Rx Automation: Fighting America’s Opioid Epidemic

Written By: John Cosenza

When viewed through a specific lens, every American generation over the past 50 years can be associated with substance and drug abuse. The era of heightened political tension and rise of hippie culture in the 1960’s gave rise to psychedelic substances such as Lysergic Acid Diethylamide (LSD), commonly referred to as acid. President Nixon’s “Public Enemy Number One” campaign aimed at hindering LSD and amphetamine use in the 1970’s drastically increased the popularity of other drugs like cocaine. The mid 1980’s – 1990’s experienced an unprecedented and far-reaching distribution of drugs including heroin and crack-cocaine, turning inner city neighborhoods across America into warzones. What came next, what the American public struggles to grapple with to this day, is perhaps the worst drug epidemic this nation has ever faced; Opioid abuse.

Opioids are a class of drugs that include both illegal substances such as heroin and legal substances such as oxycodone, hydrocodone, codeine, morphine, and many others; these substances not only relieve pain but produce extreme euphoria. Although typically safe when administered by a prescriber over a short period of time, the euphoric affect leaves some individuals highly susceptible to dependence long after their prescription has expired. According to the National Institute on Drug Abuse,

“the rate of death from overdoses of prescription opioids in the United states more than quadrupled between 1999 and 2010, far exceeding the combined death toll from cocaine and heroin overdoses” (Volkow, Frieden, Hyde, Cha).

Since 2010, the death rate has increased another 35% and shows no signs of slowing down. With tens of thousands of Americans dying each year from opioid abuse, the U.S. government has taken initiatives to curb this epidemic.

Among these initiatives is the utilization and expansion of healthcare information technology and automation software. Ohio Governor John Kasich, for example, has allocated $20 million towards new technology and tools to thwart the dramatic increase in opiate abuse. In the “New Strategies to Fight Opiate and Fentanyl Crisis in Ohio (2016 -17)”, government policies include expanding automation processes such as Electronic Pharmacy Management systems. Indeed, new strategies include:

  • Expanding integration of the Ohio Automated Rx Reporting system (OARSS) into the electronic medical records and pharmacy dispensing systems.
  • Develop an OARSS training website for higher education and residency programs to simulate use of system for future prescribers and pharmacists.
  • Use algorithms to develop proactive alerts for prescribers in the Ohio Automated Rx Reporting System.
  • Develop a report in the OARSS to allow prescribers to view their prescribing habits comparted with their peers.
  • State of Ohio Board of Pharmacy will explore providing access to the OARSS for certified drug courts in Ohio.

Pharmacy Management Systems are an essential tool in countering opioid abuse. Pharmacy automation systems track the distribution of prescribed opioids including dosage and advanced clinical tools such as e-prescribing enable direct communication between prescribers and pharmacists. In turn, pharmacists can more easily detect signs of abuse while eliminating fraudulent prescriptions.

Lt. Governor Brian Calley is tackling Michigan’s opioid abuse crisis head on; a state recording 95 opioid related deaths in 1999 to over 1,000 in 2016. Michigan lawmakers have advocated replacing an

“old and outdated antiquated system that did not have the level of width or the functionality in today’s practices to be effective” for years (Skubick).

Enter the Michigan Automated Prescription System (MAPS), a pharmacy automation system and preventative tool “that allows doctors, law enforcement, pharmacies and rehab centers to track who is giving and getting prescriptions. They look up a patient record in the system and look at what they’ve been dispensed by way of controlled substances within the systems” (Skubick).  Although Michigan and Ohio have long campaigns ahead, the expansion and modernization of pharmacy automation systems is a significant step in the right direction.

