Part 2: What VA can do to fix the doomed $16B (and counting) Electronic Health Record modernization

Never has Will Rogers’ admonition “When you find yourself in a hole, stop digging” been more appropriate than right now in terms of America’s veterans and the organization that has been charged with “caring for him who shall have borne the battle.”

The over $16 billion unneeded, unexamined, sole source award to a commercial software vendor best known for its medical billing system to replace the widely popular, trusted, integrated, tested, robust, best-in-breed enterprisewide, cloud-based Veterans Information System Technology Architecture (VISTA) is a self-inflicted wound that if allowed to proceed will fester, degrade and ultimately critically damage the VA’s ability to meet its mission.

Secretary Denis McDonough sits at perhaps the most obvious and yet the most difficult inflection point ever presented an incoming cabinet secretary. On the one hand, over $16 billion has already been committed to this effort. Huge expenditures of manpower, energy and management focus have been devoted to preparing for this conversion. Multiple reorganizations, changes to policy, changes to process and disruptions to other important programs have been launched in order to prepare for the enormous impact that this “rip and replace” of the fully functioning “central nervous” system called VISTA by a product that will at its very best replace much less than half of the functionality of VISTA and do that less productively and at huge additional costs.

And these costs will not just be in financial terms. The impacts on employee productivity, effectiveness and morale have been enormous and will continue to grow exponentially if the secretary decides to proceed with this program.

On the other hand, if the secretary stops the EHRM program the government will face multiple lawsuits, harsh criticism from all quarters and further degradation of veteran and public trust in the VA.

These are not attractive options.

Recognizing that it is easy to criticize and much tougher to solve problems, I offer the secretary the following specific recommendations for solving this epic conundrum.

1. All next steps must be filtered through a stringent view of what is in the best interest of the veteran. You are responsible for the health and care of over 9 million veterans including 325,000 World War II veterans over 75 years after the end of that war. Is it better for veterans if the VA controls the critical systems that support these men and women or is it better for the veteran if you turn that control over to a for-profit, commercial entity that must support the needs of more than 27,000 non-VA commercial facilities around the world?
2. Any consideration of practical, contractual, political, personal, personnel and organizational issues must be addressed transparently; that is, fully identified and the weight applied to these issues explained. To be more specific, if it is going to cost a great deal of money to terminate or materially adjust these contracts say that and say how much and why this is so. Likewise, if the consideration is how terminating the current VA contract will effect another department’s program that should be stated and addressed.
3. Examine where your advice and counsel are coming from. All of us have bias based on our experience, our background and our priorities. We all have different motivations and different degrees of motivation. All of this must be understood and factored into the weight given to this advice and counsel. Not everything can be taken at face value.
4. Protect your alternatives. Fully fund and staff the VISTA program office with competent and dedicated staff and protect it from those that might seek to starve it of needed resources so as to eliminate it as a viable alternative.
5. Take the time to appreciate what you have in VISTA. Challenge the notion that VISTA is an old “legacy” system in need of replacement as it is often falsely portrayed. It is not. It is a system that was designed by VA clinicians to support their needs to provide “great care” for veterans that has evolved over time and is safe, trusted and reliable, that needs updating and modernization, not replacement.
6. Insist that an independent, scientific, professional organization such as Sandia National Laboratory or Oak Ridge National Laboratory conduct an end-to-end modelling simulation of the proposed solution using best estimate workloads, credible system capabilities and realistic infrastructure assumptions to prove that this proposed system is capable of supporting both DoD and VA’s needs. Without this you are relying on assumptions, aspirations and marketing hype.
7. The VA is currently engaged with three major, interdependent, mission critical systems replacements. Failure of any one of them will cause failure in the other two. Two of these systems involve a high-risk “rip and replace” strategy. This situation must be considered as significant risk for each of these programs. At a minimum, organizations such as NASA and the Nuclear Regulatory Commission would insist on an outside entity conducting a complex systems analysis (CSA) to identify the major risks posed by these systems interdependencies. The success of the mission of the VA demands this level of scrutiny.
8. You have stated, “Our success as a team — our ability to deliver world-class care for our veterans — also depends on how we treat each other.” You must engage with that team. Not just with the officers, directors and deputies at the central office. Not just with the contractors, former contractors or recent imports from other agencies. Not just with the personnel that have “skin-in-the-game” based on their years of hard work and effort trying to make the decisions of previous administrations work. You must engage with the rank-and-file members of your team in a personally safe and trusted environment. Their concerns must be heard and addressed. Meet with them. Ask them what their concerns and considerations are. Many of them have experience with both VISTA and the proposed software solution. You have the most educated, professional and experienced team in all of government. They are using a system that they helped create, improve and grow. Forcing a system on them, especially one that reduces their productivity, burdens them with non-medical administrative tasks, reduces their confidence in the safety of the system and impacts their ability — in any way — to provide the level of care that they have come to expect using VISTA will ensure ethical, medical and professional rejection. Survey the ones you can’t meet with in person. Ask them what their concerns and issues are. You can have the most cohesive, dedicated and committed senior management team surrounding you but if the implementors, the end users, the ones dealing face-to-face with our veterans feel like an inferior solution is being foisted on them without their involvement, without their input, without their voices being heard your “team” will not succeed. Consider the wisdom of “what is imposed will be opposed”.
9. Ask and demand answers to the many critical questions that have been posed and remain unanswered. Where did this $16 billion sole source contract originate? Did it come from internal, specific VA requirements or was it politically imposed to solve the problems of another agency? Will this solution work at full scale, scope and complexity? Besides verbal vendor and contractor assurances, what evidence is there to prove that it will support VA’s needs? Has it ever operated in a similar environment? What recourses do you have in the event this solution fails?
10. Appreciate that this inflection point is your “Rubicon moment.” If you proceed with this solution you will own it. You will own all of the consequences that will proceed from your decision. When this solution fails — and it will inevitably fail — you will own all of the consequences. You will not be able to harken back to previous administrations or previous decisions to explain away the failure. There will be no “unforeseen” circumstances that you will be able to cite to explain away this failure. They have all been seen and described. They are known and cannot be “unknown.” This is your last, best chance to avoid this

Mr. Secretary, the very best advice I can offer you is that in this moment it may appear that staying the course is your best option and that halting this multi-billion-dollar juggernaut would seem like failure and a waste of money and the efforts of many dedicated and committed people. That is not the case. It would be an act of courage and fulfillment of your pledge to always put the veteran first. In the long run, when your servant leadership will be judged, when your pluses and minuses will be summed, it only matters that you do the right thing, for the right reasons, at the right time.

As a service-disabled Vietnam veteran, I wish you good luck and I am rooting for you.

Edward Meagher retired after 24 years in government, 26 years in the private sector and four years in the U.S Air Force. He served for seven years as the deputy assistant secretary and deputy CIO at the Department of Veterans Affairs. Ed divides his time between his own executive consultancy, VETEGIC, LLC and extensive involvement with several veteran focused organizations including his own Service Member Support (SMS) Foundation.

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