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VA faces pivotal moment with EHR after months of lingering usability problems


VA faces pivotal moment with EHR after months of lingering usability problems
VA faces pivotal moment with EHR after months of lingering usability problems

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This story was updated on Monday, April 12 at 8:15 p.m. with a comment from Cerner Corporation. 

When it comes to its highly-anticipated electronic health record rollout, the Department of Veterans Affairs may have popped the champagne bottles a little too early.

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The agency declared the EHR deployment last fall at the VA Mann-Grandstaff Medical Center a success.

The experience showed VA the processes and methodologies it spent months developing had worked, and the EHR, which is based on the Cerner Millennium platform, was ready to take to the rest of the enterprise, agency officials said at the time.

But months after the initial go-live, VA employees and congressional stakeholders tell Federal News Network the deployment in Spokane was far less successful than the department initially touted. And though some pieces of the electronic health record are working well, they say the initial rollout was not a viable proof of concept for VA’s $16 billion, 10-year EHR modernization effort — at least not yet.

“We are increasingly concerned about the program’s performance and impact on productivity, operations, data syndication, revenue cycle, veteran experience and other issues as reported by senior Veterans Health Administration officials as well as rank-and-file employees,” the four leaders of the House and Senate VA Committees said in a Feb. 25 letter to VA Secretary Denis McDonough. “There are significant technical and organizational challenges which must be addressed as the next steps in EHRM are planned, particularly before VA proceeds to deploy the system at the Chalmers P. Wylie VA Ambulatory Care Center in Columbus, Ohio, and beyond.”

McDonough launched a strategic review of the EHR modernization program late last month, citing an initial evaluation of the feedback he had received from Spokane.

The strategic review has support from leaders on both sides of the aisle. But employees and congressional stakeholders see the review as a crucial, decisive moment for VA to resolve usability, patient care and staff morale problems that have lingered for nearly six months — and set the EHR on the right path before deploying it to other sites.

Lawmakers will have a chance to learn more about VA’s plans for the strategic review later this week. The House Veterans Affairs Technology Modernization Subcommittee will hold a hearing Wednesday on the EHR rollout.

Members of Congress are looking for a more specific account from VA about its challenges with the new EHR, as well as a concrete action plan on how the agency plans to resolve them.

“We’d like to see a candid presentation of the challenges, small, medium and large,” a congressional aide, who requested anonymity to speak candidly about the EHR, told Federal News Network. “Some of the concerns from VA employees are very serious. [We want to see] what they’re going to do to change this going forward.”

The Cerner Corporation, the lead contractor for VA’s EHR modernization initiative, reiterated previous comments it gave when VA announced its strategic review last month. It said it supported VA’s decision to conduct a review and welcomed a chance to review lessons learned.

“It is vital that we get this right for veterans,” VA spokesman Terrence Hayes said in a statement to Federal News Network. “This strategic review will allow us to truly gather all the data and information necessary to lead to a successful launch in Columbus and future locations. It’s simply too important to rush.”

‘I would pick the pandemic’

But for some VA employees, the realizations from top leadership at the department are long overdue, since their frustrations with the new EHR started when the new platform went live.

“It was stunning how many things didn’t work,” one Spokane clinician, who requested anonymity because they did not receive permission to speak to the press, said. “The answer was just put in a ticket for that, or, ‘Here, I’ll help you try and find a workaround for that.’ It was really kind of shocking how many things didn’t work initially.”

Some tasks that once took a two or three clicks in the old health record now take 10 or more, and VA employees are still learning quirks and tricks associated with each one.

Some patient addresses weren’t migrated correctly from the old system to the new one, meaning VA clinicians are double checking veteran data to ensure prescriptions are going to right places.

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Multiple sources described instances of data failing to migrate or are transmitting incorrectly when passed from one module in the EHR to another.

The VA clinician described an instance where a doctor had written instructions for a patient in the EHR. But when the nurse down the hall opened the EHR to review those notes, the directions differed from what the doctor had initially prescribed. Luckily, the nurse and doctor confirmed the instructions with each other and prevented a patient care mistake, the VA clinician said.

Community care referrals are also taking longer with the new EHR, the VA clinician said. The doctor referred a patient to a community care provider, but the referral got dropped in the new system. The referral process should have taken two weeks but took six instead, the clinician said.

“This patient was really good at following up and calling and asking for updates,” the VA clinician said. “If he had done nothing, I wouldn’t have known that I would have needed to take any action. The referral would have just gotten dropped. It was the fact that he spoke up for himself that I even knew that the referral was not going forward. He did finally get the care he needed, but it took an extra month and so much extra work on my part than it should have.”

 VA health care professionals in Spokane are slowly learning more about Cerner Millennium and are teaching each other about the system. They often end up calling, emailing or using Microsoft Teams to communicate with each other about patient care, because using the EHR is too tedious or confusing, the VA clinician said.