Congress is also making significant steps by introducing bills such as the Heroin and Opioid Abuse Prevention and Treatment Act of 2017 and allocating funds to curb opioid abuse and provide treatment to those who suffer with dependence. In reality, the opioid abuse epidemic is unlike previous drug crises; primarily due to the fact opioids are, in most cases, legally prescribed. Whether it is a construction worker suffering from back pain or a high school student having a wisdom tooth removed, the need for opiates are typically legitimate. Thus, it is essential prescribers take the utmost responsibility and precaution when administering these powerful substances. In an age dominated by technology, prescriber responsibility, precaution, and medication safety starts with sophisticated pharmaceutical automation processes. Adopting and implementing this technology across the nation is the first step in combating this arduous crisis.

Check out the Wall Street Journal’s captivating documentary below to learn more.



Golston, Hilary. “Kasich Focuses on Opioids, Automation, Political unity; Avoids Political Landmines.” WKYC April 04, 2017

National Institute on Drug Abuse. U.S. Department of Health & Human Services

National Institute on Drug Abuse. “Prescription Opioids and Heroin Report 2015.” U.S. Department of Health & Human Services. 

Nora D. Volkow, Thomas R. Frieden, Pamela S. Hyde, and Stephen S. Cha; “Medication-Assisted Therapies – Tackling the Opioid-Overdose Epidemic.” New England Journal of Medicine, May 29th, 2014.

Skubick, Tim. “Community Crisis: How State Lawmakers are Fighting Opioid Abuse.” WLNS.com, May 22, 2017.

Wall Street Journal. “American Epidemic: The Nation’s Struggle With Opioid Addictions, Jan 3, 2017

What’s Next for Healthcare IT ?

President Donald Trump’s proposed budget to congress effectively cuts $22 million from the Office of the National Coordinator for Healthcare Information Technology (ONC) and millions of dollars from other federally funded health IT organizations. Although this budget has led many industry leaders to question the future of healthcare IT in an era of political uncertainty, strong resentment already exists between health IT vendors and bureaucratic agencies who continue to roll out strict provisions.

Healthcare IT, especially in regards to Electronic Health Records (EHR), has revolutionized clinical practices. The reduction of medication errors, the ability to communicate pertinent patient information across health care communities, and overall improved patient outcomes associated with EHRs are a testament to the recent advances in health care technology. Indeed,“Health IT can engage and support health care providers, patients, and consumers with access to timely and accurate clinical information from Electronic Health Records (EHRs) and other sources” (Basch, McClellan, Botts, Katikaneni). This notion has been widely accepted by the U.S. government and received bipartisan support with the passing of the 21st Century Cures Act in December of 2016; legislation requiring further provisions for health IT vendors to meet. Yet, research suggests most clinicians are dissatisfied with EHR systems and health IT products that cater more to government mandates than to specific needs of hospitals and private practices.

In the wake of Trump’s budget proposal, individuals such as Thomas Payne, MD, the board chair of the American Medical Informatics Association expressed their disappointment. Payne quoted

“This budget request stops progress in its tracks. The ecosystem that entices young scientists and clinicians to pursue their passion to help patients will be severely damaged, resulting in a downward spiral of innovation, delayed or forgone investment in new treatments, and a stagnant patchwork of IT-enabled patient care” (Sullivan).

Individuals from other organizations including the Healthcare Information and Management Systems Society (HIMSS) and the American Health Information Management Association (AHIMA) also expressed concern over the proposed budget.

AHIMA CEO Lynne Thomas Gordon quoted“The bipartisan passage of the Cures Act by Congress last year made clear that investment in our nation’s health IT infrastructure is critically important if we are to advance new drugs and devices and fully realize the benefits of a learning healthcare system” (Sweeney). Many now fear the budget cuts will slow, if not prohibit, the implementation of provisions outlined in the 21st Century Cures Act, which among other provisions, include improving interoperability and maintaining EHR standards under Meaningful Use (MU). However, it can be argued strict legislation has already enabled a downward spiral of innovation.

Additionally, one must question what is more essential to patient care; addressing health IT concerns physicians believe are most important to their patient’s health or tasking vendors to meet endless government mandates that diverts attention from such concerns and product innovation? So, what is next for Healthcare IT in the US, and more importantly, what sort of role will the government have throughout Trump’s presidency? The appointment of Scott Gottlieb, M.D. as Commissioner of the Food and Drug Administration (FDA) might provide an inkling of what’s to come.

