WASHINGTON — Many of the design issues delaying the continued rollout of VA’s new electronic health record (EHR) system are in the area of standardized workflow rather than simple technical glitches, VA officials explained.
Staff at the Mann-Grandstaff VAMC in Spokane, WA—the pilot site for the new EHR—told legislators last month that they are finding that the new CERNER-designed system does not always allow them to easily complete day-to-day activities in the system.
Some of these issues are the expected disconnect between a commercial EHR and the unique needs of VA. Others might have been avoided by incorporating the input of frontline staff earlier in the process—something VA leaders have admitted they neglected to do to the extent they could have. VA Secretary Denis McDonough ordered a pause in the rollout while the department conducted a twelve-week strategic review, which began March 24.
“It is frustrating business,” admitted Carolyn Clancy, MD, VA’s acting deputy secretary at a House VA subcommittee on technology modernization hearing last month. “In the end, the EHR—the technological piece—is probably a third of the solution. The rest is changing a lot of aspects of your everyday work. Things you did on autopilot you now have to think about. It’s exhausting. At the same time, I’m getting that our colleagues are pleased we heard their concern and are taking them seriously and are running them to ground and get then resolved before we move on.”
Since the EHR launched in Spokane in October 2020, VA has implemented 350 requests to tweak the system. To speed EHR-related requests along, facility leadership has urged staff to also submit a patient safety report if applicable. That ensures that the issue will be resolved within 48 hours. As of the hearing on April 14, the facility had logged 247 patient safety reports of various urgency.
Legislators have received reports, however, that some Spokane staff have given up on the ticketing process and are creating their own solutions.
“We have heard that staff have become disillusioned with the ticketing process, that tickets are being closed prematurely without explanation,” Rep. Frank Mrvin (D-IN) told VA officials. “They have stopped generating tickets and are creating their own workarounds and sharing those with staff outside of the incident management system. … Staff have resigned themselves to solving the problems themselves.”
Robert Fischer, MD, director of the Mann-Grandstaff VAMC, did not deny that this had occurred, but believes these incidents are “an exceptional circumstance rather than a routine one.”
“If our staff had an issue and I elevated it, there was immediate response, both from VA and the Office of Electronic Health Modernization (OEHRM),” Fischer said. “They accepted that feedback, processed that feedback and got on our campus to fix those issues as soon as they can.”
When asked what keeps him up at night, Fischer answered, “From my perspective, it’s staff morale. Obviously, this has been a trying year between COVID and now this Cerner millennium rollout. They’ve had to face a lot of change. We track departures very closely, and I have not seen a bump in monthly departures despite all the challenges that they face everyday.”
One way that VA hopes to address morale with the ticketing process is to add some transparency to the system and to manage staff’s expectations on just how swiftly changes can be made to the EHR.
“We’re committed to greater transparency and we’re creating a dashboard so people who put in tickets can see their tickets at every milepost,” explained Laura Kropua, MD, chief medical officer of the VA’s Office of Electronic Health Record Modernization (OEHRM). “Change requests have to be discussed by the national councils and a solution has to be found. Also, DoD has to be part of that discussion. So those change requests do take a longer time, and we need to make sure that all the people involved in that ticket understand where that ticket is and manage their expectation on how quickly we can turn those things around.”
Keeping the staff at Mann-Grandstaff happy is not just a short-term goal but integral to the VA’s strategy for the EHR rollout going forward. Both McDonough and Clancy have said that VA’s goal is for the staff in Spokane to be so confident in the system that they will act as the primary advocates for the system as it’s deployed at other sites. The rollout is scheduled to go to facilities in VISN 10, including the Columbus, OH, VAMC next. Clancy testified that VA does not expect the strategic review to cause any additional delays.
Despite the numerous workflow problems, CERNER leaders say they have received mostly positive feedback from people using the EHR.
“We’ve gotten great feedback from system performance from the VA at Mann-Grandstaff,” explained Brian Sandager, CERNER’s general manager of government services. “Their log-in times are three seconds. That took a lot longer in the previous systems. People would often log in, get up and get a cup of coffee, come back and start their work in the system. They don’t have to do that anymore.”