on how to better use their skills
to help the veteran. They need to demonstrate leadership and work in
partnership with the VSOs on how to make the systems better and on how
the VSOs can continue to assist the veteran during claims processing
and afterward.
But leadership will not succeed without effective management to
make and continue to make all this happen. Not just VA but most of the
Federal Government does not have the management strength. It clearly
doesn't have enough to deal with the level of change we are suggesting
here. For VA, there is good management talent in the veterans benefits
area. VA will need to develop that talent as well as bolster that
talent with strong managers from outside the veterans' benefits system
as well.
Duty to Assist; Expectation to Be on Time and on Target
As I conclude, I am sure that some will argue it is unaffordable or
undoable. Let me suggest not. First, it could well be built into the
$100-$150 billion economic stimulus package moving at this very moment.
Second, let me remind you that when we send our service members to war
we seem to handle the budget. We can and should do no less when they
come home and need our help. That is part of the real cost of
preventing or conducting war.
Today, there is a failure to understand and appreciate the
veteran's plight. Today's claims processing behavior is more like a
castle under siege rather than a home providing compassion, warmth,
help, and sustenance. Contrast that with the veterans' health system
where care is provided in real time with most administrative details
sorted out later. Feel what it is like for a veteran to live in
uncertainty and without support for six months or a year or more. What
if we did that for health care? It would be unacceptable. Protests
would ring in and outside of every care facility. Why do we tolerate it
for benefits determination?
For a better future, the bottom line is this. Change the
assumptions. Change the process. Use the best technology. Care for the
veteran. Meet our obligation--the duty to assist. Deliver on time and
on target. ``The duty to assist'' is an obligation that VA, with regard
to benefits, has yet to honorably discharge. ``On time and on target''
is what we expected of our veterans and what we should expect of VA.
__________
\1\ Economic Stimulus and Duty to Assist Our Veterans
What economic stimulus?
Effective upon enactment, the Department of Veterans Affairs shall:
Proactively assists a veteran with his/her claim,
Presume that a veteran filing a claim with basic evidence
supporting that claim is entitled to the associated benefit a) for the
period of one year or b) until VA completes the processing of that
claim [no more than one year], whichever is shorter, and
Begin payments to a veteran within 30 days of that
veteran filing a claim with the supporting evidence.
Within six months after enactment, the Department of Veterans
Affairs shall institute a new claims processing system that:
Proactively assist a veteran with his/her claim,
Produces a temporary or permanent decision (preferred)
within two weeks of a veteran filing a claim with basic evidence
supporting that claim, and
Begins payments to a veteran within 30 days of that
veteran filing a claim with the supporting evidence.
Why this economic stimulus?
Stimulus is temporary (budget impact), timely and on
target.
Dollars paid to veterans will go directly and quickly
into the economy to cover basic living expense.
Housing foreclosures will be reduced as veterans are able
to stay current on their mortgages.
The misery of our veterans with disabilities and awaiting
a benefits decision will be substantially reduced as the backlog is
essentially eliminated.
The Department of Veterans Affairs will be incentivized
to move as soon as possible to a ``real time'' claims processing
system.
An important symbolic and real step would be taken to
address the needs of veterans with current and future disabilities
returning from Iraq and other wars.
An important symbolic and real step would be taken to
keep the promise to care for our servicemembers when their service
results in disabling conditions. This also has a positive impact on
recruitment and retention.
The Nation would finally be really moving toward meeting
the obligation of ``Duty to Assist''.
Bipartisan support is highly likely.
Prepared Statement of Kim A. Graves, Director, Office of Business
Process
Integration, Veterans Benefits Administration, U.S. Department of
Veterans Affairs
Mr. Chairman and Members of the Subcommittee, it is a privilege to
be here today to talk about the use of information technology to
enhance claims processing within the Veterans Benefits Administration
(VBA).
VBA has made significant strides in the use of information
technology to improve claims processing in all of our benefit programs.
Our current focus is the development of a comprehensive strategy to
integrate the various initiatives already underway, leveraging
successes already accomplished. VBA is collaborating with the Office of
Information and Technology (OI&T) in developing this strategy to ensure
our mission needs are met and that the appropriate enterprise
architecture is employed.
At the core of our strategy is the implementation of a business
model for Compensation and Pension processing that is less reliant on
paper documents. The use of imaging technology and computable data to
support claims processing in our Insurance, Education and Loan Guaranty
programs has been successful for many years. Initial pilot efforts in
our Compensation and Pension business line have demonstrated the
feasibility of using this type of technology for these benefit programs
as well.
Our comprehensive strategy, the Paperless Delivery of Veterans
Benefits initiative, is envisioned to employ a variety of enhanced
technologies to support end-to-end claims processing. In addition to
imaging and computable data, we will also incorporate enhanced
electronic workflow capabilities, enterprise content and correspondence
management services, and integration with our modernized payment
system, VETSNET. In addition, we are also exploring the utility of
business rules engine software for both workflow management and to
potentially support improved decisionmaking by claims processing
personnel. A recent Request for Information yielded a variety of
products that may be useful in our end-state vision.
As part of our strategy for improving the claims processing
business model, VBA recently contracted with IBM to conduct a study of
the current process and suggest improvements. We expect their report
shortly and will assess their findings as we move forward with
documenting our strategy.
As noted previously, two pilot programs are currently underway and
have demonstrated the utility of imaging technology in our Compensation
and Pension business line. Both projects utilize our Virtual VA imaging
platform and related applications. Virtual VA is a document and
electronic claims folder repository.
The first pilot supports our income-based pension program. It
involves imaging documents received in conjunction with the annual
income verification and reporting process. This imaging allows the
three Pension Maintenance Centers (PMCs) to make the necessary claims
adjustments without need for retrieval and review of the paper claims
file.
The second pilot supports the compensation program at the
centralized rating activity sites for our Benefits Delivery at
Discharge (BDD) program. The separating servicemember's medical records
and supporting claim information are imaged at the outset of the claims
process. This allows rating veterans service representatives to make
decisions based solely upon review of the imaged records without
recourse to a paper claims file. Further refinements of the business
process are now underway to identify gaps in the existing system
capabilities which will enhance our understanding as we evaluate
options for expanding use of this technology.
An additional pilot project is also under development. This project
will examine issues such as user authentication and using online forms
to provide the capability for the initial ``electronic'' filing of
benefit claims. This is the first step in implementing online ``self-
service'' to allow veterans to manage some of their interactions with
VA electronically.
Integration with VETSNET is also a critical success factor in our
overall strategy. We have made significant progress in the
implementation of VETSNET over the past two years. Approximately 98
percent of all original compensation claims are being processed end-to-
end in VETSNET, and we are now paying monthly compensation benefits to
more than 850,000 veterans--or approximately one out of every three
compensation recipients--using this modernized platform. With our next
conversion of records from the legacy Benefits Delivery Network (BDN),
scheduled for April, VETSNET will be the primary payment system for
Compensation and Pension benefits.
Integration and data exchange with the Department of Defense are
also essential, as is our continued expansion of exchange of health
care information with the Veterans Health Administration.
In 2001, the Compensation and Pension Records Interchange (CAPRI)
application was developed jointly by VHA and VBA. CAPRI provides VBA
claims processing personnel access to information from the Veterans
Health Information Systems and Technology Architecture (VistA) and that
is used in the development and documentation of disability benefit
claims. CAPRI also provides access to some Department of Defense
medical records through integration with the Federal Health Information
Exchange (FHIE) framework. As part of our vision for the future, we
will eventually move this data directly into our paperless benefits
delivery platform as part of the veteran's ``e-file.''
As we continue to move forward with the efforts described here, we
are focused on developing an integrated project plan, ensuring the
needs of our veterans and their families are documented and attainable.
Demonstrable milestones and performance metrics will be incorporated so
that we and our stakeholders are able to assess our progress in
achieving our vision.
To assist in developing this plan, we are working closely with our
OI&T partners to develop a Request for Proposals to engage the services
of a Lead Systems Integration contractor. The integrator will provide
support in documenting both the business and technical requirements for
implementation of our strategy.
I assure you the Under Secretary for Benefits is committed to
implementation of the Paperless Delivery of Veterans Benefits
initiative. Together with our partners in the Office of Information and
Technology, we believe this goal is not only attainable, but is
imperative to ensure the best possible service to our Nation's
veterans. Thank you for the opportunity to address these important
issues.
Mr. Chairman, this concludes my prepared testimony. I would be
happy to answer any questions you may have.
Prepared Statement of Stephen W. Warren, Principal Deputy Assistant
Secretary for Information and Technology, Office of Information and
Technology, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, I would like to thank
you for the opportunity to testify today, on the use of information
technology to enhance claims processing, within the Department of
Veterans Affairs (VA), as well as utilizing data from the Veterans
Health Information Systems and Technology Architecture (VistA), to
assist in the processing of disability claims. These are very important
issues that affect the life of every veteran and their just
compensation for disabling injuries, received while serving our
Country.
I would like to begin by addressing VA's efforts at leveraging
information technology to improve the timely delivery of veterans'
benefits. The Office of Information and Technology (OI&T) has been
collaborating with the Veterans Benefits Administration (VBA), in the
development of a comprehensive strategy to enable the achievement of
their target business model. The operational concept of the Paperless
Delivery of Veterans' Benefits initiative is to employ enhanced
technology platforms to include imaging, computable data, electronic
workflow capabilities, and enterprise content and correspondence
management services. The initiative will integrate with VBA's core
business application and modernized payment system, the Veterans
Service Network (VETSNET).
OI&T also supports VBA's market research of business rules engine
software, and other decision support technologies, which can be
leveraged to support improved and expedited decision making, by claims
processing personnel. OI&T recently released a Request for Information
(RFI) from industry. The RFI resulted in the demonstration of
technologies that may help support VBA's business strategy. The RFI
process helps VA gain a better understanding of how private industry
and other government agencies employ these technologies to support
their business models. OI&T has also conducted analyses of technical
architectures, business applications, and Commercial-Off-The-Shelf
(COTS) products, utilized to support the business processes of the
Social Security Administration (SSA), as well as the Veterans Affairs
organizations of Australia and Canada.