Gottlieb’s nomination was supported by his close ties to the pharmaceutical industry and impressive resume; serving as the deputy commissioner for medical and scientific affairs at the FDA during the Bush administration. Gottlieb argues regulation of healthcare IT is “scaring away digital entrepreneurs” and will push a deregulation agenda (Sweeney). Deregulation may attract talent to an industry riddled with onerous mandates stemming from HITECH, ARRA, the 21st century Cures Act and MU. Yet, it should not be assumed deregulation will counter all unforeseen consequences of budget cuts. The correct solution will most likely have to incorporate a healthy balance. Although it is essential for the government to participate in a mission to advance healthcare IT, bureaucratic agencies may not necessarily be the proper body to dictate terms.

Indeed, deregulation has long been sought by both health IT vendors and physicians; many organization are now calling for the cancelation of MU Stage 3. Moreover, Evan Sweeney, author for FierceHealthcare argues,

“Those in the digital health industry are hoping for a behind-the-scenes shift that emphasizes collaboration and removes barriers to innovation” (Sweeney).

If Trump’s budget is approved, coupled with deregulation, it will be interesting to see how the health IT industry reacts. Will this inspire the private sector to shift focus from meeting federal mandates to improving patient care and innovation? Will MU Stage 3 be canceled and enable health IT vendors to work closely with their customers rather than work for the government? Although it is still too early to tell, the 115th US Congress will have to determine the fate of an industry that yearns to enhance technological innovation for those who need it most, America’s patients.

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Basch, Peter; McClellan, Mark; Botts, Christopher; Katikaneni, Pratyusha (2015). High Value Health IT: Policy Reforms for Better Care and Lower Costs.” The Brookings Institution 2015.

Sullivan, Tom (2017). “Trade Groups pan Trump’s cuts to Health IT.” HealthcareITNews, 5.23.2017

Sweeney, Evan (2017). “ 3 Ways Trump’s FDA Nominee Could Reshape Digital Health.” FierceHealthcare, 5.16.2017

Sweeney, Evan (2017). “Trump Slashes ONC’s Budget by $22M amid Wider cuts to Health IT Initiatives.” FierceHealthcare, 5.23.2017

Image Reference

Randle, Jim; Hannas, Chris (2017). “Proposed Trump Budget: More Military; Less for Social Programs.” VOANews, 5.23.2017,  https://www.voanews.com/a/trump-proposed-budget/3867437.html


MU & HITECH: The Death of EHR Innovation

In 2009 the Obama Administration became the drivers of healthcare policy by implementing a series of legislative acts including the HITECH Act and its Meaningful Use (MU) standards. Over the last eight years, sweeping reforms and regulations effectively transformed the world’s 5th best healthcare system into an industry riddled with frustration. Today, many question the advantages of such regulations while others desperately yearn for the pre MU days of healthcare.

There is no doubt MU and HITECH had positive impacts on the healthcare industry at large. For example, the Medicaid EHR incentive program has increased EHR adoption in hospitals from 11.9% in 2009 to 59% in 2014 – a nearly fivefold increase. During roughly the same period, EHR adoption in office-based physician practices rose from 48% in 2009 to 78% in 2013 (Meigs, Solomon 2). Moreover, many

“physicians perceive that EHR use yields overall clinical benefits, more efficient practices and financial benefits, and improves timely access to medical records as well as the quality of communication with other providers” (Jamoom, Patel, Furukawa, King 1).

Despite these success stories and positive claims, the introduction of HITECH and MU is not without consequence from an end-user perspective.

