Time for the VA to Clean Up Its Act

One year after a Veterans Affairs (VA) scandal was ignited here in Phoenix, the number of veterans on wait lists is 50 percent higher than at the same time last year, according to VA data (1). The VA is also facing a nearly $3 billion budget shortfall. VA Secretary Bob McDonald has asked for “flexibility” to reallocate billions of dollars in clinical funds to cover the shortfall.

Since the scandal broke last year, VA providers have increased their workloads, adding 2.7 million more appointments than the previous year. However, the VA has played "games" with patient eligibility for years. When money was plentiful VA administrators would open the doors to patients since the following years' budgets were based on the number of patients seen. However, when money was tight, the doors would be slammed shut leaving many patients in the lurch scrambling to obtain health care elsewhere. Now it appears that patients might be returning to the VA.

“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.” Now the VA is asking Congress' permission to use clinical funds to pay for the budgetary shortfall.

The VA has threatened furloughs and hiring freezes to reduce spending. This seems to be quite sensible. However, in the past, the VA has cut clinical positions which undoubtedly contributed to longer wait times. For example, when I was chief of pulmonary at the Phoenix VA, one of my physicians retired, giving 6 month notice. However, we were not allowed to replace the physician because of a "hiring freeze". This apparently only applied to clinicians since a new associate director was hired.

As we predicted over a year ago, the VA would continue to be troubled due to lack of reform and oversight (2).  The present VA secretary, Robert McDonald, is still relatively new on the job and inexperienced in both healthcare and government service. His inaction suggests that he may be confused, or worse, listening to long-entrenched central office bureaucrats. Below are some suggestions which could result in substantial savings and would have little impact on patient care.

Furlough the staffs of the Veterans Integrated Service Networks (VISNs), the 21 VA regional offices which are scheduled to be downsized. The VISNs provide no healthcare and the savings in salaries from the nearly 5000 employees would be substantial (2). Similarly, VA central office which grew from 800 employees to 11,000 in less than 15 years could probably do with a few less administrators (3).

Local VA bureaucracies reflect the growth of central office and VISN bureaucracies. It is unclear what many of the hospital associate and assistant directors do other than sit in meetings. Most hospitals could do without them for a while. Similarly, compliance officers and patient "advocates" really serve no purpose. Despite multiple patient complaints about wait times, the lack of action that led to the VA scandal demonstrates that they are not effective. There are also some physicians and nurses who do not see patients. For example, most VA Chiefs of Staff do not see patients. Nursing administration is bloated with "clip board" nurses who do little than attend meetings and create an ever increasing, and seemingly never ending, stream of paperwork for nurses who are already overworked. Surely, we could do without some of these people. 

It seems unlikely that VA officials will implement any meaningful cost savings. Instead they will try to preserve the status quo by petitioning Congress to allow them to shift clinical funds depriving veterans of healthcare. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card”. This program allows certain veterans to obtain taxpayer-funded care from private doctors. VA administrators have blamed the budget shortfall on this program along with a new treatment for hepatitis C (1). The VA has been accused of dragging its feet on the Choice program and once again appears to be trying to sabotage the program and keep the funds. Gibson said in the interview that in future years more money will also be needed. He said he intended to tell lawmakers, “Veterans are going to respond with increased demand, so get your checkbooks out.”

VA administrators appear more concerned with keeping money inside their dysfunctional agency than caring for vets. Based on past history, Congress will probably let the VA shift the money and none of the recommendations above will happen. If furloughs occur, they will be lower level employees and result in little financial saving. Of course, administrative bonuses will be hefty this year because in their eyes, the administrators have successfully averted a financial crisis. Unless there are some fundamental changes made at the VA, the trend of the last 20 years of bloating the bureaucracy at the expense of healthcare will continue.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Oppel, RA Jr. Wait lists grow as many more veterans seek care and funding falls far short. New York Times, June 20, 2015. Available at: http://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html (accessed 6/24/15).
2. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef]
3. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med 2014;371:295-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Time for the VA to clean up its act. Southwest J Pulm Crit Care. 2015;10(6):350-1. doi: http://dx.doi.org/10.13175/swjpcc088-15 PDF

A Tale of Two News Reports

On Wednesday, February 25, 2015 two new stories aired, one on National Public Radio (NPR) that I heard riding home that afternoon and the other later in the evening on the CBS Evening News with Scott Pelley. Both stories were on the Department of Veterans Affairs (VA) but I was struck by the contrasting style of the two reports.