A Statement of Work (SOW) is currently being prepared to engage the
services of a Lead Systems Integration Contractor (LSIC). The purpose
of this contract is to assist VBA with the development of an
overarching strategy and business requirements for the Paperless
Delivery of Veterans' Benefits initiative. These key deliverables will
enable OI&T to begin specifying the supporting technical architecture
and business application.
Mr. Chairman, I would now like to highlight how the utilization of
data from the Veterans Health Information Systems and Technology
Architecture (VistA) assists in the processing of disability claims.
The business application used by VBA, to navigate and retrieve clinical
data within VistA, is called the Compensation and Pension Record
Interchange (CAPRI). Online access to medical data, housed in VHA's
VistA, supports the disability benefits determination.
CAPRI also provides access to some DoD medical records, through
integration with the Federal Health Information Exchange (FHIE)
framework. CAPRI was nationally deployed during Fiscal Year 2001, and
delivers cutting edge ``point and click'' technology to the users'
desktop. Since its deployment, the application has been repeatedly
enhanced, as new categories of clinical data in VHA and DoD became
available.
Mr. Chairman, In closing I want to assure you that we remain
steadfast in our efforts, to continuously optimize any and all
information technology improvements, as we strive to improve our
veterans' benefits IT environment. Our goal is that these efforts,
coupled with the support of VBA and our partners in the private sector,
will greatly improve the business processes, which will significantly
enhance the disability claims process for our Nation's heroes. Thank
you for your time and the opportunity to address these issues. I would
be happy to answer any questions you may have.
Statement of Raymond C. Kelley, National Legislative Director,
American Veterans (AMVETS)
Mr. Chairman and Members of the Subcommittee:
Thank you for providing AMVETS (American Veterans) the opportunity
to submit our views regarding the use of artificial intelligence in VA
claims processing.
The claims backlog that plagues the Veterans Benefits
Administration (VBA) has been a great concern for veterans, and AMVETS
is pleased to see the Committee on Veterans' Affairs is taking the time
to genuinely study this issue so long-lasting, effective changes can
take place. AMVETS believes the use of artificial intelligence (AI)
could greatly reduce the time involved in processing disability claims.
The use of AI to reduce the amount of data provided to reflect only the
information that is necessary to make timely and accurate decisions is
not a new idea. The government has been using AI to select applicants
for Federal positions and AI is being used in occupational health
services to determine compensation for private and government
facilities. So the question is not can AI be used to assist VA in the
claims process, it is, to what extent can and should it be used?
AMVETS generally supports the idea of using AI to improve the VA's
claims processing system with some reservations. Integrating AI into
the VBA to assist in the disability claims system could greatly improve
the efficiency of the claims process or it could exacerbate the
problems in the current method of adjudicating a claim. The use of AI
would bring about a 100% electronic method of recordkeeping, which
would provide easy access to records at all phases of the claims
process. This would prevent the loss or misplacement of information.
AI has the potential to significantly increase speed and accuracy
during the triage and pre-determination stages of the claims process.
At these points of the process, over and under development of claims
happens all too often. With AI reviewing all of the incoming medical
records, compensation and pension (C&P) exams that need to be ordered
would be identified. This could prevent redundancy in examinations and
ensure all necessary exams are requested and conducted, preventing the
Rating Veteran Service Representative (RVSR) from beginning their work
only to realize that additional C&P exams will be required. The rater
now has the choice of either doing a partial rating, or stopping the
rating, requesting the appropriate C&P exams, and completing the rating
decision when the C&P exams return. Normally, this is a 60 day process.
Disparity in the rating system from one regional office to another
has become a major issue in disability claims compensation. The use of
IA could, if developed properly, provide the rater with the appropriate
diagnostic code for the determination of the percentage of disability
for which a claimant qualifies. This is because AI also has the ability
to recall all diseases and medical conditions and almost
instantaneously compare all of the veterans' conditions against its
database. Because of this, rare diseases and conditions that rating
specialists see infrequently, such as keratoconus, will not be
overlooked. Conversely, AMVETS has a concern that too much reliance on
AI could result in not allowing logic to be used in determining the
qualification of disability, something only a human can provide. So a
line would need to be draw on how much responsibility will be given to
the AI.
However, the level of complexity of the AI would require brings
about concerns on its own accuracy. The AI software would either have
to be able to read hand-written documentation or physicians would have
to type all of their findings. Also, there are certain tests that are
represented in diagram or table form, such as the loss of field of
vision test and the results of audiologist exams. The AI would need to
understand and interpret these types of exams or be able to recognize
their presence and prompt the rating officer to review them. This issue
begs the question, will AI be grandfathered or will it have a starting
point? If there is a grandfather provision, the AI will need to
recognize medical terminology that has a tendency to change over time.
To utilize artificial intelligence properly, the terminology
inputted into the system would have to match the terminology the system
recognizes. This brings to light the inconsistencies between the
checklists contained in the Disability Evaluations Examination
Worksheets used by VA physicians to conduct compensation and pension
(C&P) physical examinations and the criteria contained in 38 C.F.R.,
Part 4, SCHEDULE FOR RATING DISABILITIES. In many cases, the
descriptive words do not match. AMVETS' concerns are that AI software
is not smart enough to provide accurate results when a physician's
report does not exactly match the description of the rating even though
the intent of the report describes the disability and the rating
veteran service officer (RVSR) could interpret the meaning of the
report though logic.
There is a fundamental disconnect between the check list that
prompts physicians on the Disability Evaluation Examination Worksheet
that is used during the Compensation and Pension Exam, and the
description in 38 CFR Part 4 that is used by the RVSR to determine the
percentage, if any, that will be granted to a claimant. For AI to be an
asset to the claimant, the physician's write-up must match the language
used in 38 CFR Part 4. Under the current system of evaluation, a rating
officer can determine the intent of a physician's evaluation.
To receive a 30% disability rating for PTSD, 38 CFR Part 4 states:
Occupational and social impairment with occasional decrease
in work efficiency and intermittent periods of inability to
perform occupational tasks (although generally functioning
satisfactorily, with routine behavior, self-care, and
conversation normal), due to such symptoms as: depressed mood,
anxiety, suspiciousness, panic attacks (weekly or less often),
chronic sleep impairment, mild memory loss (such as forgetting
names, directions, recent events).
A claimant may have these conditions and they may be documented in
the physician's evaluation. However, if the physician states the
patient has some memory loss, rather than listing it as ``mild'' memory
loss, then AI may not discern between the words or phrasing used by the
physician and what it is looking for as it relates to 38 CFR Part 4.
These logical word choices could easily result in the claimant
receiving a lower or no rating for a disability. For artificial
intelligence to be applicable it would be necessary to develop a
Disability Evaluation Examination Worksheet that is based on the
language used in 38 CFR Part 4 so semantics or synonyms would not
reduce or prevent a claimant from receiving disability compensation.
This would be easiest to facilitate on ratings of lost limbs or joint
problems and become more complex when dealing with issues that have
multiple variables such as PTSD or TBI.
Again, AI could greatly benefit VA and the claimants if the system
was allowed to work in all phases of the claims process and the
information received by the system was completely and properly
reviewed. Also, it is important to maintain the ability to intervene
with human logic when necessary.
Mr. Chairman, this concludes my testimony.
Statement of Steve Smithson, Deputy Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Committee:
Thank you for giving The American Legion the opportunity to present
its views on the topic of using artificial intelligence to improve the
Department of Veterans Affairs (VA) claims processing system. As VA's
claims backlog continue to grow, it is important to explore new ways to
utilize advances in technology that VA can implement to adjudicate
benefits claims in a more timely and accurate manner. We commend the
Subcommittee for holding this hearing.
The American Legion welcomes innovative ideas, such as electronic
claims processing and other uses of technology, which will enable VA to
improve the service it provides to this Nation's veterans, especially
in the arena of benefits delivery. We must, however, caution that
automation does not guarantee quality claim development and speed does
not guarantee accuracy or quality of data entry. Moreover, although the
use of such technology might improve the process, it is not a magic
bullet that will fix all the problems that are currently plaguing VA's
disability claims process. Areas such as inadequate staffing levels,
training, quality assurance, accountability, premature adjudication of
claims and other problems resulting from VA's current work measurement
system, as previously addressed by The American Legion in testimony
before the Subcommittee, must be adequately dealt with before any real
improvement resulting from use of artificial intelligence can be
realized. Therefore, artificial intelligence based programs that direct
the development and the adjudication of claims should be published in
the Federal Register so that the public, especially stakeholders such
as The American Legion, can provide written comments.
The American Legion believes that the human element should never be
removed from this equation and we are pleased that various experts that
testified before the Subcommittee on the use of artificial intelligence
in claims processing also agreed with this philosophy. Additionally, it
must also be kept in mind that the bulk of the time and effort expended
by VA in the disability claims process is not in the actual
adjudication or decisionmaking part of the process; rather it is the
part of the process that involves the development of the claim prior to
adjudication. This process involves informing the claimant of the
evidence that is needed to substantiate the claims as well as assisting
the claimant in obtaining the needed evidence, such as military
personnel and medical records, relevant medical evidence (both private
and VA), scheduling compensation and pension examinations and other
efforts necessary before the claim is ready to be adjudicated. Evidence
development can be very time consuming and it is extremely important
that any electronic claims system utilized by VA in the future
adequately address this important part of the process, not just the
actual adjudication of the claim, or any actual improvement in the
current process will be minimal at best.
Mr. Chairman and Members of the Subcommittee, I appreciate the
opportunity to present The American Legion's view on this issue. This
concludes my testimony.
Statement of Kerry Baker, Associate National Legislative Director,
Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
I am pleased to submit for the record, the views of the Disabled
American Veterans (DAV) on the issue under consideration today. In
accordance with our congressional charter, the DAV's mission is to
``advance the interests, and work for the betterment, of all wounded,
injured, and disabled American veterans.'' We are therefore pleased to
support various measures insofar as they fall within that scope.