In the wake of HITECH and MU, many EHR vendors were forced to slam on the breaks of technological innovation in order to satisfy strict regulations. This is particularly true for small-scale EHR vendors, the forerunners of healthcare IT innovation, who must accelerate the standards of innovation to compensate for a lack of abundant resources. Unfortunately, focusing on meeting the strict standards of MU hindered the abilities of small-scale EHR vendors to work intimately with physicians and truly understand their needs. Indeed,

“many people blame the HITECH Act and its meaningful use EHR program for incentivizing software vendors to craft products that meet the federal government’s specific criteria at the expense of innovative features and functionality” (Monegain 1).

What is more frustrating for EHR vendors is the significant growth in physician dissatisfaction with their technology. In Electronic Health Record Use a Bitter Pill for Many Physicians, Stephen Meigs and Michael Solomon argue,

“a recent study revealed that the use of EHR systems is a contributing factor to professional dissatisfaction among physicians. Dissatisfaction with EHR technology is trending upward, with 12% more physicians expressing unhappiness with their EHR system in 2012 than in 2010” (Meigs, Solomon 2).

It is likely this increase in dissatisfaction can be partially linked to the continuous roll out of burdensome regulations within MU stages 1 and 2. Moreover, it is naturally expected this level of dissatisfaction will rise with further impending regulations included in MU stage 3, expected to roll out in 2018. Indeed, Dr. John Halmaka, Chief Information Office of Beth Israel Deaconess Medical Center, recently stated,

“Stage 1 created a foundation of functionality for everyone, that was good. Stage 2 tried to change too much too fast and required an ecosystem of applications and infrastructure that did not exist. Stage 3 makes many of the same mistakes as Stage 2, trying to do too much too soon. There needs to be a new approach” (Shaw 1).

But what exactly will this new approach look like?

In many cases, EHRs that were designed pre-MU originally had high user satisfaction. Unfortunately, many software systems were redesigned to obtain MU subsidies and, subsequently, user satisfaction dropped (Monegain 1). Ultimately, federal regulations have incentivized EHR vendors to produce and implement a product that does not align with their innovative missions nor meets the expectations of healthcare facilities. In turn, what was expected to be a win-win scenario has increasingly resulted in a lose-lose.

Frustration is felt on both sides; both from the EHR provider and the physician. This notion is reinforced by the recent actions taken by the American Hospital Association (AHA). On November 30th, 2016, the AHA wrote a letter to President Trump and his administration asking to cancel Stage 3 of the Meaningful Use program (Slabodkin 1). In a letter signed by 5,000 member hospitals, CEO Richard Pollack quotes, “we urge your Administration to modify or eliminate duplicative, excessive, antiquated, and contradictory provider regulations.”Pollack also noted that hospitals are advancing health information technology and must ensure they “have the workforce and health IT infrastructure to best support care delivery” (Slabodkin 1).

The same can be said for EHR vendors who would love for the opportunity to get back to their mission of providing the most technologically innovative products available. According to Charles Webster, MD,

“most physicians today would not go back to pre-EHR days, but many who used EHRs before MU use would definitely go back to pre-MU days. The incentive-driven mandates have essentially pinned down the current crop of EHR technology from significant advancements” (Monegain 1)

and may continue to do so if MU Stage 3 is implemented. As physician dissatisfaction rises, EHR innovation stagnates, and tax payers continue to support this $35 billion dollar project, it is becoming increasingly difficult for anyone to justify MU or HITECH. Perhaps this is why Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services announced,

“MU as it has existed – with MACRA – will be effectively over and replaced with something better” (Shaw 1). It is time EHR vendors get back to business and “ratchet up the competition based on features and functionality rather than merely meeting government criteria” (Monegain 1).

Until then, both hospitals and EHR vendors will have to anxiously wait until the HITECH and MU era is effectively replaced or ultimately canceled.

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Jamoom, Eric W. et al (2016). “EHR Adopters vs. Non-Adopters: Impacts Of, Barriers To, and Federal Initiatives for EHR Adoption.” Healthcare (Amsterdam, Netherlands) 2.1 (2014): 33–39. PMC. Web. 14 Apr. 2017.