The first story was an NPR report on back injuries in nurses (1). According to the report nurses suffer more back injuries than almost any other occupation — and they get those injuries mainly from doing the everyday tasks of lifting and moving patients. The report stated that the VA has invested over $200 million in protecting nurses predominately by providing lifts and other devices for moving patients. VA hospitals across the country have reduced nursing injuries from moving patients by an average of 40 percent since the program started. The reduction at the Loma Linda hospital where the report was focused was closer to 30 percent — but the injuries that employees suffered were less serious than they used to be. Loma Linda spent almost $1 million during a recent four-year period just to hire replacements for employees who got hurt so badly they had to go home. However, this past year they spent nothing because according to the report nobody got hurt badly enough to miss work.

The VA's reputation for accurate information has been called into question. The Phoenix VA was the ground zero of an investigation which eventually discovered that about 70% of VA hospitals were falsifying patient waiting reports (2). Perhaps everything in this NPR report is true, however, the NPR report reminded me of so many I heard over the past two decades where any medical report was accepted by the media at face value. Many of the reports I knew were not true because I worked at the VA. There are several reasons to be skeptical. First, it is from the VA. Second, the director of the Loma Linda VA was Donald F. Moore until late 2012. Prior to that position Moore had been the director of the Phoenix VA. Third, the reported drop in injuries borders on the unbelievable. Nursing supervisors likely need to get approval to replace injured nurses.  Perhaps a directive either not to report any back injuries or that approval of replacement nurses would not be granted was issued. There are many ways to falsify the data, but NPR was nonquestioning in their report.

Later that evening CBS Evening News correspondent Wyatt Andrews reported that he found widespread mismanagement of VA claims. The mismanagement resulted in veterans being denied the benefits they earned, and many even dying before they get an answer from the VA (3). Five whistleblowers at the Oakland, California, Veterans Benefits office told CBS News that more than 13,000 claims filed between 1996 and 2009 ended up stashed in a file cabinet and ignored until 2012. VA supervisors in Oakland ordered marking the claims "no action necessary" and to toss them aside. Whistleblowers said that was illegal. Last week, the VA inspector general confirmed that because of, "poor record keeping" In Oakland, "veterans did not receive... benefits to which they may have been entitled." How many veterans is not known, because thousands of records were missing when inspectors arrived. In the last year, the inspector general has found serious issues in at least six VA benefits offices, including unprocessed claims in Philadelphia, 9,500 records sitting on employees' desks in Baltimore and computer manipulation in Houston to make claims look completed when they were not. VA Central Office said in a statement, "..electronic claims processing [has] transformed mail management for compensation claims ... greatly minimizing any risk of delays due to lost or misplaced mail...For any deficiencies identified, steps are taken to appropriately process the documents and correct any deficiencies." Much of this sounded very familiar and similar to the patient wait times the VA falsified last year.

The CBS report closed with a statement from the Veterans service organization Veteran Warriors, which advocates for veterans who are having difficulty with their claims. The Veteran Warriors said in a statement: "Too many cases have come to light, wherein the VA leaders have destroyed, deleted, hidden and manipulated veterans claims - their very access to benefits and services - and NOT ONE OF THEM has been criminally charged. It is time for our nations' leaders to stop listening to the endless "lip service" of accountability and demand answers. If they do not get them, it is time for repercussions to be felt by those who obviously believe they are above the law and insulated from prosecution." It was clear that the Veteran Warriors did not believe the VA and also clear that neither did CBS News.