Regarding the implementation of an electronic claims' processing
system, the DAV is not opposed to VA utilizing a test facility to begin
implementation of such software on an experimental and limited basis.
We will limit our support for this type of project in this manner until
such time as adequate research and testing has been completed that
provides evidence that a massive rollout of such technology is
feasible. Additionally, while we support this novel idea, we caution
Congress not to act in haste whereby legislation becomes law that
imposes on the VA a requirement to implement such technology within a
specific timeframe, especially when the potential technology has not
been sufficiently identified. Imposing too short of a time limit for VA
to implement such a virtual structure will only thwart its long-term
success.
A more reasonable approach would be to enact legislation that
requires VA to submit to Congress a broad and over-arching plan by a
reasonable date outlining the technology identified and the manner in
which such technology will be utilized. Once this plan is complete, the
groundwork will be laid for VA to coordinate with various entities,
i.e., Congress, Veterans Service Organizations, Department of Defense,
etc., in order to begin turning the plan into reality on a larger
scale. The DAV would welcome the opportunity to work with the Agency,
to include any contractors, in order to assist in the development of an
electronic claims process system.
The DAV also feels that using the term ``artificial intelligence''
is inappropriate as it is defined as ``the capability of a machine to
imitate intelligent human behavior.'' \1\ The goal of any form of
electronic claims process should be to automate, and thereby shorten as
much as possible those portions of the claims process that currently
consume the majority of time. Expecting a form of technology to imitate
intelligent human behavior with respect to the decisionmaking process
of VA's benefits delivery system, particularly where evidence weighing
and judgment calls on such evidence are required, appears as an
untenable goal--automation rather than human imitation is the first
logical phase of this undertaking.
---------------------------------------------------------------------------
\1\ Merriam-Webster's Collegiate Dictionary, 10th Ed., Pg 66.,
Merriam-Webster, Inc. Springfield, Massachusetts
---------------------------------------------------------------------------
Contrary to some beliefs, the majority of time spent by VA on
disability claims is in preparing the case for a decision. This
includes receiving the claims by VA, establishing the claim in VA's
current computer systems, and developing the evidence to support the
claim. Evidence development, whether in the form of gathering military
service records from the service department, military records from the
Records Processing Center, private health records, VA health records,
VA or private medical opinions, and stressor verification through the
U.S. Army and Joint Services Records Research Center for claims of
service-connection for Post Traumatic Stress Disorder, consumes the
vast majority of the claims-processing time. Therefore, any viable
electronic claims-processing system implemented with real expectations
of shortening the claims process must focus on all VA functions and
development leading up to the rating decision more so than just the
rating decision itself.
As far as automating functions of the decisionmaking process,
caution must be exercised. Obviously, the first reasonable step in
automating the final decisionmaking process would be to start with
strict fact-based scenarios wherein a set of mandatory fact patterns
equates to a mandatory award of benefits. The DAV believes that any
attempt to go beyond this level of automation in the beginning phases
of implementation, would likely cause more problems than it would
solve. For example, rating decisions are required to contain adequate
reasons and bases that explain to the claimant the purpose behind a
particular decision.\2\ This becomes especially important when VA
denies benefits. Without a detailed explanation of why a claimant is
not entitled to a benefit sought, veterans and their dependents will
have no recourse to correct what may only be minor deficiencies in
their claims. Judgment necessary to communicate this type of
explanation on a case-by-case basis will be inherently problematic for
an automated process.
---------------------------------------------------------------------------
\2\ 38 C.F.R. Sec. 3.103(b)(2006) (``Claimants . . . are entitled
to notice of any decision made by VA affecting the payment of benefits.
. . . Such notice shall clearly set forth the . . . the reason(s) for
the decision. . . .'') (emphasis added).
---------------------------------------------------------------------------
Additionally, any authorizing legislation concerning the issues
herein must be accompanied by sufficient appropriations required to
carry out such authorizations. To do otherwise would be tantamount to
legislation incorporating its own veto.
Ultimately, the DAV believes that proper utilization of technology
has the potential for positive change by yielding the type of
assistance that could bring the VA claims process into the 21st
Century. Nonetheless, to be highly successful, Congress must avoid any
proclivity to view this as a purely VA problem. The VA merely sits at
the bottom of a whirlpool fueled by outside information. Automating the
processes within the VA without automating the processes by which the
VA acquires and assembles its information--information on which its end
product is dependent--will do little to expedite VA's claims process.
We appreciate the Committee's interest in these issues, and we
appreciate the opportunity to present the DAV's views, which we hope
will be helpful.
Statement of Paralyzed Veterans of America
Chairman Hall, Ranking Member Lamborn, members of the Subcommittee,
Paralyzed Veterans of America (PVA) would like to thank you for the
opportunity to present our views on this important issue. PVA
appreciates the efforts of this Subcommittee to address the rapidly
growing claims backlog.
The interest to develop or adapt the necessary programs to help
with claims processing is greater now, than ever before. In recent
hearings Congress has informed the Department of Defense (DoD) and the
Department of Veterans Affairs (VA) that they must accelerate their
efforts toward achieving the long overdue policy of ``seamless
transition.'' In testimony last year the information technology (IT)
specialists reported that it will be at least 2012 before the DoD and
VA medical records will be interoperable. Moreover, this projection of
five years into the future does not take into account unanticipated
problems. As both agencies work toward this monumental goal, we believe
the VA should also continue the development of electronic processing of
claims.
PVA believes that the use of artificial intelligence (AI) in the
processing of claims could help reduce the backlog of claims and
increase the accuracy of the process. AI has been used in health care-
benefits delivery systems of the Federal Government and private
industry for years.
One serious problem recognized by the veterans' service
organizations and other organizations that have examined the claims
process is that many claims are not developed properly. A fully
developed claim presented to the VA can generally be quickly decided.
Using AI to process claims will not necessarily, overcome the problem
of an unprepared claim, nor will it properly process an incomplete
claim. We must acknowledge that the backlog problem starts in the
beginning with proper development completing a claim. This is tedious
and detailed work that must be completed by the veteran filing the
claim for himself or herself, or working with a trained veterans'
service officer. VA employees reported to the Veterans' Disability
Benefits Commission that veterans who were assisted in filing a claim
or appeal by either a VA benefits counselor or a veterans' service
representative filed a better, well-documented claim.
PVA Service Officers receive 18 months of training using electronic
programs, text books, on-the-job observance and final testing. After
completing this program the service officer is usually placed under the
direction of a senior service officer. And yet, this only provides the
basic knowledge necessary to properly prepare a claim. Still, there is
little comparison between a PVA prepared claim and a claim prepared
totally by the average veteran. We believe the VA must direct more
effort toward proper preparation of a claim before it is submitted to
the Rating Veterans Service Representative, (RVSR) for review.
Many examples of the large disparity in compensation awards have
been discussed in hearings during the 110th Congress. It has been
reported that a significant percentage difference exists when comparing
the same disability rating from two different VA Regional Offices
(VARO) in separate states. The use of AI could standardize the final
decision on compensation.
The process of using AI could be integrated into the system in 2-4
years as software is developed. However, it should be carefully tested
and audited as the final product of the system is meant to be an
accurately decided claim. Until that time, the VA will still need
resources and staff. The Independent Budget for FY 2009 estimates the
Comp and Pen service will need 12,184 total full time employees to
address new claims and the claims backlog.
We also recommend that the VA consider expanding the process of
bringing back retired VA claims personnel. This has proven successful
in expediting the processing of claims.
PVA would favor testing the electronic processing of claims in
certain regions perhaps as a pilot program. We would hope that VSOs,
the veterans' community, and the interested parties would be involved
in evaluating the finished product. If a program using artificial
intelligence proves beneficial in accurately processing some types of
claims, we believe this could be a significant step forward for the VA.
PVA would like to thank you for the opportunity to submit this
written statement. We appreciate the efforts of the Subcommittee to
address the important issue of veterans' claims backlog. We look
forward to working with the Subcommittee on this issue during the
second half of this Congress. We would be happy to answer any questions
that you might have.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 4, 2008
Tom Mitchell, Ph.D.
School of Computer Science
Machine Learning Department
Carnegie Mellon University
5000 Forbes Ave.
Pittsburgh, PA 15213
Dear Dr. Mitchell:
In reference to our Subcommittee hearing on the Use of Artificial
Intelligence to Improve the VA Claims Processing System on January 29,
2008, I would appreciate it if you could answer the enclosed hearing
questions by the close of business on March 4, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
The Use of Artificial Intelligence to Improve the VA's Claims
Processing System
Tom M. Mitchell, Ph.D.
United States House of Representatives
Committee on Veterans' Affairs
Subcommittee on Disability Assistance & Memorial Affairs
Hon. John J. Hall, Chairman
April 2008
Question 1: If VA were using the technology you described, how many
days could it take VA to rate a case given that some claims have upward
of 10 conditions per claim?
Response: The computer technology I describe executes very quickly
on the computer, similar to the speed of TurboTax, which calculates
taxes in a few seconds despite the complex Tax Code. Therefore, the
number of days it would take the VA to rate a claim would be determined
not by the computer technology (whose processing would only require
seconds, not days), but instead by the delays it faces in collecting
the data on which these decisions are based. In our round table
discussion, the VA asserted that it faces large delays in pulling
together the information required to rate a claim. Perhaps that delay
could also be reduced by technology that maintains online a record of
which information is in hand, and which is still to be obtained.
Question 2: How complex is this type of technology and how long
would it take to create such a system?
Response: A prototype expert system, similar to TurboTax, could be
implemented and ready for test deployment in a matter of months, not
years, given a relatively small team of fewer than a dozen experts in
this technology. Of course the full time-to-deployment includes more
than the time needed to develop the software itself. It also includes
the time it would take to make organizational changes to adopt the
software, to train people on how to use it, etc. I do not have
sufficient information to estimate the speed at which the VA could
adopt the software once it was ready, so I will leave that part of the
question to others.
The timeline I would recommend for introducing such expert systems
to the VA would involve (1) develop a prototype expert system to be
used initially by only a small subset of the people who rate claims.