Meigs, Stephen L., and Michael Solomon (2016). “Electronic Health Record Use a Bitter Pill for Many Physicians.” Perspectives in Health Information Management 13.Winter (2016)

Monegain, Bernie (2017). “Paper or Pixels? Clunky EHRs Have Providers Looking to the Past.” HealthcareIT News, 4/11/2017.

Shaw, Gary (2016). “Cerner Growing Fast, But Health Care IT Rules Grow Faster.” Investor’s Business Daily, 1/26/2016.

Slabodkin, Greg (2016). “AHA asks Trump to Cancel Meaningful Use Stage 3.” Health Data Management, 12/02/2016.

EHR vs. ROI: Is it Worth it?

Written By: John Cosenza

In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) initiated a large-scale implementation of Electronic Health Record (EHR) systems. Despite broad consensus EHR systems can significantly improve healthcare performance and patient outcomes while reducing costs, many healthcare facilities resisted the incentive. According to Julia Adler-Milstein, Carol E. Green, and David Bates,

“The primary barriers to adoption have been financial: most physicians have cited lack of capital and uncertain return on investment as substantial hurdles” (Adler-Milstein, Green & Bates 562).

Government initiatives have certainly encouraged adoption but existing literature reports mixed results on the financial benefits. Such implementations are often “fast-tracked in an effort to meet meaningful use requirements, typically restricting providers from realizing a clear return on investments” (KPMG Institutes). However, almost one decade after the introduction of HITECH, sufficient time has passed to more accurately assess a correlation between EHR implementation and a ROI.

In “Return on Investment in Electronic Health Records in Primary Care Practices: A Mixed-Methods Study”, Yeona Jang, Michael Lortie, and Steven Sanche analyze this correlation in primary care practices. According to the authors,

“the implementation of EHR systems within primary care practices is seen as particularly complex, with physicians and other staff in primary care practices citing obstacles such as difficulty in adapting to the significant changes in workflow and the time commitment required to learn to use the new software while prioritizing patient care” (Jang, Lortie, Sanche 1).

Despite these obstacles the sampled primary clinics typically recovered their investment within an average of 10 months; primarily due to a drastic increase in patient visits with improved “active-patients-to-clinician-FTE and active-patients-to-clinical-support-staff-FTE rations” post implementation (Jang, Lortie, Sanche 3). Moreover, the ability to quickly process claims enabled all but one clinic to report an increase in annual net revenue. However, this study focuses solely on primary care clinics and is therefore limited. If other healthcare settings are analyzed they may not necessarily bare similar results.

In fact, certain healthcare organizations including M.D. Anderson attribute the annual loss of revenue and layoffs to EHR implementation; recently the University of Texas M.D. Anderson Cancer Center announced its plans to eliminate at least 1000 jobs through layoffs and retirements. According to Cara Smith of the Houston Business Journal,

“The institution’s financial woes started when it rolled out a new electronic health records system in March. The nonprofit cancer hospital anticipated the system would create an initial loss in productivity as the users – physicians and mid level clinicians – started using the system. To combat that, the institution bolstered its cash reserves and staffed additional contractors and part-time personnel to create a smoother transition” (Smith).

The cuts in staff are expected to save M.D. Anderson approximately a $120 million a year with the hopes off countering the costly implementation of the EHR system; a system which could have cost M.D. Andersen somewhere in the realm of $100 – $200 million or more.

New York City Health + Hospital Corporation (NYC HHC) experienced similar issues to M.D. Andersen since implementation of their new EHR system in 2013; the original contract and subsequent maintenance over six years cost NYC HHC an approximate $764 million. Since implementation, a number of C-suite execs have been fired and replaced due to poor budgeting and a series of unforeseen delays. More recently

“In the last six months, the system has also juggled recent layoffs of 70 positions dubbed ‘redundant managerial level, non-clinical’ positions, as well as changes in leadership”(Sanborn 1).

