The computer scheduling program created in 2002 was supposed to allow the Department of Veterans Affairs to identify veterans who had waited the longest for medical care.
Officials called it the Electronic Wait List, or EWL. VA employees were told to put new patients with severe medical disabilities linked to their military service on the list after they had waited more than 30 days for an appointment. That way, these veterans could be identified for faster medical care.
Eventually, most new VA patients, service-connected disability or not, went on the waiting list after 30 days.
But about 2010, the VA allowed its hospitals to lengthen to 120 days the time veterans must wait without an appointment before they are put on the waiting list, potentially cutting thousands of veterans across the nation from the list, according to a Tampa Bay Times review of VA records and interviews.
The time frame is now 90 days.
Some critics say the changes were a deliberate ploy by VA leaders to make this much-watched measure of hospital performance look better than it actually was.
"This looks to me like just one more of the VA's gaming strategies that have been identified in the last year," said Anthony Hardie, a Bradenton resident who is on the board of directors of Veterans for Common Sense, a nonprofit advocacy group. "It looks like VA leaders simply gave up on trying to fix the problem."
The EWL has been the focus of attention in recent months, as the agency's inspector general reported 57,000 veterans were on the list nationally, while another 64,000 VA-enrolled veterans without appointments were never placed on the EWL at all.
Officials at the VA hospital in Phoenix, where a whistle-blower said 40 patients died while awaiting care, have been accused of keeping a secret waiting list to disguise the facility's poor performance in eliminating a patient backlog. And around the nation, the IG reports, VA employees used unauthorized scheduling tricks to hide delays in patient care.
What sets the changes to the Electronic Waiting List apart is that they were sanctioned by the VA and were not part of a scheme by rogue employees or hospitals.
VA officials say the agency lengthened the time frame for inclusion on the EWL to provide clarity and uniformity to the lists used by VA facilities across the nation.
They insist it was not a gaming strategy. But at the same time, they acknowledge the VA is trying to "rethink" past practices.
"If there is one message I'd want your readers to get,'' said Dr. Carolyn Clancy, a VA assistant undersecretary of health for quality, safety and value, "is that it is a new day" at the VA.
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Dropping veterans who had not waited the full 120 days from the waiting list had an immediate and expected impact: The VA's EWLs looked much improved.
At the James A. Haley VA Medical Center in Tampa, the waiting list dropped from 4,981 veterans to 1,800 after it started cutting patients from the list, Haley officials said in 2012. Last month, Haley's 120-day EWL stood at 173, an audit by the VA's inspector general shows.
At the C.W. Bill Young VA Medical Center in Seminole, the EWL dropped from 1,408 in December 2010 to 269 in April 2012. Last month, the EWL stood at 103.
VA leaders have always placed a premium on measuring performance and patient care. The EWL was created because the agency did not have a standard measure of how long new patients — those who had not been seen by the VA in the last two years — waited for an appointment.
In a 2002 memo, Laura Miller, then a VA deputy undersecretary, said agency hospitals had created "ad hoc" waiting lists and that "waiting times for new enrollees seeking care are anecdotally reported to be long."
"We will attempt to formalize an 'electronic waiting list' … to more consistently and accurately reflect demand across (the VA) and reduce the risk to enrollees lost to follow-up due to clerical error," the memo said.
The EWL was considered a critical tool. It's a much-watched measure of hospital performance. It helps facility leaders allocate resources. It ensures veterans are not lost in the VA's intimidating bureaucracy.
It was one of several factors that impact executive bonuses.
One sign of the EWL's importance is a 2012 memo by regional VA officials to Florida veterans hospitals that told employees to check their waiting lists for veterans placed on them in error. "It is important that we have an accurate measure … as it affects the perception of access," the memo said.
Critics have argued EWLs and tools like them are too easily manipulated.
"This is a typical practice of VA hospitals that are not making their numbers," Gordon Erspamer, a San Francisco attorney who has represented several veteran advocacy groups, told the Times in 2012. If the VA is late providing care, he said, "The VA redefines the meaning of late."
Today, while still using the EWL to target patients who have waited the longest for care, the VA no longer makes it a measure of performance. It is hoped this will reduce pressure to manipulate numbers.
In some ways, the EWL is almost irrelevant, said Dr. Mike Davies, executive director of the VA's access and clinic administration program.
He said the agency can see how long a patient has been waiting for care even if they aren't on the list. "So there's transparency for the waiting times for every single appointment," he said.
VA leaders have long known some hospitals used "workarounds" to make their books look better.
"Workarounds," a 2010 memo by VA leadership noted, "may mask the symptoms of poor access and, although they may aid in meeting performance measures, they do not serve our veterans."
William R. Levesque can be reached at firstname.lastname@example.org or (813) 226-3432.