This team of raters should work closely with the software team who are
developing the expert system, to provide them with feedback about the
user interface and functions, and to create a rapid re-design cycle in
which the prototype software is developed, tested, refined, retested,
refined again, etc. In this way, the VA users can have a strong voice
in the design of the software that they will want in the end to use.
(2) once a small team of VA raters have gone through this cycle, they
can become the advocates to help spread this technology inside the VA,
and to help train others on how to use it, and why it will be helpful.
I expect the first step can be completed in about a year.
Question 3: If VA could ``data mine'' as you have suggested, and
reduce the mundane tasks staff currently perform, could the computer
also send employees alerts to notify veterans of other benefits that
they may not have applied for or may not be aware exist?
Response: Yes, and in fact my contacts at Highmark Blue Cross tell
me they use data mining of their own medical claims in precisely this
fashion, for example to alert patients with chronic medical conditions
of services that similar patients take advantage of, but which they are
not filing for. The key idea here is this: data mining provides a
computer-based approach to discovering regularities across many
benefits claims. For example, one regularity might be ``if veterans who
file for compensation for loss of a leg, typically also file for a
wheelchair.'' Such a regularity can be automatically tested for each
new claim, to determine whether it applies to this claim, and if so to
alert the filer of the claim. Of course this is a simple rule, but the
fact is that there can be hundreds or thousands of such regularities,
and the data mining system can both discover these regularities and use
them to send email alerts to veterans when relevant.
Question 4: What would the cost be associated with implementing and
operating such a system?
Response: I am not certain of the answer to this. My advice would
be to consult with one of the software companies that has already
developed similar software for medical insurance companies. They would
have much more expertise than I to answer this question.
Question 5: You recommend that VA study the use of automation. What
aspects of it do you foresee included in such a study? How long should
such an analysis take?
Response: I do recommend the VA seriously study the use of
automation. It is clear that automation can be helpful, so I doubt that
in and of itself is the right question. The appropriate question is
instead ``which aspects of VA benefits can/should be automated or semi-
automated?'' Surely some simple steps (e.g., sending reminders to
veterans that we are still waiting for information X to finalize the
claim) can be automated. Other steps--those requiring substantial human
judgment--might not be amenable to full automation. But even these
steps in the workflow might be improved in accuracy and efficiency by
computer assistance. One example is that when a human rater is
considering a difficult case, the computer could retrieve and present
the five most similar claims out of the many thousands that had been
processed in the past. This is a use of computers to support human
decisionmaking, and is what I referred to as case-based reasoning.
More broadly, I believe the VA should consider introducing (1)
fully electronic claims records coupled to the electronic medical
reports for the veteran, (2) expert systems technology for automated
and semi-automated processing of claims, (3) case-based reasoning
systems to assist human claims processors by presenting the most
similar historical claims, and (4) data mining systems that can
discover regularities in historical claims and can spot new claims
determinations that appear anomalous with respect to this historical
precedent.
In our round table discussion, I was surprised to find how little
the VA has apparently studied this issue in the past, and even more
surprised to see how little has come out of such ``studies.'' In my
opinion, the kind of ``study'' the VA should do is not merely a study
that produces a written document. Instead, it should do a study
centered around active experiments that introduce computer technology
in specific, limited, experimental ways, and the study should report on
the experiments and the results. Such a study need not take years to
complete--it should take months instead. Why not run a study that
introduces each of the four technologies I suggest above, each in a
limited way with a limited number of claims processors participating.
If this were done, then a year from now we'd understand what really
works, what really doesn't, and where the surprises lie. Studies that
just involve thinking without experimenting are less likely to produce
truly useful insights.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 4, 2008
Randolph Miller, Ph.D.
Professor, Former Chair
Department of Biomedical Informatics
EBL 416
Vanderbilt University School of Medicine
2209 Garland Ave.
Nashville, TN 37232-8340
Dear Dr. Miller:
In reference to our Subcommittee hearing on the Use of Artificial
Intelligence to Improve the VA Claims Processing System on January 29,
2008, I would appreciate it if you could answer the enclosed hearing
questions by the close of business on March 4, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Response to Questions from the Honorable John J. Hall
Chairman, Subcommittee on Disability Assistance and Memorial Affairs
U.S. House of Representatives
Hearing on the Use of Artificial Intelligence to Improve VA Claims
Processing System
From: Randolph A. Miller, MD of Vanderbilt University Medical Center
Composed February 28, 2008 for March 6, 2008 Meeting
Question 1: The VA does three things when it adjudicates a claim:
1) it establishes there is a diagnosis; 2) it connects the diagnosis to
the Veteran's time in the service; and, 3) it rates a level of severity
of the disability. Do you think that the VA could use rule-based expert
systems or some other application to complete these functions in
assessing disability?
Response: The short answer to the question is yes, the VA could use
expert systems technology to improve the speed and quality of VBA
disability claims processing. Nevertheless, the current, predominantly
paper-based methods of claims processing must become more automated
before it is even possible to consider use of expert systems. Such
expert systems require accurate and detailed electronic records as
input data in order to be effective.
The testimony on January 29 before the House Subcommittee on
Disability Assistance and Memorial Affairs clearly documented that
paper forms the basis for current VBA claims processing. The hearing
illustrated how paper-based records are easily misplaced or lost, and
how they become fragmented as different groups within VBA require
concurrent access to different parts of a Veteran's records while
processing a claim.
So the key question is how can the VA get from what is the current
state of claims processing to a better, automated future state. In my
written statement submitted for January 29, I outlined what I believe
are three important phases of effort for doing so. Phase I would
consist of building an electronic infrastructure to automate the steps
of the existing disability determination system, in order to gain
efficiency. While automation can eventually lead to a more complete
redesign and overhaul of the claims processing system, it would be too
disruptive--to both VA employees and to Veterans waiting for disability
determinations--to scrap the current system and start over from square
one all at once. Once the Phase I infrastructure was in place and being
used gainfully, Phase II would enhance the automated infrastructure by
adding decision support capabilities, some of which would involve
expert systems technology. Clinical decision support programs provide
assistance to healthcare workers in solving problems. Decision support
includes expert systems as one of its many categories. The goal of
decision support programs is to enhance the capabilities and efficiency
of qualified and capable humans, not to replace the humans. Finally,
Phase III would create quality monitoring and feedback processes to
help the VA enhance, evolve, and improve disability determination
processes over future years.
The steps for each of the three phases are as follows:
PHASE ONE_BUILD INFRASTRUCTURE TO AUTOMATE STEPS OF EXISTING DISABILITY
DETERMINATION SYSTEM, TO GAIN EFFICIENCY
Phase I, Step 1: At time of discharge from active duty, all
Veterans should have a disability examination by a qualified healthcare
practitioner that sets an initial, temporary level of disability. When
any disability exists, appropriate payments should begin immediately
upon discharge from the service as a prerequisite for discharge from
active service.
The record of the ``active service discharge disability
determination'' should be stored electronically. When this disability
determination occurs, there should be a target time, based on the level
of disability and the Veteran's needs, to complete a more ``permanent''
disability rating (which would be equivalent in its objectives to
current disability determination by VBA, but different process-wise, as
detailed below). This goal ``time to `permanent' status determination''
should be set at active duty discharge to be one of 3 months, 6 months,
or 1 year. Of course, disability status is not really ``permanent'' in
that the disability condition can evolve over time, and the Veteran
should always retain the right to appeal to assign a different status
than was set. The Veteran would receive disability benefits at the
temporary level until the ``permanent'' level evaluation is completed,
and then receive benefits at the ``permanent'' level, with no
interruptions in between.
Phase I, Step 2: Identify the entire range of the types of records
(documents and forms) that VBA must track to process an individual's
claim. Give each record type a unique name, and create a definition and
template for its contents. Similarly, identify the steps of disability
determination that VBA goes through (i.e., each type of decision made
by VBA) as it processes a claim from initial application to completion.
Give a unique name to each step in processing.
This is self-explanatory. The process should be completed within 2-
4 months, given adequate staffing and resources.
See for example, prior work done within the VA in this regard:
Brown SH, Lincoln M, Hardenbrook S, Petukhova ON, Rosenbloom ST,
Carpenter P, Elkin P. Derivation and Evaluation of a Document-naming
Nomenclature. J Am Med Inform Assoc. 2001;8(4):379-390.
Phase I, Step 3: Develop and implement a plan to convert all
relevant VBA records to electronic form.
In changing to a more electronic disability determination system,
one must be careful to convert almost all routine activities of VBA
raters to being electronically based, with actions analogous to what
they now do with paper. If both paper and electronic systems were in
active use, a VBA rater would always have to check both systems to see
if ``missing'' items in one system are actually not ``missing'', but
present in the second system. It would potentially be worse--more
cumbersome and slower for disability determinations--if VBA raters had
to use both types of record systems together in processing a Veteran's
application, than to use only one or the other system.
The most straightforward way to begin conversion to electronic
processing is to identify where paper records are currently generated,
and where existing VHA/VBA software is applicable to creation of
electronic versions of that paper-based information. For all other
paper records that cannot be easily converted in this manner, the
document naming system should be used to label them, and then records
in each category should be electronically scanned to create
electronically retrievable records with their dates of creation and
their ``named'' labels. Ultimately, subsequent projects should develop
tools to capture the content of all disability-related records at their
source, through electronically-structured and standards-coded forms
that create ``computer-processable'' content--using future electronic
capture tools analogous to the existing VHA CAPRI system. The
conversion should proceed based on each local/regional VBA office being
converted as rapidly as possible before going on to the next office--
trying to do a VBA system-wide conversion on a single day could create
too much chaos, due to the intensive level of support required in each
local/regional office during such conversions. Once a large enough
conversion support team existed, with adequate conversion experience,
the pace of conversion could accelerate. All offices across the U.S.A.
should be converted within a six to nine month span, using this model
of starting slow and building momentum.
Phase I, Step 4: Create a VBA automated record-tracking system that
uses as a checklist the named set of steps created in Step 1 above, and
uses the names of each record/document type to determine the status of
each document for any given applicant.