A single ROI narrative is difficult to establish because circumstantial differences across the healthcare spectrum result in disparate outcomes. Underlying differences including facility type, facility size, the specific practice or field of care, staff size, and EHR products themselves all play a role in determining a ROI. However, there is a universal factor that most authors and healthcare information technology experts agree upon.

This universal factor is the ability of healthcare practices and facilities to optimize their EHR systems to the utmost extent. The studies reveal the most successful facilities and practices are those systematically raising the bar of EHR innovation. Indeed,

“Some clinics seem to be more innovative than others in using EHR in their practices to achieve significantly better operational and financial results. The analysis suggests that a clinic’s ability to take advantage of EHR to support process changes has a significant effect on the time required to achieve cost recovery from an investment in EHR” (Jang, Lortie, Sanche 6).

Julia Adler-Milstein, Carol E. Green, and David W. Bates, authors of “A Survey Analysis Suggests That Electronic Health Records Will Yield Revenue Gains for Some Practices and Losses for Many” similarly argue,

“When we examined what distinguished practices that were able to achieve a positive ROI from those that were not, we found the largest difference was that successful practices used their EHR system to increase revenue to a greater degree. Our study suggests the adoption of an EHR system can have a markedly positive financial impact, particularly for practices that effectively leverage their systems” (Adler-Milstein, Green & Bates 566-568).

Heather Haugen, vice president of Healthcare Provider Solutions at Conduent, 2017 HIMSS Conference attendee, and the creator of the Breakaway learning methodology echoes the same notion. In an interview with Show Daily: The Official News of HIMSS 2017, she states, “the commitment of organizations to really get the outcomes they expect from their EHRs is what we’re trying to achieve now. It’s our focus today in healthcare” (Haugen 11).

These experts suggest a positive ROI is likely to depend on a facility’s commitment to leverage their EHR systems in new and innovative ways for years to come; not simply after go-live. When considering EHR adoption physicians and administrators typically think of short-term outcomes. This mindset discourages pockets of medical community leaders from realizing the financial benefits are a complex and long term endeavor and, in turn, do not focus on developing long term strategies. Indeed, Haugen argues “many organizations look at the initial cost of implementation but fail to consider the long-term resources needed to sustain and leverage an EHR” (Haugen 11).

Designing a long-term plan meeting the specific needs of a facility is often a greater obstacle than the lack of funds. However, as noted above, partnering with the right EHR vendor that presents a financially feasible system is equally important. Ultimately,

“practices and health systems must complete an arduous journey to revise care delivery processes so that they can leverage the full capabilities of Health IT” (Berger 20).

When this arduous journey is visualized and effectively put into action in accordance with specific needs, even the most financially challenged healthcare facilities can implement the right EHR system and experience a positive long-term ROI.

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Adler-Milstein, Julia., Green, Carol E., & Bates, David W (2013). “A Survey Analysis Suggests That Electronic Health Records Will Yield Revenue Gains for Some Practices and Losses for Many.” Health Affairs Vol.32, No.3, (2013).

Berger, Eric (2013). “Electronic Health Records, Promises Promises: Experts Advise Patience for Return on Investment.” Annals of Emergency Medicine, Vol.62, No.1 (2013).

Haugen, Heather (2017). “Getting the Most out of Your EHR Implementation and Adoption.” Show Daily: The Official News of HIMSS 17, 2017.

Jayanthi, Akanksha (2015). “Execs fired as Cost of Epic EHR Rollout Grows at NYC Health and Hospitals.” Health IT & CIO Review, 8/21/2015.

Jayanthi, Akanksha (2016).”What’s the Deal With NYC Health + Hospitals’ EHR Transition? 9 Things to Know.” Health IT & CIO Review, 3/25/2016.

KPMG Institutes (2017). “Beyond Implementation: Optimizing EHRs to Realize Results.” Healthcare & life Sciences Institute, Feb. 8th (2017).

Sanborn, Both Jones (2017). “NYC Health + Hospitals Delays Next Phase of $764 Million Epic EHR Implementation.” Healthcare Finance, 2/16/2017.

