Modernizing the VA: One Veteran Tech Leader’s Roadmap to Interoperability

Veteran and health tech leader Sean O’Connor shares a personal and technical roadmap to modernizing the VA, tackling cultural, logistical, and digital challenges head-on.

Please introduce yourself by stating your name, title, and any relevant experience you’d like to share.

Sean O'Connor: I'm Sean O'Connor. I'm the co-founder and chief commercial officer of DexCare. DexCare is a company that was incubated within Providence. Providence is one of the larger not-for-profit health care systems in the country, and it was born to try to solve some complex access issues that Providence is facing in terms of getting consumers connected to the right provider, at the right time for the right reasons, which we can talk a little bit about today.

More pressing for this conversation, I'm also a third-generation veteran. Both of my grandfathers fought in World War II. One was an airman on a PBM in the Pacific and was shot down and won a Purple Heart. My other grandfather supported the war in Europe. Then, my father and my uncle served in and around the Vietnam era. I'm a 9/11 veteran who served during 9/11 and got out several years after that crisis.

We're very familiar with the US Department of Veterans Affairs (VA) and some of the unique holes in our country in terms of providing care for those who serve. I'm also very familiar with some of the challenges the VA has had in modernizing interoperability and scaling to serve the needs of men and women in the 21st century.

What are some cultural nuances within the VA that civilian health tech leaders often underestimate or misunderstand?

O'Connor: It's an incredibly complex and unique health care delivery system in our country when you think about the mission it's asked to solve and support, and some of the nuances it has to work within. You can start with the fact that roughly 50% of the patient population that engages in care routinely with the VA is greater than 65 years old. It's an aging, older population, which means sicker patients and more comorbidities than the average private health system in the US.

There is also the fact that VA treats some unique things that the private sector doesn't see, such as wound trauma, toxic exposure, improvised explosive devices (IEDs), combat wounds—all the trauma cases. The VA is incredibly well-equipped to service the men and women who come back from deployments with really unique injuries that are, again, unique to the VA health care system.

There is also the mental health crisis—which I'll still call a crisis—within the VA. Mental health has become something our society talks about more as a whole. Since the pandemic, it's become healthier to talk about it, get counseling, and get help. But the mental health crisis has been plaguing the VA for decades.

Congresswoman Miller-Meeks provided an update in March on the VA spend and some of the impact they're having on some of these unique areas of health care delivery, mental health being a big one. The VA received roughly $21 billion in funding in 2001 to support its mission. That same year, 17 men and women took their life every day. You fast-forward to 2024, the VA received an extra $100 billion, so $121 billion of service at the same mission, and that number's still the same. It hasn't moved at all.

To receive that much money and not make an impact on something as pressing as that to our country is gut-wrenching. It's a complex issue. There are a lot of reasons why that’s the case. You can start with the fact that most of the veterans that take their lives don't engage in the VA for health care to begin with. But as a health care delivery ecosystem and as health care technology entrepreneurs, we have to find a way to change that statistic.

I'd say the last thing that's very unique to the VA is how it's funded, how it's appropriated, and who sets the policies there. You have Congress setting laws around how the VA should govern, setting appropriations for how the VA should spend the money, and then providing oversight. There's no other health care system in the world that has to deal with that many different stakeholders on both sides of the aisle to try to drive policy and access and improve care to men and women.

It's also still the largest health system in the country. The size, the complexity, the uniqueness of the mission, how laws are set and funded for it, and how to work around government infrastructure make it incredibly complex, but also incredibly important.

When I first moved to Seattle, I didn't know anybody up here, so I wanted to go to the VA, sit down a lobby, and just talk to people. There's that American icon of having an institution where men and women wear their hats so you can see where they serve, you can see where they're from, and it's an incredibly important fabric for our country. We have to do a better job of helping the VA modernize and provide care to the folks that are leaning on it.

How do you balance the promise of digital health innovation with the reality of existing patient and clinician behaviors in the VA?

O'Connor: The positive side of it is we've seen plenty of examples of how we've been able to influence those behaviors in the private sector.

Digital health went on this massive boom during the pandemic. However, pre-pandemic digital health adoption in the private sector was really slow. People were slow to adopt telehealth, and online scheduling was super slow. The pandemic forced society, the health care system, and consumer behavior to move toward modernization and greater interoperability for some really large, multistate, complex health care systems that operate with similar footprints to the VA.

We've seen plenty of examples where systems as big as Kaiser, Providence, and others have been able to take digital health tools and influence provider and consumer behavior to change because they're designed with those folks in mind from the beginning. I think that's key.

The last couple of companies that I started up began in large, multistate, complex health care systems, and we were very purposeful in bringing in a combination of health care folks plus folks with no health care backgrounds—consumer companies like Amazon, Netflix, online companies that have great consumer adoption of products—and merged those two things together to figure out how we can help disrupt the health care model from within. You can't just throw stuff out there in a noncompliant way. There's a ton of regulation and HIPAA that's important to health care, so you have to understand that.

You also have to understand the stresses that providers are under from going from the operating room to running a clinic and all the nuance that goes into that. Any technology delivered into that environment has to work efficiently with both end users in mind. I think the good news is—back to your question—we’ve seen plenty of examples, post-pandemic, of health care systems in general that were slow to adopt digital innovation, move much faster over the last 5 or so years.