The checklists should be based on both an understanding of the
definitions of each disability provided in CFA 38 Part 4 (and its
amendments), and also an audit of adequately completed disability
determination records for each type of disability possible in CFR 38
Part 4. Thus, for each condition, there should be a list of the types
of records and documents that are potentially relevant to disability
determinations of that type, but also a list of the ``standard named''
processing steps that are required to carry the determination to
completion. The record tracking system will show which steps and which
documents are relevant in general, and which steps and which actions of
that set the VBA has deemed required in a given Veteran's case, and
then which of those required documents and steps are completed/
available through the electronic system, and which steps and procedures
remain to be completed. The VA's AMIE and CAPRI systems have to some
extent done this for components of the disability examination by the
clinician, so the approach taken in developing those systems might
inform the development of this more general tracking system.
As noted above, once documents that comprise the full VBA record
each have names, the existing documents initially can be scanned and
stored and made reviewable by their formal names. Decisions that have
been made would be displayed using their formal names. Scanning is a
low-level form of technology that could free VBA workers from having
only one paper document to review. However, scanning essentially
creates a picture of the original document that humans can read and
process. The latter scanned documents are, for the most part, not
readable or understandable by machines.
There are already portions of the VBA record that go beyond the
simple technology of scanning, such as the CAPRI disability examination
system used within VHA (and available for viewing at VBA). Note that
scanning is a lowest-common-denominator first step that can move
everything forward. The ultimate goal should be to make all disability
related materials based on fully electronic data capture forms, like
CAPRI.
Once a document is scanned (or captured electronically using a
template form), it should be stored centrally, with good backup and
recovery capabilities, not at local offices on desktop computers--
modeled after the way that the VA's VistA electronic medical record
system now works. The Internet can be used to view the centrally stored
record from diverse VBA and VHA locations concurrently--substantially
speeding up the ability to process a record. Similarly, the electronic
checklist of steps required to complete a disability determination
should be treated as if it were part of each Veteran's electronic
medical record. The current status of each disability determination
step, as well as target dates for completion of each required step,
should be readily viewable from a central storage location. A reminder
system can be built to warn VBA employees when the ``next step'' for
each Veteran becomes due, and repeated reminders can be issued for
steps that are overdue. At the completion of this step, there would be
a tracking system in place that can immediately indicate where in the
overall process each Veteran's application stands, and what documents
are available to support both past and future decisions.
Phase I, Step 5: Transition from a scan-based set of forms that
were originally on paper to a computer-template based set of forms that
collect primary data electronically (once, and from the most
knowledgeable source) to enable better computer-based assistance in
disability determinations.
To develop electronic-templated data collection criteria for each
disability condition would require human review of the latest version
of CFR 38 and amendments for each condition, and creating: (a) a list
of findings, coded in standard terminologies, such as SNOMED-CT or
LOINC, required to be present to establish the disability, (b) a list
of findings, coded in SNOMED-CT or LOINC required to be absent to
establish the disability, (c) a list of findings that help to support
the presence of the condition but which are not required to establish
the condition, coded in SNOMED-CT or LOINC, (d) a list of the document
types (using the standardized document names per above) that are
relevant to determination of the specific disability condition, (e) the
list of CAPRI frame identifiers that are relevant to determination of
this specific disability, (f) names for each of the 700 conditions
coded wherever possible in ICD, DSM, or SNOMED-CT, and (g) narrative
text that describes the remaining criteria for the establishment of the
specific disability condition that could not be coded in steps (a)
through (c). This process could expand upon, and derive useful
information from, the list of the required procedures/steps/documents/
records for each disability category that was built in Phase I, Step 4
above.
Phase I, Step 6: Create an automated ``dashboard'' for each VBA
site (and which can be ``rolled up/summarized'' at the regional or
national levels) that tracks all Veterans who have applied for
disability compensation, the state of their applications, the status of
their disability determinations, and uses color codes to indicate when
steps are incomplete or overdue.
This step is somewhat self-explanatory, and should be the end-
product of the previous steps in Phase I (especially steps 4 and 5). It
should directly lead into Phase II Step 1.
Phase I, Step 7: Determine how to best facilitate Veterans'
application processes for disability determinations, using electronic
entry forms and other automated methods to make the process more
efficient and effective for Veterans and their families.
PHASE TWO_ENHANCE AUTOMATED INFRASTRUCTURE FOR DISABILITY DETERMINATION
WITH DECISION SUPPORT FEATURES
Phase II, Step 1: Design, build, and implement, on top of the new
VBA electronic tracking system, a rating system that enables claims to
be electronically prioritized so that the most obvious or easiest to
decide claims can be adjudicated more quickly.
Once the automated tracking system is in place and running smoothly
in pilot sites, a team of system designers, which should include
computer-interface design experts, and socio-technical implementation
experts, should obtain input both from expert disability raters (i.e.,
experienced, highly respected VBA employees) and from the most
experienced and capable users of the new electronic tracking system.
The collective wisdom of the group should focus on the question of how
to determine, at any given time, which disability claim records are the
most important to process rapidly (i.e., where a Veteran clearly and
urgently needs assistance but is not getting assistance), and which
records are easiest to process rapidly (i.e., require minimal effort to
resolve).
The result of these deliberations should be used to design and test
a system that can create prioritizations that match those of human
experts on preliminary system testing, with the goal of pointing out to
VBA reviewers at each site what their priorities should be. Ongoing
validation of such a system will be required, with frequent feedback
from VBA end-users.
The system should be merged with the tracking system of Phase I
Step 6, to indicate which cases merit immediate attention of what sort,
and with what priority. The system should set deadlines for relevant
actions to occur, and remind VBA caseworkers of work requiring
attention. An escalation process should inform managers at the local,
then regional and national levels of the number and nature of cases
requiring attention that have not received it in a timely manner, and
could help to make sure adequate resources are devoted to resolving
disability determinations promptly.
The system should also be expanded to track the percent disability
and the disability award amount for each disability category from CFR
38 Part 4.
The tracking system should also be made available to each Veteran
who applies for disability determination to provide a summary level of
where the application stands in its progress to completion, providing
the Veteran with what steps have been completed, which steps remain,
what documents have been received, and which are still outstanding.
Care must be taken to make sure that the tracking system does not
provide confusing or disturbing information to the applicant Veteran.
Phase II, Step 2: Use expert diagnostic system techniques to assist
human judgment in diagnosis of disabilities within VA rating system. As
a part of this effort, completely redefine electronically the criteria
for disability determination (in CFR 38 Part 4), and in doing so,
create electronically actionable objective criterion lists as well as
lists of which subjective judgments are required by human disability
experts to complement the objective criteria in making decisions.
A number of techniques developed over the past three decades for
clinical decision support [see references at end of this step below]
are relevant to future enhancements to a VHA/VBA disability
determination and documentation system. At the national level, the VHA
has been a major contributor to clinical decision support through its
evolution of the VistA electronic medical record system. In addition,
many talented individuals working within the VHA and VBA have also made
contributions. It should be noted that Dr. Robert Kolodner, currently
Director of ONC (the Office of the National Coordinator for Health
Information Technology within the Executive Branch of the Federal
Government) previously served with great distinction as a leader of
informatics efforts within the VA.
An important technological approach relevant to VBA claims
processing is clinical diagnostic decision support applications [see
references below for this step], which can be probabilistic (Bayesian),
criterion-based, or heuristic (``artificial intelligence'' expert
systems) in nature. In general, such systems take as input standardized
vocabulary descriptors that characterize a patient's condition (such as
history, physical examination, or laboratory findings) and produce as
output a ranked list of possible diagnoses and a suggested approach to
determining which diagnoses are present--with respect to a specified
target set of allowed or possible diagnoses (which would be those
specified by CFR 38 Part 4 and its amendments for the case of the VBA).
It is important to note that diagnostic expert systems are useless
in the absence of objective criteria to be used in making diagnoses.
Such systems also require that all input data be in electronic form.
The diagnostic criteria can include subjective ratings by human experts
as part of the ``objective'' rating process, so long as the
instructions for the human raters are clear, and the raters are
calibrated to be equally reliable as other raters in carrying out such
subjective assessments.
Relevant to these considerations are two recommendations from the
Institute of Medicine's (IOM's) June 2007 report, ``A 21st century
System for Evaluating Veterans for Disability Benefits'' (National
Academies of Science Press, 2007; Copyright National Academy of
Sciences. http://www.nap.edu/catalog/11885.html), listed below:
``IOM Recommendation 4-1. VA should immediately update the
current Rating Schedule, beginning with those body systems that
have gone the longest without a comprehensive update, and
devise a system for keeping it up to date. VA should
reestablish a disability advisory Committee to advise on
changes in the Rating Schedule.''
``IOM Recommendation 4-6. VA should determine the feasibility
of compensating for loss of quality of life by developing a
tool for measuring quality of life validly and reliably in the
veteran population, conducting research on the extent to which
the Rating Schedule already accounts for loss in quality of
life, and if it does not, developing a procedure for evaluating
and rating loss of quality of life of veterans with
disabilities.''
The effort to redefine the conditions for which disability
compensation is appropriate should be standards-based (ICD, DSM,
SNOMED-CT, LOINC) as described above. Text-mining and natural language
processing methods (see references for Phase II, Step 3 below) could be
used to determine which coded terms are currently used in disability
determinations through review of the thousands of existing electronic
disability-related VistA and CAPRI records, and from samples of paper
records converted by OCR (if of adequate quality) or alternatively by
direct typing of samples of old records into electronic format. This
review, coupled with the effort to extend disability criteria as
recommended by the IOM Report, could result in computer-processable
``criteria table'' definitions (see references 7-10 below for this
step) for each disability condition that would maximize the objective
representations of each condition (while still retaining free text if
necessary to describe the aspects of human judgment required in each
determination). As previously recommended, the list of document types
and procedures relevant to determination of each disability category,
as well as the orders required to carry out the procedures in VistA,
could be added to an expanded revision of CAPRI.
A key component of redefining the conditions listed in CFR 38 Part
4 would be to include conditions that are well documented now that were
not originally in the Codes, such as Post Traumatic Stress Disorder.
