The tenure of Dr. David Shulkin as secretary of Veterans Affairs made headlines in all the ways that Trump administration officials usually do.
Shulkin came into the job of leading the Department of Veterans Affairs after a career in healthcare management, during which he held posts including CEO of Beth Israel Medical Center in New York City, chief medical officer of the University of Pennsylvania Hospital and University of Pennsylvania Health System, and professor of medicine at Albert Einstein College of Medicine, among other high-level jobs. The son of an army psychiatrist, he earned his undergraduate degree at Hampshire College and his medical degree from the Medical College of Pennsylvania in 1986.
He joined the VA in 2015 as undersecretary under President Obama, then was promoted to head the organization when Trump took office in 2017. He defended himself against allegations that he did too much sightseeing during a 2017 European trip before being fired by tweet in March of 2018.
But when Shulkin visits the Princeton Tech Meetup on Monday, December 2, his focus will be as much on what can and should still be done to help America’s veterans as it will be on the drama of working for Trump as he discusses his book, “It Shouldn’t Be This Hard To Serve Your Country.” The talk will be held at 15 Seminary Place in New Brunswick from 3:45 to 5:30 p.m. The event is being held by the tech meetup along with Rutgers University and James Barrood and the Scarlet Startups group. For more information, visit www.meetup.com/Princeton-Tech.
While Shulkin may seem like an unusual speaker for the tech meetup, which is focused on technology and business, it turns out that Shulkin’s tenure at the VA had everything to do with improving the way it uses technology. When he took the job he planned to use his extensive experience overhauling healthcare systems in the private sector to make the VA more efficient and effective.
When Trump became president there was a school of thought that his deranged statements and behavior over the previous year were nothing more than campaign tactics and that he would settle into role of president and take his job seriously. Shulkin was in the camp that thought the Trump presidency would be somewhat normal.
“Hopefully much of the rhetoric and issues we saw in the campaign were going to change, and we were going to bring the country together in bipartisan fashion,” he says. The fact that Shulkin, an Obama appointee, had been given the job was a good sign. Whereas the Obama administration was a “well-oiled machine” by the time Shulkin joined, he says, the new administration offered a “looser environment” where there was much more direct access to the president, and that when taking action, he could skip steps that he previously had to go through.
One of the first items on Shulkin’s agenda was overhauling the VA’s electronic health records system, which had been created in-house about 30 years ago. “It was essentially not going to meet our needs in the future,” he says. “And I didn’t believe the VA should be in the software business.” He also wanted a system that would provide interoperability with other healthcare providers. His solution was to hire a commercial provider to create a new electronic health records system.
The old system, he learned, had been created almost four decades ago using the MUMPS programming language, which had been designed in 1966 for use by healthcare providers. “It was very difficult just to be able to get the type of software engineers able to keep the system up,” he says. “And when you think about hiring software engineers at government salaries when the competition is Facebook and Google and Amazon, it was just becoming impractical for us to remain in the business of evolving a homegrown system to be a contemporary system.”
Shulkin says the cost of upgrading the old system was greater than switching to a commercial product.
Shulkin said another priority was to expand the use of telemedicine: the ability of healthcare providers to see patients anywhere in the world via videoconferencing. “We had to meet the access needs of veterans that live in every nook and cranny in the country,” he said. Doing that required changing the regulations that governed when doctors could use teleconferencing to see patients. He aimed to make the VA more consumer-centric and give patients the ability to see doctors using their own computers and mobile devices rather than traveling to a clinic with teleconferencing equipment.
“We were able to provide healthcare anywhere in the country, which I thought was important,” Shulkin said. “Patients had difficulty getting access to specialists if they lived in rural areas, and we found a way to address those needs. Sometimes it can really be life or death difference in getting access to care. If you’re holding a job and asked to drive 60 miles to a VA clinic, that’s going to take up the whole day from work. This type of technology really does make a huge difference.”
Telemedicine also allowed the VA to make more efficient use of its resources. Doctors with gaps between patient visits could fill the time with telemedicine calls seeing patients all over the country. Since the doctors are mostly on salary, the extra patient visits don’t add to increased payroll costs.
“This wasn’t new technology,” Shulkin says. “Telehealth platforms have been available for decades, but the way we are doing this, rolling it out to over 50 different specialty programs from tele-dental medicine to tele-behavioral health, I think no one has been doing it at such scale and scope as the VA, and we really are a leader in this.”
The third major technology initiative was to begin using artificial intelligence to identify veterans most at-risk for suicide. Veteran suicide had been a priority for Shulkin since the beginning, and one of his first moves was to expand mental healthcare. In reviewing the data it turned out that most veterans who committed suicide did so within one year after leaving the military. Only about 40 percent of those leaving the military were eligible for mental health benefits, so Shulkin increased mental healthcare to cover everyone during the first year. He also expanded it to cover those with “less than honorable” discharge status.
Shulkin said the use of AI was an internal project. VA researchers had been looking at using the administration’s large database to look for patterns that would identify those who were at most risk for suicide over the next year and give them appropriate interventions. Shulkin heard about the research project and had it put to use. “Researchers like to study things and publish them and present them and don’t necessarily think about how to transition it into practical applications. I insisted that they move it into the field because I thought it was really that big of an urgency and something that could help.”
During his tenure, Shulkin outsourced some VA operations, such as its electronic healthcare system, to private industry, which he thought would handle the job better. However, he spoke out against a general push from within the Trump administration to privatize the entire VA system. “I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans,” he wrote in a New York Times op-ed.
“The reason I took the job is because I care deeply about what happens to our country’s veterans,” he said. “Vets deserve better than they’re getting, and that is very much a value of mine that I will continue to advocate for the rest of my life.”