The providers are more productive, and the consumers are getting access to care more efficiently. If we can do it in some of those large, complex systems, I'm hopeful and optimistic that we can do it in the VA as well through the right combination of change management and technology.

It's never just one thing. Technology is generally less than half of the problem, but it's a key part of interoperability and modernization. There are workflows, code logic, stop codes, and things like that that are unique to how the VA does scheduling care and are a bit different, but there are plenty of examples of how that's worked in the private sector.

The last thing is that the current leadership at the VA is taking a much more proactive role in talking about the need to act, improve access, and modernize the technology. There is a lot more attention being put on the foundational infrastructure to try to deliver care more seamlessly across the VA, which is great for veterans who struggle with getting access in a timely and efficient manner.

You’ve spoken about breaking down data barriers. What are the key technical or organizational obstacles, and how do you propose overcoming them within the VA ecosystem?

O'Connor: The foundation that the VA sits on today is very hard to scale from an interoperability and modernization standpoint. To give the VA credit, they were at the forefront of electronic health record (EHR) adoption in early days. In the 1970s, they started experimenting with this—with VistA—and then in the 1980s they started to implement it and were some of the first health care systems to scale that at a large level.

It was needed because, for all of the complexities in delivering care on a nationally integrated delivery network, to have that modernization was really important. Fast-forward to today—from the 1980s to 2025—that system is very antiquated in a number of areas.

They have roughly 130 different VistA instances. From a lot of the VA leaders we talked to, there's a lot of custom code delivered across those. They're not scalable; the same logic doesn't exist across many of them. The VA signed this deal with Cerner, now Oracle, in 2018. Oracle, to date, has only rolled out half a dozen systems that have been updated out of the 130.

It's been a very slow, methodical process. There are some unique things to how the VA operates around things like stop codes and how they do scheduling that are different than other places, as well as the lack of ability to share inventory and capacity across different VistA instances. All those things will make it challenging. But there are ways, through some of the technology modernization that has gone on over the last 5 years, to start to overcome some of the legacy electronic medical record (EMR) technology and put wrappers around it to make them work a little more efficiently, which we're excited to try to help them with at some point in time.

What would a high-functioning, tech-empowered VA look like in five years?

O'Connor: The ability to come onto an infrastructure that allows for the VA to take advantage of its national scale would be super important. A national, on-demand, virtual telehealth network would be a foundation to start with. That's something we did with Kaiser. Kaiser had over half a dozen different EMR systems and they had a problem, similar to the VA, where all that data was siloed in one EHR. It's tough to get a global view of supply and demand across an entire network.

According to the VA today, in some publicly available data and our conversations with VA leaders, anywhere from 9 million to 14 million appointments go unutilized every year across the VA. Think about all that waste that's out there in the ecosystem because these systems don't talk. If a patient needs to get onto a care appointment and there are no providers available in New Jersey, but there's one in Connecticut, just being able to overflow to that provider and get seen in a timely manner—and fulfill some of the Dole Act's missions of same-day care—shows how technologies can take down these different silos of inventory and bring them into one queue to allow for a national network to truly be optimized.

The first thing we say is: let the VA leverage its scale and break down these different silos of 130 different VistA instances and half a dozen, and growing, Cerner instances, and create one global view of all the VA inventory that exists today and service those men and women in same-day care fashion better, sooner, quicker.

And then we should start to take down some of the data silos that exist in these and figure out how to provide more timely access to on-demand care. I looked this morning, for me to schedule an appointment at the Seattle VA, it's 17 clicks from my login authentication to get to a basic primary care appointment. A calendar then popped up and asked me to pick 3 options, morning or afternoon on two or three different dates. That doesn't tell me if there's any availability. It doesn't tell me if those dates actually work or if they're available, just that someone will call me back.

Think about anything else in our life today where we're trying to schedule something online and we have to go through 17 clicks, then pick three options, and don't know if it's available—just have wait for someone to call you back. Murphy's Law: they'll call you back when you're in a meeting, and then you play a game of phone tag forever, and weeks go on before something's scheduled. Making online care accessible and easy is very important. Click to book, authenticate, show availability, show care team, book it, and get it done.

Additionally, we need to truly bring in a global view of all the community care that the veterans have access to. They have access through the Mission Act and can get care inside or out to the VA, depending on availability and complexity of disease state. Having all of that in one view to be able to let the veteran take care of his or her care access in appropriate time is a great vision for the next 5 years, if VA can start to make some progress there.

We need to break down the data silos and create a national network that allows the care providers to treat veterans. We need virtual care—anywhere, 24/7, in any state. We also need to take down some of the data silos to allow veterans to direct book online, both inside and outside the community, so that they don't have to go back on these telephone calls. This would also make the call center agents’ jobs easier when they don't have to navigate 9 different screens or 2 different desktops and to look at inventory from one VistA instance to the other.

There are ways that modernization and interoperability can help the VA as they go through the challenge of backending their EMR system. To us, as technology entrepreneurs who work in really complex health care systems, that's what “great” will look like for the VA over the next 5 years.

There are plenty of mission-driven technology companies, like ours, that are willing and able to help, if the VA raises their hand and says it’s interested in trying to improve some of those areas.