Another important aspect would be to allow for coding for future
disabilities that are clearly related to active service but which do
not fit well into the existing code of disabilities at the time. Such
``not elsewhere classified'' cases should be very carefully described
in detail, and periodically reviewed (see Phase III, Step 3 below).
Once the above representation scheme for each disability condition
was in place, an expert system using the ``criteria table'' approach
could be developed to assist VBA raters in determining the completion
status of each disability determination, and added to a more advanced
version of the previously mentioned dashboard system. The AI-RHEUM
expert diagnostic system (references #7-10 below for this step),
developed initially at the University of Missouri at Columbia and at
Rutgers University, and subsequently at the U.S. National Library of
Medicine (NLM), might be used as a starting point for the proposed VHA/
VBA expert system, because it uses ``criterion tables'' for diagnosis,
which may fit well with a reformulated version of disability
definitions in CFR 38 Part 4.
Two of the original developers of that system are currently at
NLM--Donald A.B. Lindberg, MD, is the Director of the NLM, and Lawrence
C. Kingsland III, PhD, is a computer scientist at the Lister Hill
Center within NLM.
References for Phase II, Step 2:
1. Duda RO, Shortliffe EH. Expert Systems Research. Science. 1983
Apr 15; 220(4594):261--268.
2. Miller RA, Pople HE Jr, Myers JD. INTERNIST1, An Experimental
Computer-based Diagnostic Consultant for General Internal Medicine. N
Engl J Med. 1982; 307:46876.
3. Bankowitz RA, McNeil MA, Challinor SM, Parker RC, Kapoor WN,
Miller RA. A computer-assisted medical diagnostic consultation service:
implementation and prospective evaluation of a prototype. Ann Intern
Med. 1989; 110:82432.
4. Miller RA. Medical diagnostic decision support systems--past,
present, and future: a threaded bibliography and brief commentary. J Am
Med Inform Assoc. 1994;1(1):8-27.
5. Aliferis CF, Miller RA. On the heuristic nature of medical
decision-support systems. Meth Inform Med. 1995 Mar;34(1-2):5-14.
6. Tom Mitchell. Machine Learning, McGraw-Hill: New York, NY.
1997.
7. Kulikowski CA. Expert medical consultation systems. J Med
Syst. 1983 Jun;7(3):229-34.
8. Kingsland LC 3rd, Lindberg DA, Sharp GC. Anatomy of a
knowledge-based consultant system: AI/RHEUM. MD Comput. 1986 Sep-
Oct;3(5):18-26.
9. Porter JF, Kingsland LC 3rd, Lindberg DA, Shah I, Benge JM,
Hazelwood SE, Kay DR, Homma M, Akizuki M, Takano M, et al. The AI/RHEUM
knowledge-based computer consultant system in rheumatology. Performance
in the diagnosis of 59 connective tissue disease patients from Japan.
Arthritis Rheum. 1988 Feb;31(2):219-26.
10. Bernelot Moens HJ. Validation of the AI/RHEUM knowledge base
with data from consecutive rheumatological outpatients. Methods Inf
Med. 1992 Sep;31(3):175-81.
Phase II, Step 3: Develop the ability to recognize, in clinical
documents, terms that match findings or diagnoses of relevance to VBA
disability determination.
An important ``expert system'' technique relevant to clinical
informatics is natural language text processing [see references at end
of this step]. Using a target vocabulary of defined clinical terms or
concepts, such as provided by the U.S. National Library of Medicine's
Unified Medical Language System Metathesaurus, or by the SNOMED-CT
terminology system officially endorsed by the U.S. Government (which is
a subcomponent of UMLS), such programs can scan a ``free text''
document, such as a clinical note, and identify which of the target
concepts are present in the document [references 1-4]. The utility of
such an approach for VBA disability determination has already been
demonstrated by a pilot project to identify spinal-injury-related
findings from free text disability exam records, and to correlate those
findings with an electronic representation of the criteria used by VBA
to determine disability [reference 5].
Ad hoc or heuristic approaches can combine manual techniques with
semi-automated approaches to characterize clinical domains or
conditions [references 6-7]. Such approaches have been used to derive a
standardized vocabulary for patients' problem lists from a large set of
examples in free text [reference 6], and to attempt to convert
information stored in disparate DoD and VHA clinical record systems
from one representation format to the other [reference 7].
Once disability-relevant terms can be abstracted from clinical
documents with adequate reliability, it will be possible to combine
such lists with the diagnostic approaches mentioned in Phase II, Step
2, to be able to suggest which disabilities that a Veteran (or possibly
even an active servicemember prior to discharge from the service) might
qualify and be screened for.
References for Phase II, Step 3:
1. Uzuner O, Goldstein I, Luo Y, Kohane I. Patient Smoking Status
from Medical Discharge Records. J Am Med Inform Assoc. 2008; 15: 14-24.
2. Chen ES, Hripcsak G, Xu H, Markatou M, Friedman C. Automated
Acquisition of Disease--Drug Knowledge from Biomedical and Clinical
Documents: An Initial Study. J. Am. Med. Inform. Assoc. 2008;15(1):87-
98. PrePrint published January 1, 2008; doi:10.1197/jamia.M2401
3. Friedman C, Shagina L, Lussier Y, Hripcsak G. Automated
Encoding of Clinical Documents Based on Natural Language Processing. J.
Am. Med. Inform. Assoc. 2004;11(5):392-402.
4. Denny JC, Smithers JD, Miller RA, Spickard A III.
``Understanding'' Medical School Curriculum Content Using KnowledgeMap.
J. Am. Med. Inform. Assoc. 2003;10(4):351-362. PrePrint published July
1, 2003
5. Brown SH, Speroff T, Fielstein EM, Bauer BA, Wahner-Roedler
DL, Greevy R, Elkin PL. eQuality: Electronic quality assessment from
narrative clinical reports. Mayo Clin Proc. 2006; 81(11):1472-1481.
6. Brown S, Miller RA, Camp H, Giuse D, Walker H. Empirical
Derivation of an Electronic Clinically Useful Problem Statement System.
Ann Intern Med. 1999; 131(2):117-126.
7. Bouhaddou O, Warnekar P, Parrish F, Do N, Mandel J, Kilbourne
J, Lincoln MJ. Exchange of Computable Patient Data Between the
Department of Veterans Affairs (VA) and the Department of Defense
(DoD): Terminology Standards Strategy. J Am Med Inform Assoc. e-
published Dec 20, 2007 doi:10.1197/jamia.M2498
PHASE THREE--CREATE A QUALITY FEEDBACK PROCESS TO ENHANCE AND EVOLVE
THE DISABILITY RATING PROCESS OVER TIME
Phase III, Step 1: Using the disability determination tracking
system described in Phase I, Step 6 and in Phase II, Step 1, develop
progressively more sophisticated summary statistics that identify the
following quality tracking metrics.
Proposed quality tracking metrics include:
a. The time required from initial application submission by a
Veteran to completion of disability status determination by VBA.
1. Subset by disability type (of the 700 conditions in CFR 38
Part 4)
2. Subset by VBA Disability Office at local and regional levels
3. Subset by steps required from start to end, to find
``logjams'' to work on
b. Use the data to determine which VBA raters fall outside the
norms for the region or the Nation in terms of time to resolution of
each Veteran's claim, consistency of VBA ratings, rate of responding to
alerts and reminders, etc. These data should be used to help provide
better follow-up training and instruction to VBA employees who require
it, and if that is not effective, to find positions in VA for which the
employee is better suited.
c. Use the data to review and refine the list of the core set of
documents and steps required to determine each category of disability,
over time. For example, at some time in the past, CT scans and MRI
scans became more definitive and useful than plain x-rays for certain
types of disability determination.
d. Consistency of assignment of disability category, percent
disability, and awards for disability, for Veterans with similar sets
of findings.
Phase III, Step 2: Progressively refine the ability of natural
language processing approaches to extracting disability-related
information from free text records, and apply it to both DoD and VHA
records to help screen for Veterans who may qualify for disabilities.
This is somewhat self-explanatory, and represents time-wise
refinement of Phase II
Phase III, Step 3: Track disabilities that do not fit well into the
existing disability code (see Phase II, Step 2 above), and based on
prevalence (a) notify DoD and VA of their existence, and criteria for
diagnosing them, and (b) once well-established, modify by amendment CFR
38 Part 4 to include the new categories.
Just as the medical profession tracks and defines a small number of
new diagnoses annually (notable examples include Legionnaire's disease
in 1976-77, AIDS in the early eighties, and Lyme Disease--which had
been described and forgotten in the early 1900s, but re-emerged in an
outbreak that started in Connecticut in the late seventies), there are
new service-related disability conditions that will continue to emerge,
such as Agent Orange exposure from the Vietnam War era, Gulf War
syndrome from the Gulf War in the early nineties, and closed head
injury brain trauma in the current Gulf War. It is important to have
categories that allow assignment of disabilities at appropriate levels
to Veterans even when their disorders do not fit neatly into existing
CFR 38 Part 4 codes. It is equally important to encode the findings of
such Veterans with ``in-between-the-codes'' disabilities in standard
descriptive terminology so that such cases can be monitored at the
national level, and when new patterns emerge, they can be further
studied, categorized, and given new diagnostic labels.
Development of new diagnostic labels for disabilities in Veterans
has a number of ramifications. First, at the pragmatic level,
definitions of the new conditions must be developed in the then-current
electronic format used system-wide by the VHA and VBA, with
appropriately coded standardized criteria and steps for diagnosis
(consistent with Phase I and Phase II commentary above). Second, once
such syndromes are characterized, if the conflict in which they arose
is still ongoing, DoD personnel should be made aware of how to diagnose
the condition in its early stages, so that hopefully the cause(s) can
be determined, and preventive measures developed, whenever possible,
within DoD, to lessen the occurrence of the condition during active
service. Finally, once the condition has a formal definition, all VHA
and VBA should be trained on how to detect and characterize the
condition in a standard manner.
Phase III, Step 4: The software and underlying medical knowledge
underlying the VHA and VBA rating systems described in this document
should be periodically reviewed with end-users and by outside experts
for continuous quality-related improvements.