The experience has demoralized some VA employees in Spokane, who are trying to track problems and develop workarounds for the EHR while juggling their duties during the COVID-19 pandemic.

“I really love my job, but the last few months have been by the far the worst in terms of job satisfaction,” the clinician said. “I would rather be dealing with the pandemic than dealing with Cerner. Given a choice, I would pick the pandemic.”

Tough decisions ahead for VA’s EHR program

Congressional stakeholders said they were encouraged VA seemed open to resolving the challenges with the EHR’s current design, configuration and workflows.

“While we recognize some degradation in productivity is to be expected in the months following any EHR go-live, we are worried that not enough progress is being made to fully mitigate these issues,” senators and House members wrote. “We appreciate that Dr. Richard Stone, VA’s acting undersecretary for Health, and other senior officials traveled to Mann-Grandstaff in late January to gain first-hand knowledge of the issues that staff are facing. We believe now is the best opportunity to correct the local and systemic issues revealed during the Mann-Grandstaff deployment.”

The VA clinician said local leadership in Spokane appeared to have gotten through to agency officials at the national level in recent months.

Based on Stone’s observations and complaints from employees, Cerner and agency officials formed a number of tiger teams with users in Spokane, employees from VA’s Office of Electronic Health Record Modernization and members of the VA national councils that initially configured the platform.

But those familiar with the tiger teams said the groups mostly made lists of ongoing problems.

“The tiger teams’ accomplishments were underwhelming,” a congressional source, who also requested anonymity to speak candidly about the EHR, told Federal News Network. “They only took up a subset of the problems with the EHR, and they only solved a subset of those.”

Some of the more persistent challenges with the EHR may be due, in part, to changes VA made to the original Cerner Millennium platform.

And while some functions of the new EHR such as urgent care and scheduling are working well, other areas where VA’s operational practices differ from private sector processes are more problematic, the congressional source said.

“Cerner has been warning and alluding to the idea all along that it’s a bad idea to try and customize their software,” the source said. “But a lot of VA’s needs are novel, and in fact VA needed to customize quite a bit and did. It looks like those warnings were right, and customizing caused a lot of these problems. So it kind of leaves them between a rock and a hard place.”

The department formed more than a dozen councils, made up of VHA clinical staff from the field and employees from VA’s central office, to create and standardize workflows for various functional areas of the new EHR.

The goal, the department has said, was to develop common practices that all staff across the VA network could use once the EHR was deployed to their own sites.

“Those councils aimed very high, and they spent all of 2019 and even into early 2020 trying to configure it to the workflows that fit VA’s oddities and satisfy VHA broadly,” the congressional source said. “We can see from the product in Spokane that it didn’t work well. The idea is a paradox that is fraught with risk, we’ve learned, and its process is flawed. Either VA has to pull a rabbit out of a hat and fix their process so it can be partly customized and configured to the EHR so it fits them like a glove, or they have to find a way to accept the literal commercial product.”

Congress sees review as critical moment for VA EHR

Those decisions aren’t easy ones, which is why congressional stakeholders see VA’s ongoing strategic review as a pivotal moment for the department’s electronic health record modernization efforts.

The review comes on the heels of a report from the Government Accountability Office, which advised VA against moving forward with any future EHR deployments until it resolves “high severity” findings. VA had made progress, however, in resolving many severity findings before the initial rollout last fall and found acceptable workarounds for many of the remaining ones.

In his first hearing since taking on the secretary’s job, McDonough promised to inform Congress if the strategic review showed VA needed to reconsider the Cerner Millennium project.

“I don’t think that’s what we’re going to find, but if we do find that then I’m going to be the first one up to there to say to you that this is not working,” he told the House VA Committee last month.

VA said its strategic review could take up to 12 weeks, but congressional stakeholders worry the department is determined to keep to a pre-set timeline. They want VA to detail concrete goals and demonstrable metrics for the review and stick to them, even if it means pushing back future EHR deployments.

“The strategic review is a good idea. But it needs to end when the problems are solved, not when a predetermined clock runs out,” Mike Bost (R-Ill.), ranking member of the House Veterans Affairs Committee, said in a statement to Federal News Network. “Make no mistake, the problems in Spokane will become the problems in Columbus and on and on until they are taken care of. That’s why we need to take care of them now.”

At Mann-Grandstaff, the experience of the last six months has sparked a conversation among the staff about the future of EHR modernization effort. Some believe Cerner Millennium will eventually be an improvement over VA’s legacy Computerized Patient Record System.

But others aren’t so sure, and they too are fearful VA will choose to move on and continue future deployments before tackling the biggest outstanding issues.

“Hopefully we can improve it with our feedback and all of that, to the extent possible,” the VA clinician said. “I don’t really know how nimble Cerner is in terms of how it can be improved, but at the very least the next facility should not have to repeat what we went through — and still are going through. We pushed hard for that, and it seems like that got through.”

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