The weak reporting on medical issues has been apparent to me for some time. The CBS report suggests that this may be changing. The VA scandal may point out that medical reports need to questioned just like other news stories. Truthfulness does matter and the VA continually blaming clerks and other lower level employees for administrative inadequacies or attacking the whistleblower has become tedious. Even the present inspector general's report blamed the closing of the Veterans claims on "poor record keeping". In this instance CBS news was doing their job questioning the VA but NPR was not.

Richard A. Robbins, MD

Editor

SWJPCC

References

1. Zwerdling D. At VA hospitals, training and technology reduce nurses' injuries. NPR. February 25, 2015. Available at: http://www.npr.org/2015/02/25/387298633/at-va-hospitals-training-and-technology-reduce-nurses-injuries (accessed 3/7/15).
2. Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. [CrossRef]
3. CBS News. Whistleblowers: Veterans cheated out of benefits. February 25, 2015. Available at: http://www.cbsnews.com/news/veteran-benefits-administration-mismanagement-uncovered-in-investigation/ (accessed 3/7/15).

Reference as: Robbins RA. A tale of two news reports. Southwest J Pulm Crit Care. 2015;10(3):143-4. doi: http://dx.doi.org/10.13175/swjpcc038-15 PDF

A Veterans Day Editorial: Change at the VA?

"Meet the new boss,

Same as the old boss.

Won't Get Fooled Again!"

            -Peter Townshend

Today we honor our veterans. A year ago VA patients languished on waiting lists waiting for healthcare. VA administrators hid the truth at over 100 VAs and took bonuses for meeting their wait time goals. Money has been poured into the VA, patients in rural areas are seen outside the VA, and it is now supposedly easier to fire other senior VA officials. Dennis Wagner authored an article in the Arizona Republic that claimed the VA has made some changes but more changes are needed (1). I agree with the need for change but would argue that there has been no real change at the VA.

Last week I saw a VA patient in my private practice. He was paying for tiotropium or Spiriva®, a long-acting anticholinergic used in chronic obstructive pulmonary disease, out of his pocket. He was under the impression that the VA did not "carry" tiotropium. I told him that this was not true and that he should go to the VA and ask to be seen in pulmonary clinic if his primary care physician could not prescribe tiotropium. He was sent to the pharmacy where the pharmacist wanted to know why I would prescribe this expensive drug. He was sent back to my office for a response. I xeroxed a copy of my notes and gave them to the patient. I do not know whether he got the tiotropium but my guess is that probably not without some hassle. This is unchanged from prior to the scandal when patient care was undermined by healthcare support staff. No real change there.

Last night, the new Secretary of the VA, Robert McDonald, was on "60 Minutes" (2). He announced that he is "reorganizing" the VA. Although details were not stated, this sounded mostly like a consolidation of websites, not a bad thing, but hardly a "reorganization". He also said how sorry he was for past mistakes and how the new VA was going to do better. I had déjà vu going back to the mid 90's with Ken Kaiser's "Prescription for Change" (3). Eric Shinseki, the VA secretary recently forced to resign, used similar rhetoric and was "mad as hell" at the falsified wait lists (4). No real change there.

McDonald used the term "customers" to refer to VA patients (2). This has occurred off and on since the mid 90's and is a term some healthcare providers find offensive. We do not flip burgers at McDonald's and find it inappropriate and offensive to equate healthcare professionals with businessmen selling Charmin, Luvs, Pampers, Gillette razors, Covergirl makeup, etc. No real change there.

Earlier this week, the VA named a new director at the Phoenix VA, ground zero of the VA scandal (5). He is the former director of the Milwaukee VA and director of the VA's Rocky Mountain regional network, apparently coaxed out of retirement to serve for about a year as director at the troubled medical center. He replaces two directors who served a matter of months. While director at the Rocky Mountain VA region he named Cynthia McCormack, former chief of nursing at the Phoenix VA, as director of the Cheyenne VA (6). Cheyenne was second only to Phoenix in having the widespread falsification of wait times discovered. Sharon Helman, the Phoenix VA director sits at home suspended while collecting a paycheck but McCormack appears to continue to direct the Cheyenne VA. No real change there.