Question 2: Can VBA claims be electronically prioritized so that
the most obvious or easiest to decide claims can be adjudicated more
quickly?
Response: Yes, this was detailed in my answer to Question 1. Please
refer to Phase II, Step 1 above.
To recapitulate what was said above:
Phase II, Step 1: Design, build, and implement, on top of the new
VBA electronic tracking system, a rating system that enables claims to
be electronically prioritized so the that most obvious or easiest to
decide claims can be adjudicated more quickly.
Once the automated tracking system is in place and running smoothly
in pilot sites, a team of system designers, which should include
computer-interface design experts, and sociotechnical implementation
experts, should obtain input from both expert disability raters (i.e.,
long-term VBA employees) and from the most experienced and capable
users of the new electronic system. The collective wisdom of the group
should focus on the question of how to determine, at any given time,
which disability claim records are the most important to process
rapidly, and which records are easiest to process (i.e., require
minimal effort to resolve rapidly). The result of these deliberations
should be used to design and test a system that can do such
prioritization, to point out to VBA reviewers at each site what their
priorities should be. Ongoing validation of such a system will be
required, with frequent feedback from VBA end users.
Question 3: In your testimony, you mentioned a ``quality feedback
loop.'' How can technology enhance the VA's efforts at monitoring
quality in its claims processing?
Response: In my answer to Question 1 above, items under ``Phase
III'' all fall into the quality feedback category, and comprise a
complete response to Question 3.
Question 4: Can you further comment on the diagnostic system
developed at the U.S. National Library of Medicine as to how it could
be a starting point for VA disability claims?
Response: This was discussed in the response to Question 1, under
Phase II, Step 2. Lawrence (Larry) C. Kingsland, III, PhD, would be the
most appropriate person to contact at NLM (301-496-9300), as he has a
long history of developing and evolving criterion-based diagnostic
systems.
To recapitulate:
Phase II, Step 2: (excerpt)
Once the above representation scheme for each disability condition
was in place, an expert system using the ``criteria table'' approach
could be developed to assist VBA raters in determining the completion
status of each disability determination, and added to a more advanced
version of the previously mentioned dashboard system. The AI-RHEUM
expert diagnostic system (references #7-10 for this step), developed
initially at the University of Missouri at Columbia and at Rutgers
University, and subsequently at the U.S. National Library of Medicine
(NLM), might be used as a starting point for the proposed VHA/VBA
expert system, because it uses ``criterion tables'' for diagnosis,
which may fit well with a reformulated version of disability
definitions in CFR 38 Part 4. Two of the original developers of that
system are currently at NLM--Donald A.B. Lindberg, MD, is the Director
of the NLM, and Lawrence C. Kingsland III, PhD, is a computer scientist
at the Lister Hill Center within NLM.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 4, 2008
Marjie Shahani, M.D.
QTC Management, Inc.
1350 Valley Vista Dr.
Diamond Bar, CA 91765
Dear Dr. Shahani:
In reference to our Subcommittee hearing on the Use of Artificial
Intelligence to Improve the VA Claims Processing System on January 29,
2008, I would appreciate it if you could answer the enclosed hearing
questions by the close of business on March 4, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
QTC
Diamond Bar, CA.
March 3, 2008
Ms. Orfa Torres
335 Cannon House Office Building
Washington, DC 20515
RE: Questions on Artificial Intelligence to Improve the VA Claims
Processing System
Ms. Torres:
Attached is our response to the questions submitted by the
Honorable John J. Hall regarding the Hearing on the use of artificial
intelligence to improve the VA claims processing system. Please do not
hesitate to contact me for additional information.
Sincerely,
Dr. Marjie Shahani
Vice President
Enclosure
__________
Response to Questions from Hon. John J. Hall
Chairman, Subcommittee on Disability Assistance and Memorial Affairs
U.S. House of Representatives
Hearing on the Use of Artificial Intelligence to Improve VA Claims
Processing System held on January 29, 2008
From: Marjie Shahani, MD
Senior Vice President, QTC Medical Service, Inc.
Question 1: The Evidence Organizer sounds like it could make some
impact on increasing the number of cases a day a rater could rate. A
33% increase sounds good, but not great. Is there any way we could be
doubling that figure?
Response: Yes, the Evidence Organizer can make such an impact.
Increasing the realized productivity of rating specialists to rate
a case is dependent on multiple factors.
First, it is critically important to move away from paper-based
claims and supporting evidence. This would involve obtaining and
converting claims and supporting medical evidence to a digital,
searchable format. It is our understanding, from discussions with
retired rating specialists and working with the VA, that the majority
of their time is spent searching and weighing the medical evidence
available on file. The Evidence Organizer will assist in accomplishing
these tasks for the rating specialists thereby:
Reducing the time the rating specialist spends reviewing
and identifying the pertinent medical records for the individual issues
claimed
Reducing the time the rating specialist spends
correlating the medical evidence to the diagnostic codes
In addition, the Evidence Organizer can be linked to the current VA
rating specialist's tool, RBA 2000, allowing flexibility of
transferring information from the Evidence Organizer directly to the
rating document.
The Evidence Organizer will enhance the delivery of a more timely,
standardized and accurate rating decision. Similar to other rule-based
systems, utilization of the Evidence Organizer provides iterative
improvements through fine-tuning of the rules and training the system
thus producing increasing improvement of productivity and accuracy with
use and time.
Question 2: If a computer system could be matching key words as you
described, would it still be necessary to generate a narrative report
that needed to be read? Wouldn't it just be easier to avoid that step
and let the computer match the criteria from the rating schedule to the
findings in the exam template?
Response: The Evidence Organizer does not generate a narrative
report. It is a decision support system designed to enhance the
efficiency of the Rating Veteran Service Representative (RVSR) or
rating specialist by directly matching the medical evidence to criteria
contained in the rating schedule.
The Protocol Software application tool built by QTC and utilized by
the examining physicians to perform the examinations according to VA
AMIE worksheet requirements generates a narrative report. This is a
separate tool all together.
Question 3: To take the concept a step further. If an entire record
is scanned into a computer using a high speed scanner and indexed at
the same time--and that could be hundreds of pages in about half an
hour--once that index was completed and key words were matched, then
couldn't some sort of rule-based expert system as described by Doctors
Mitchell and Miller apply the VA Rating Schedule and calculate a
rating?
Response: Yes. A rating decision could be calculated by a rule-
based expert system; however additional information would need to be
added into the computerized system beyond the evidence and the rating
schedule.
The Rating Schedule and the Code of Federal Regulations embody the
laws and procedures that apply to a properly evaluated disability.
Based on our knowledge in working with the VA, these are not the only
guides utilized by an RVSR in determining entitlement to benefits and
selecting a percentage evaluation when certain disability criteria are
met.
Additional information that would need to be added to the expert
system would include:
Policy statements
Procedure statements
Administrative decisions
Secretaries' decisions
Court of Appeals for Veterans Claims (CAVC) precedents,
and
Other legal precedents governing Department of Veterans
Affairs (VA)
Incorporating all these into the rule-based expert system will
allow for the software application to provide a recommended rating.
The rating results generated by the expert system will be as
accurate as the rules configured in it and the completeness of the data
(files) accessible to it in digital searchable form.
Question 4: We've often heard that claims have become more complex
with over eight conditions per claim instead of just one or two. Could
an expert system rate all of those conditions given that the claim was
already in a ``ready to rate'' format such as the one described by Mr.
Hunter? How long would it take?
Response: Yes. A properly built and fine-tuned rule-based expert
system could rate multiple conditions in a prompt manner. A specific
timeframe to produce the completed decision would be dependent on the
complexity of the algorithms and accuracy of the rules configured in
the expert system and the infrastructure used to host the expert
system; however, we anticipate this could be completed in minutes since
we believe that the algorithms can be built in linear complexity.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 4, 2008
Mr. Ned Hunter
Stratizon Corporation
5425 Peachtree Way
Norcross, GA 30092
Dear Mr. Hunter:
In reference to our Subcommittee hearing on the Use of Artificial
Intelligence to Improve the VA Claims Processing System on January 29,
2008, I would appreciate it if you could answer the enclosed hearing
questions by the close of business on March 4, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
March 6, 2008
``The Use of Artificial Intelligence to Improve the VA's Claims
Processing System''
Ned M. Hunter, President and Chief Executive Officer, Stratizon
Corporation, Atlanta, Georgia
Question 1: Can you tell me more about where you are at with the
Virginia pilot project?
Response: The pilot is stalled due to funding. The application is
built and ready to go.
Question 2: Are other states or agencies using TurboVet and what
have been their results?
Response: No. Eight other states have expressed interest since
presenting at NASDVA.
Question 3: If VA was no longer relying on paper records and was
primarily using an electronic system, how long do you think it would
take them to process a claim?
Response: It depends the integration of processes, both business
and technical. We believe at least a 60% improvement in process cycle
efficiency could be achieved.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 4, 2008
Mr. Gary Christopherson
Strategic Management and Performance
4327 Clagett Road
University Park, MD 20782
Dear Mr. Christopherson:
In reference to our Subcommittee hearing on the Use of Artificial
Intelligence to Improve the VA Claims Processing System on January 29,
2008, I would appreciate it if you could answer the enclosed hearing
questions by the close of business on March 4, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Hearing on Use of Artificial Intelligence to Improve the VA's Claims
Processing System
January 29, 2008 QFR Responses of Gary A. Christopherson
Former Senior Advisor the Under Secretary for Health and Chief
Information Officer
Veterans Health Administration, Department of Veterans Affairs
Former Principal Deputy Assistant Secretary for Health Affairs,
Department of Defense
Question 1: In your written testimony you state that you helped
improve the VistA health information system. Can you emphasize your
involvement? How is VistA a model and how can VBA implement this model
or share in it?
Response: Starting in the year 2000, I served as the Chief
Information Officer for the Veterans Health Administration. When I
arrived, the current plan by the previous CIO was to abandon VistA and
move to a commercial product. After a thorough review of VistA from
both the health care and information technology perspectives, I
recommended that we build a new generation of VistA--called HealtheVet
VistA--from the foundation of the existing VistA. That recommendation
was unanimously approved by VHA, VA and OMB and was funded at a rate of
an additional $125 million/year. That new development began in 2001.