Smith, Cara (2017). “M.D. Andersen to cut 1,000 Jobs in Houston.” Houston Business Journal

Yeona, Jang., Lortie, Michael A., & Sanche, Steven (2014). “Return on Investment in Electronic Health Records in Primary Care Practices: A Mixed-Methods Study.” Journal of Medical Internet Research, Vol.2, No.2 (2014).

Vexed Veterans: The Continuum of Care in the VA

Written By: John Cosenza

On January 6th, 2016 outrage ensued across the nation as Esteban Santiago-Ruiz, a military veteran with a history of mental health issues, opened fire on innocent travelers in Fort Lauderdale-Hollywood International Airport. Shortly after the shooting, Florida Governor Rick Scott labeled the incident a ‘senseless act of evil.’ Yet, is it that simple? Was this simply a random act of evil or another unfortunate event stemming from a much larger issue? Should the American public support the execution of this troubled man? Or, should the American public take a moment and ask why veterans are more prone to act out violently?

The effectiveness of preventing acts of violence by means of execution or imprisonment is up for debate, but is no doubt a short-term solution. Moreover, the Veteran’s Health Administration (VA) has faced intense public scrutiny in recent years; the 2014 Phoenix facility scandal being the catalyst for uncovering widespread corruption and incompetence. Perhaps then, it is time to reevaluate the VA’s ability to implement effective means of long-term care for veterans suffering with mental and behavioral health illness.

However, before any solution can be brought to the table, it is first necessary to determine the origins of this melancholy event. In order to gain more knowledgeable insight on this topic, Meta interviewed a military veteran who wishes to remain anonymous. The following conversation highlights struggles of transitioning veterans and discusses strategies that may improve the continuum of care within the VA.

Q: If you were in a position to prevent another incident like Ft. Lauderdale, what would you do or change about the VA?

A: First, I would just like to say the VA has excellent programs like free healthcare, free education, financial compensation, therapy, and employment opportunities. I was able to get a college degree because of the VA. But there is definitely room for improvement. There should be a serious effort to establish more accessible care. Local VA facilities like VA urgent care centers or VA walk in clinics should be established rather than have one hospital that might be 40, 50, or more miles away. Second, and more importantly, the VA needs to take a stronger stance on educating returning veterans and their families. It should be mandatory for the VA to register returning veterans so they can quickly reach out and discuss the programs they offer, where you can seek help, etc. Many veterans don’t seek help because they simply feel as if no one cares, or they don’t matter to our society, or don’t know what kind of help is available. If you don’t make an effort to seek help, then you will never get it. A simple phone call from a VA physician or employee, a call that veterans usually never get, can, in my opinion, make a big difference.

Q: Were you contacted by the VA when you arrived home?

A: No. I was home for 5 months and was never contacted by anyone from the VA. It was not until a friend finally convinced me to visit my closest facility that I spoke with someone from the VA. If I had not made the effort to go, I don’t think I would have ever been contacted.

Q: Do you think the VA failed Esteban in this manner?

A: It was not just the VA. Many channels failed. His family noticed his behavioral changes when he came home and that should have been the first red flag. In his mind he was, what we call ‘down range’, or still back in Iraq or Afghanistan. He went to the FBI and sought help, who then washed their hands and turned him over to the local police because he apparently did not present any serious issues, even after admitting to hearing voices and other things that should have been taken as serious red flags. This man sought help and it should have been followed all the way through, from the FBI, to the local police, to his local VA facility. Once his local VA facility learned of the situation, they should have reached out to him and continued to keep tabs on him. I don’t know if they did or didn’t, but this is where we must improve. Getting veterans to seek care is hard enough so when a veteran actually seeks care because they know things aren’t right you can’t let them slip through the cracks.

Q: Do you think this is a method the VA can use to bring about a more effective continuum of care?