Although a handful of administrators have been fired by the VA, the data falsification was rampant, with most VAs apparently falsifying their records (2). Yet these administrators retain their jobs and continue to rule their healthcare empires. McDonald claimed that names had been turned over to the Department of Justice (DOJ), but the DOJ declined to prosecute, and that administrative law judges were blocking the firing of administrators (2). No real change there.

The VA still functions with a lack of oversight. Congressmen make statements and issue press releases when politically convenient. The VA office of inspector general (VAOIG) still does investigations in response to whistle-blowers. After turning over their findings to VA central office to water down, the VAOIG usually makes some recommendations that are quickly accepted but not acted on by the VA (7). No real change there.

Lastly, there is the popular media. For years we heard about Ken Kizer's "Prescription for Change" and the miracle of the transformation to the VA (3,8). This infuriated many of us who knew it was not true (9). We wondered why the press was so accepting of the claims. They certainly are not on other political issues. However, in this case Dennis Wagner of the Arizona Republic, CNN and several other news sources stayed with the story and ferreted out the truth. Real change there. Hopefully, news media with continue their investigative reporting and question VA officials when they put forth self-serving data that is difficult to believe. This is my hope and may be the only result of the VA scandal that will force change. Hopefully the media "won't get fooled again".

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Much change in wake of VA scandal; more needed. Arizona Republic. November 8, 2014. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/11/08/phoenix-va-scandal-changes/18716281/.
2. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/.
3. Kizer KW. Prescription for change. March 22, 1995. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf
4. Cohen T, Frates C. Shinseki 'mad as hell' about VA allegations, but won't resign. CNN. May 23, 2014. Available at: http://www.cnn.com/2014/05/15/politics/va-scandal-eric-shinseki-preview/.
5. Wagner D. VA names new director for Phoenix medical center. Arizona Republic. November 4, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/11/04/phoenix-veterans-affairs-medical-center-interim-director-brk/18467665/.
6. Cheyenne VA Medical Center. Leadership team: Cynthia McCormack. Available at: http://www.cheyenne.va.gov/about/leadership.asp.
7. Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. [CrossRef]
8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-27. [CrossRef] [Pubmed]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef] [PubMed] 

Reference as: Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. doi: http://dx.doi.org/10.13175/swjpcc150-14 PDF

Questioning the Inspectors

In the early twentieth century hospitals were unregulated and care was arbitrary, nonscientific and often poor. The Flexner report of 1910 and the establishment of hospital standards by the American College of Surgeons in 1918 began the process of hospital inspection and improvement (1). The later program eventually evolved into what we know today as the Joint Commission. Veterans Administration (VA) hospitals have been inspected and accredited by the Joint Commission since the Reagan administration.

The VA hospitals often share reports regarding recent Joint Commission inspections and disseminate the reports as a "briefing". One of these briefings from a recent  Amarillo VA inspection was widely distributed as an email attachment and forwarded to me (for a copy of the briefing click here). There were several items in the briefing that are noteworthy. One was on the first page (highlighted in the attachment) where the briefing stated, "Surveyor recommended teaching people how to smoke with oxygen, not just discuss smoking cessation". However, patients requiring oxygen should not smoke with oxygen flowing (2,3).  It is not that oxygen is explosive but a patient lighting a cigarette in a high oxygen environment can ignite their oxygen tubing resulting in a facial burn (2,3). A very rare but more serious situation can occur when a home fire results from ignition of clothing, bedding, etc. (3).

A quick Google search revealed no data for any program teaching patients to smoke on oxygen. It is possible that the author of the "briefing" misunderstood the Joint Commission surveyor. However, the lack of physician, nurse and respiratory therapist autonomy makes it easy to envision administrative demands for a program to "teach people how to smoke on oxygen" wasting clinician and technician time to do something that is potentially harmful.