Based on internal reviews by VHA and the staff nationwide and on
external reviews by a number of health care experts, VistA has been
applauded as probably the most functional electronic health record
system in the world. With next generation HealtheVet VistA, this
functionality would be substantially enhanced and built on the latest
information technology.
VBA is using and could use it more effectively by cutting and
pasting the health care information into the VBA applications. With a
redesigned VBA application, the data could be directly imported without
retyping or cutting/pasting. Importing the data greatly speeds up the
search for the needed information, the application of that data to the
VBA decisionmaking process, and the actual decision and any subsequent
updates.
The VistA application itself is a model for how one should
construct the future VBA decisionmaking environment where the data is
available electronically, in standard formats, coupled with decision
support tools (e.g. artificial intelligence), and operating in real
time supporting real time decisionmaking.
Question 2: You mention in your testimony that claims can be
processed in real time and rated in a single day. Given your background
with VA and your knowledge of its capabilities, what does VBA need so
it can capitalize on artificial intelligent technology and reach that
real time goal?
Response: First, the veteran should have the option of entering all
the information they have online so that it is available to the VBA as
soon as the application is submitted. Whatever medical or other
documentation is available from other than DoD or VA can be submitted
at attachments in standard formats. Whatever medical or other
documentation is available from DoD or VA electronically should be
available as it is generated. This is the case with VHA information
today. It is partly true for DoD information today. As more of this
data is digital and standardized, the power and speed of decision
support tools increases.
If more information is needed, a temporary rating could be issued
based on what has been submitted and a signature by the veteran. If
more information is needed, that should be able to be obtained within
30 days and allow a ``permanent'' decision to be made within 30 days.
For either, the appropriate payment should be started within 30 days of
the application. Decision support tools (including artificial
intelligence can easily support this model. This can be done today and
can be done even better in the near future with enabling technology.
Question 3: We have heard a lot today about what the technology can
do to improve timeliness, accuracy, and consistency far beyond what
people are capable of doing. So, what role does that leave for the
Regional Office employees? If we free up their time from processing
papers would they be able to spend more time advising veterans and
their families on their claim and other available benefits or do you
think implementing more technology will result in a loss of jobs?
Response: Technology is unlikely to reduce the need for Regional
Office employees any time in the near future. What it does do is allow
them to be involved in more important work in support of the veteran
and VA.
First, there is always going to be the need for human intervention
deal with more complex claims and where the decision support has limits
(lack of digitized and standardized data; claims that fall outside
current decision rules). Second, veterans need a partner to assist them
prior to making a claim, when making a claim and on an ongoing basis as
their situation changes. Third, veterans need people to ``meet and
greet'' them at the door as a way to welcome them to a potential
benefit based on their service to the Nation. Fourth, employees could
become case managers where they actively and proactively engage with
the veteran to make sure what needs to happen with respect to benefits
does happen. This could reach further to helping coordinate, working
with the veteran, VA programs with non-VA programs.
There is no good reason why any existing employee should lose his/
her job. There is all the additional valuable work described above.
Further, whatever loss of jobs does occur would likely occur over a
long time period and could likely be handled through normal attrition.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 4, 2008
Hon. James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
In reference to our Subcommittee hearing on the Use of Artificial
Intelligence to Improve the VA Claims Processing System on January 29,
2008, I would appreciate it if Mr. Stephen Warren and Ms. Kim Graves
could answer the enclosed hearing questions by the close of business on
March 4, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Questions for the Record
The Honorable John J. Hall, Chairman
House Veterans' Affairs Committee
Subcommittee on Disability Assistance and Memorial Affairs
January 29, 2008
Use of Artificial Intelligence to Improve the VA Claims Processing
System
Mr. Stephen Warren
Question 1: In your statement you described a Request for
Information that industry responded to that would help VA leverage
decision support technologies, so what was the outcome of that process?
How are you going to use that information?
Response: Industry responses to the request for information (RFI)
revealed a variety of tools and services available on the open market,
which may assist the Department of Veterans Affairs (VA) in developing
a business model that is less reliant on paper. During the vendor
presentations stage of the RFI, it became evident that the paperless
delivery of veterans benefits initiative has many interrelated
elements, requiring a significant level of planning and integration to
ensure successful implementation. To that end, VA has decided that the
most prudent course of action is to engage the services of a lead
systems integrator (LSI). The role of the LSI will be to work with VA
to document business requirements, assess the current and planned
information technology landscape, and develop an overarching program
plan to implement the desired end-state. The information gathered
during the RFI process will be provided to the LSI for consideration,
as they assist VA in developing its implementation strategy.
Question 2: VistA has helped bring the Veterans Health
Administration to the cutting edge of healthcare in America. No other
system has as dynamic an electronic system as VHA. So, why doesn't VBA
benefit from it in the same way? Why are the Regional Offices taking an
electronic medical record, printing it, and flagging it with post-its
and rubber bands?
Response: The Veterans Benefit Administration (VBA) does benefit
from the advances in the Veterans Health Information Systems and
Technology Architecture (VistA). Through the compensation and pension
records interchange (CAPRI) interface, VBA personnel may request
medical examinations necessary for the evaluation of disabilities
claim. In addition, VBA personnel may search and download information
contained in the VistA system, relevant to the veteran's claimed
conditions. In our desired end-state, VBA employees will be able to
capture this information electronically into the veteran's ``e-File'',
for use in administering compensation benefits. This type of electronic
information sharing and claims processing is a cornerstone of the
paperless delivery of veterans benefits initiative.
Question 3: During the hearing you were unaware of the disbanding
of the Office of Seamless Transition. Why has that office disappeared
while there are still so many problems that transitioning
servicemembers and their families face? How is VBA informing veterans
that they can file a claim online?
Response: In October 2007, the Veterans Health Administration (VHA)
reorganized the Office of Seamless Transition, in order to better meet
the needs of severely wounded servicemembers and veterans. The clinical
components of the office were realigned under the newly established
Care Management and Social Work Service, whose mission is to address
the needs of wounded and ill servicemembers. The employees, who were
members of the Office of Seamless Transition, are a part of the new
Care Management and Social Work Service.
The transition assistance and case management that VA provides to
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
servicemembers, families and veterans have not changed as a result of
the reorganization of the Office of Seamless Transition. It is VA
policy that all claims for OEF/OIF veterans receive priority
processing. The severely injured OEF/OIF claims are case managed,
whether the seriously injured servicemember is transitioning from
military to civilian life or remains on active duty. There is no higher
priority for any VA employee, than ensuring the needs of those
seriously injured in OEF/OIF are met in a timely and appropriate
manner.
VA uses a variety of methods to inform veterans that they can file
a claim online. A few examples include face-to-face transition
assistance program briefings; printed materials, such as pamphlets and
brochures; and through our Web site under the heading ``Apply Online.''
Question 4: Can you provided a more detailed report on the results
of the RFI mentioned during the hearing? What was the industry response
and what will VBA do with that information?
Response: The RFI yielded 19 submissions from industry. These
submissions covered such areas as business-rules engines, integration
services, decision-support applications, and independent verification
and validation services. Based on the initial submissions, VA requested
that 11 vendors prepare a more targeted oral presentation. These 11
vendors covered the spectrum of the categories described above. During
the course of the presentations, it became evident that the paperless
delivery of veterans benefits initiative has many interrelated
elements, requiring a significant level of planning and integration to
ensure successful implementation. To that end, VA has decided that the
most prudent course of action is to engage the services of a lead LSI.
The role of the LSI will be to work with VBA and the Office of
Information and Technology (OIT) to document business requirements,
assess the current and planned information technology landscape, and
develop an overarching program plan to implement the desired end-state.
The information gathered during the RFI process will be provided to the
LSI for consideration, as they assist us in developing our
implementation strategy.
Question 5: Please provide a copy of the IBM Report requested
during the hearing.
Response: IBM will deliver its final report and provide executive
briefings to VBA in March 2008. A copy of the final report will then be
provided to the Committee.
Ms. Kim Graves
Question 6: During the hearing, you mentioned an end-to-end claims
process that will be paperless and computable, which based on the
testimonies from the second panel is very realistic and should be the
norm already. So, when will we see this new veteran's e-file and how
long will this new system take to process a claim? Will it be more
accurate and consistent?
Response: The end-to-end claims process described in the testimony
is our desired end-state vision for claims processing. We have already
engaged in two pilot efforts which have demonstrated this type of
``paperless'' claims process, using an ``e-File'', is feasible. The
results of our RFI solicitation, as well as the presentations of the
hearing panelists, provide for a number of potential opportunities to
enhance the claims process. All potential solutions will be considered
by the LSI as we develop our overarching strategy to reach the desired
end-state. In addition, realistic performance metrics will be developed
so that we may assess our progress in moving forward with this
initiative. We fully expect to see improvements in the claims process
as we move toward this end-state.
Question 7: What is the problem with accepting an electronic
signature?
Response: VA agrees the claim process should be modernized to
enable claimants to submit claims electronically and conduct other
business with VA electronically, similar to the electronic business
transactions that have become the mainstay of modern America. We are
committed to this modernization as a high priority and are assessing
the changes that are necessary to achieve this goal.
Question 8: Why did it take VBA a year to rate and compensate Mr.
Cleveland?
Response: This information was provided to the Chairman only due to
the personally identifying information contained in the response.
Question 9: What can Congress do or what do we need to do to help
VA to improve and use technology to process disability claims?
Response: We believe we have identified a prudent course of action
in seeking to bring on a LSI to assist us in developing and
implementing our long-term vision of Paperless Delivery of Veterans
Benefits. This strategy is consistent with the Social Security
Administration's ``eDib'' initiative. As part of this process, we will
more clearly define the end-state; we will articulate achievable
milestones for implementation of capabilities and improved processes;
and we will develop a long-term funding and acquisition strategy.
Congressional support of our overall plan will be critical to our
success.