WASHINGTON, DC ― Staff at the Columbus, OH, VAMC, the last VA facility where the department’s new electronic health record system was installed, are experiencing many of the same kinds of problems that occurred in Spokane, WA, where the EHR was piloted. Those include uncertainty as to whether orders placed using the system will reach their intended destination and an increased level of physician burnout directly attributed to frustrations with using the EHR.
With the rollout paused until 2023, VA hopes to use the interim to fix these issues before installing the system at any future VA sites; however, VA leaders told legislators that, as it stands, the EHR is not ready to move forward.
“I do have deep concerns about how the system is functioning for frontline employees and veterans. I had the chance to see that myself at a visit to Columbus, Ohio recently,” VA Undersecretary for Health Shereef Elnahal, MD, testified last month before the Senate Appropriations Subcommittee on Military Constructions, Veterans Affairs and Related Agencies. “I saw folks struggling with the system, deeply. Among the most concerning things that I saw was a phenomenon whereby our frontline clinicians would put in an order or try to interface with the system. They were not confident in many cases and in many clinical settings that those orders were getting where they needed to go. There was a lot of reworking and rechecking that had to be done to meet those veterans’ needs.”
He added, “I personally observed folks telling me that the system was stressful to use, and leadership was telling me folks were leaving in part because of the difficulty of the workflows. EHR deployments generally make things difficult in their initial phases. … But nonetheless, that was a phenomenon that was communicated clearly when I was at Columbus.”
While some clinicians at the facility found promise in the system, they were in the minority.
“Right now, I do not see a system that is meeting most of the frontline clinicians’ needs, and that concerns me,” Elnahal declared.
Currently, VA’s rollout schedule has the department installing the system in Ann Arbor, MI, in late January 2023, then moving on to Seattle in early March and Cincinnati and Dayton, OH, at the end of March.
VA said it still hopes to meet that timeline, as well as the overall 10-year rollout deadline for the project, but officials say that they are willing to push the deadline out, if problems with the system persist.
“We’ve been working feverishly to try and make that target,” explained VA Deputy Secretary Donald Remy. “We’ve been looking at. If we have to go beyond the 10 years, what does that look like? We don’t have a specific time period beyond the 10 years. [We’re] still looking at all the factors. Nor do we have a dollar amount attributable to that.”
Much Higher Cost
A recent independent analysis of the project conducted by the Institute for Defense Analyses (IDA) has the project coming in at 13 years and at a much higher estimated cost–$50 billion compared to VA’s initial $16 billion.
Part of that increase is attributable to the extra three years in the rollout and the longer period of sustainment included in IDA’s estimate. Much of the increase is due, however, to IDA factoring in costs that VA has not.
“One of the big elements is the productivity loss that we estimated that’s not in scope in the VA estimate,” explained IDA researcher Brian Rieksts, PhD. “That’s the cost of sending veterans out to the community to private caregivers while there’s a disruption at the facility. … That includes additional staffing that’s needed during go-live to help those physicians and clinicians [learn the system].”
As for IDA’s belief that the project will take longer than VA’s hoped-for 10 years, Rieksts said, “We estimate a range of one-to-five additional years. That’s based on looking at historical programs and the challenges they’ve had. Events that have led to delays [at early VA sites] indicate that this program will not behave differently than historical programs.”
VA’s Office of the Inspector General (OIG) also said it lacks faith that VA will hit its 10-year mark. The agency watchdog has been asking VA to provide a master schedule for the project since it’s inception, which VA has yet to do.
“They have nothing at VA that tells us how they’re going to get from start to finish site by site and what’s included in that effort. They promised one this year, and we hope to see it,” testified Deputy VA Inspector General David Case.
Case noted that the next phase of VA’s rollout is particularly ambitious, since it includes a number of what VA considers “complex facilities,” where it will require more effort to integrate the new EHR.
“Can they get lessons learned to go complex facility by complex facility during that short period of time … and will [new] lessons appear [during that rollout]? All of that is so uncertain that we really can’t say how long it will take,” Case said.
The new EHR was designed by Cerner Corp., which was bought earlier this year by Oracle. The EHR is the same base system that has been rolled out at DoD’s medical facilities with far less trouble.
Legislators asked Mike Sicilia, executive vice president of Industries for Oracle, why VA has experienced these kinds of major issues, while DoD has not.
“Training at VA sites was not as strong as what it was at some of the DoD sites,” Sicilia explained. “And the complexity of the population at VA is different than the complexity of the population among active service personnel. Therefore, there are more intense workflows, and more configurations to the system may be needed.”
However, the largest issue–one that has been known about for years–is that, over time, VA has made facility-specific changes to the system, creating what are essentially 133 unique versions at 171 facilities.
“Sometimes it’s difficult from a change management perspective … because everyone wants everything they have today to work exactly as it does today in the brand-new system,” Sicilia declared. “And that’s difficult when you have so many custom versions of a system.”