Although this is an extreme and absurd example of healthcare directed by bureaucrats, review of the remainder of the "briefing" is only slightly less disappointing. Most of the Joint Commission's recommendations for Amarillo would not be expected to improve healthcare and even fewer have an evidence basis. The Joint Commission focus should be on those standards demonstrated to improve patient outcomes rather than a series of arbitrary meaningless metrics. For example, a Joint Commission inspection should include an assessment of the adequacy of nurse staffing, are the major medical specialties and subspecialties readily accessible, is sufficient equipment and space provided to care for the patients, etc. (4-5).  By ignoring the important and focusing on the insignificant, the Joint Commission is pushing hospitals towards arbitrary and nonscientific care reminiscent of the last century. These poor hospital inspections will undoubtedly eventually lead to poorer patient outcomes.

Richard A. Robbins, MD*

Editor

References

1. Borus ME, Buntz CG, Tash WR. Evaluating the Impact of Health Programs: A Primer. 1982. Cambridge, MA: MIT Press.
2. Robb BW, Hungness ES, Hershko DD, Warden GD, Kagan RJ. Home oxygen therapy: adjunct or risk factor? J Burn Care Rehabil. 2003;24(6):403-6. [CrossRef] [PubMed]
3. Ahrens M. Fires And Burns Involving Home Medical Oxygen. National Fire Protection. Association. Available at: http://www.nfpa.org/safety-information/for-consumers/causes/medical-oxygen (accessed 3/12/14).
4. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 Oct 23-30;288(16):1987-93. [CrossRef] [PubMed]
5. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14(8):499-511. [CrossRef] [PubMed]

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Questioning the inspectors. Southwest J Pulm Crit Care. 2014;8(3):188-9. doi: http://dx.doi.org/10.13175/swjpcc032-14 PDF

HIPAA-Protecting Patient Confidentiality or Covering Something Else?

A case of a physician fired from the Veterans Administration (VA) for violation of the Health Care Portability and Accountability Act of 1996 (HIPAA) illustrates a problem with both the law and the VA. Anil Parikh, a VA physician at the Jesse Brown VA in Chicago, was dismissed on a charge of making unauthorized disclosures of confidential patient information on October 19, 2007.  On January 3, 2011 the Merit Systems Protection Board (MSPB) reversed Dr. Parikh’s removal.

Dr. Parikh's initially made disclosures to the VA Office of Inspector General and to Senator Barack Obama and Congressman Luis Gutierrez, in whose district the Jesse Brown VA lies.  Dr. Parikh alleged that there were systematic problems within the Jesse Brown VA that resulted in untimely and inadequate patient care. The confidential patient information Parikh disclosed included examples of the misdiagnoses and misdirection of patients within the hospital. Specifically, Dr. Parikh alleged that a physician failed to diagnose a patient’s rectal abscess and sent him home rather than refer him for proper surgical treatment. Two patients who should have been accepted in the emergency room were improperly directed to the urgent care area. One of these patients who should have been admitted to the intensive care unit was improperly placed on the general medical floor, resulting in the eventual deterioration of his condition to the point where he required intubation. Parikh later testified that he made these disclosures out of concern for patient health and safety.

The IG referred the matter to Mr. James Jones, director of the Jesse Brown VA for investigation. Mr. Jones assigned Dr. Jeffrey Ryan, Associate Chief of Staff, to investigate the allegations. Dr. Ryan concluded that there was no evidence of mismanagement or misdiagnosis and the IG closed their case. Dr. Parikh then disclosed the information to Denise Mercherson, his own attorney; Dr. Fred Zar, the director of the internal medicine residency program at Loyola, the American College of Graduate and Medical Education (ACGME) and other members of Congress serving on Congressional VA oversight committees. After these disclosures, Parikh was fired by Mr. Jones.

After exhausting his appeals to be reinstated with the VA Office of Special Counsel, Parikh filed an individual right of action (IRA) with the MSPB contending that his disclosures were protected under the Whistleblower Protection Act (WPA), and that the VA removed him based on those protected disclosures. The administrative judge hearing the case found that Parikh failed to establish MSPB jurisdiction over his appeal because “he failed to make a nonfrivolous allegation that any of his disclosures were protected under the WPA”.  Parikh then filed a petition for review by the full board, and the MSPB reversed the initial decision.  The issue for MSPB was whether Parikh's disclosures were protected under the WPA. Although the administrative judge initially hearing the case found that Parikh failed to establish that he reasonably believed these disclosures were evidence of a substantial and specific danger to public health or safety, the full MSPB disagreed. They found that the nature of the harm that could result from patient care and management issues that Parikh disclosed was "severe” that could result in patient death.