A: Yes. The VA can improve long-term care by establishing a serious outreach community and culture. Did the FBI or police contact his local VA facility and warn them of his condition? I don’t know, but if they did, did the VA contact Esteban and ask him to come in for an evaluation? Did anybody contact his family to see how he was doing or to educate them on VA services? Did anybody check with him after he got his weapon back or call him to just see how he’s doing, or if he needed help? These are the questions we need to start asking. It is very easy for someone to slip through the cracks if nobody is keeping tabs or showing concern. Beyond follow up appointments or getting back lab or test results, you typically don’t hear from anybody in the VA. It seems like nobody learns their lessons or is held accountable, or updates policies to handle these situations that present similar red flags. They often wash their hands and move on. The VA ought to update their standard procedures or protocols to meet this type of persistent outreach.

This conversation of course does not reflect the experiences of every veteran. As stated above, the VA provides excellent services that benefits thousands of veterans throughout their transition process. However, as our conversation ended it became more apparent Esteban, a mentally disturbed man who sacrificed his life to serve our country, possibly faces execution; likely due to the lack of proper care, education, and outreach. Not necessarily because he was an incarnation of evil. Yet, there may be solutions to prevent further acts of violence.

Firstly, the VA can be localized to meet needs of veteran communities. Integrating urgent care centers or walk in clinics with VA physicians and services can be an incentive for veterans to seek care who currently have to drive hours or across state boarders. Secondly, the establishment of serious and persistent outreach may prove effective. In fact, the VA has cited studies in suicide prevention which support this notion. Indeed, a 2009 report titled Strategies for Suicide Prevention in Veterans cited a study in which two groups of patients, one controlled and one experimental, were seen in a Pittsburgh hospital. The study reveals, after discharge,

“Patients were in contact with staff at least biweekly to provide treatment, or to monitor the treatment when it was provided by other services. Patients assigned to the control group were treated in the usual manner in the ER or hospital, and released with written appointments; no attempts were made to provide outreach to those who failed to follow up. The outcome was the number of suicide reattempts in the 4 month follow up period. The treatment group had 4.8% reattempt rate, while the control group had a 15.8% reattempt rate, a statistically significant difference” (Shekelle, Bagley, Munjas 20).

In the same report, a study conducted in San Francisco on patients admitted to psychiatric hospitals for depression and violent outbreaks bare significant similarities to the previous study. Indeed, the results reveal,

“Patients in the contact group received short, personalized letters from staff who had conducted their initial interviews expressing concern about the patient, and inviting the patient to respond. Patients in the no-contact group and those who had complied with the initial post-discharge therapy received no letters. In five years after the index contact, the treatment (contact) group had a suicide rate of 3.9% compared to the control (no-contact) group at 4.6%” (Shekelle, Bagley, Munjas 24).

It is difficult to determine whether civilian based strategies will have the same effect on military veterans, whose life experiences are drastically different. However, if the VA is aware of these benefits, have they taken necessary measures to implement wide scale outreach programs?  If not, perhaps the VA can invest in outreach methodologies such as registering and contacting returning veterans to schedule evaluations and discuss different pathways of care, as the interviewee suggests. From there, the VA can improve long-term outreach efforts with their patients to accurately determine the next steps of care, if needed. This experiment may produce similar results from the studies above and, in turn, reduce violence among veterans and ultimately improve the VA’s continuum of care. These simple strategies can bring a glimmer of hope to veterans who feel they don’t matter to society or don’t know if they should seek care. In some cases, a simple glimmer of hope may have a significant impact. Although establishing local VA facilities and providing persistent outreach will not solve every issue within the VA, it apparently continues to be an overlooked, but obvious starting point.




Bowman, Dan. “Lawmakers Approve $260M for VistA Modernization, but Demand Interoperability With DOD.” FierceHealthcare, Mar. 28th, 2016.

Shekelle, Paul MD., Bagley Steven MD, MS., Munjas, Brett BA. “Strategies for Suicide Prevention in Veterans.” Department of Veterans Affairs Health Services Research & Development Service, January 2009.

Interview with: Anonymous Military Veteran. January 10th, 2016.