The VA argued that Parikh's disclosures were prohibited under HIPPA. According to Lisa Yee and Timothy Morgan, lawyers for the Chicago VA General Counsel, Parikh's disclosures were not covered by the WPA because the WPA and the Privacy Act of 1974 excludes disclosures prohibited by law. The VA also argued that Dr. Parikh's disclosures were prohibited by HIPAA. The MSPB had little trouble rejecting both these arguments, finding that one of the exceptions is a disclosure to a Congressional committee. The VA lastly argued that Dr. Parikh's disclosures were prohibited by VA policy since the VA had not approved disclosure of the information. However, the MSPB found that the VA's policy in question was not a "substantive" rule, but merely a reference to the HIPPA and the Privacy Act. The MSPB found that the disclosures were a factor to his removal and ordered him reinstated with back pay.

Physicians considering a career with the VA should carefully examine this case. The MSPB concluded that the VA retaliated against Dr. Parikh, not for disclosing confidential patient information, but whistleblowing. After over 3 years, Dr. Parikh has his job back but his work situation is probably not “friendly”. And what has become of the VA administrators and their lawyers who violated WPA by retaliating against Dr. Parikh-to my knowledge, nothing.

The adversarial relationship between the VA administrators and physicians appears to be a one-way street. A physician can have their career destroyed by the VA, but if the accusations are unjustified, there are no consequences to the accusers. On the other hand, physicians that voice concerns for patient care and safety can have their professional reputation ruined by the VA. Particularly concerning is the misuse of HIPAA by VA attorneys as a weapon against physicians.

Dr. Parikh’s case would not appear to be an isolated event. A quick review of the news reveals a VA nurse in Albuquerque was charged with sedition for criticism of the Bush administration’s handling of hurricane Katrina and Iraq (2).  In Phoenix a VA physician was fired after forwarding an e-mail from a Senator John McCain staffer suggesting physicians go to a McCain political rally and lobby for a new VA research building (3). The Phoenix VA chief of hematology/oncology resigned after his name was placed in the National Practioner Databank; an action he felt was unjustified (4). Most recently the Phoenix VA public relations director was demoted after giving unfavorable testimony about VA administrators (5). If the VA is having trouble recruiting as their recent TV advertising suggests, they might consider a different approach. A good start would be the use of HIPAA to protect patient confidentiality rather than cover something else.

Richard A. Robbins, MD

Editor

References

1. US Merit System Protection Board. 2011 MSPB 1. Docket No. CH-1221-08-0352-B-2. Available at: http://www.mspb.gov/. Accessed 9/10/13. 
2. Dees DE. VA nurse in New Mexico accused of sedition. Mother Jones. 2006. Available at: http://www.motherjones.com/mojo/2006/02/va-nurse-new-mexico-accused-sedition. Accessed 9/10/13. 
3. Franklin RE. VA doc fired for political email. Arizona Star. 2011. Available at: http://azstarnet.com/news/local/va-doc-fired-for-political-email/article_3e353bbf-b04a-52ff-8a9c-6cb49e78a47a.html. Accessed  9/10/13.
4. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight burearcracy. Southwest J Pulm Crit Care. 2013;6(1):29-35.
5. Wagner D. VA official in Arizona demoted after her testimony. Arizona Republic. Available at http://www.azcentral.com/news/arizona/articles/20130314va-official-arizona-pedene-demoted-after-testimony.html  accessed 9/10/13.

Reference as: Robbins RA. HIPAA-protecting patient confidentiality or covering something else? Southwest J Pulm Crit Care. 2013;7(4):236-8. doi: http://dx.doi.org/10.13175/swjpcc128-13 PDF