VA Secretary’s weird hill to die on

Dec. 1, 2021. Mark that day down somewhere. That is the day that Veterans Affairs Secretary Denis McDonough decided to abandon 30 years of collaborative effort, the accumulated knowledge of hundreds of thousands of doctors, nurses, technologists and other clinicians, billions of dollars of investment and the best care available for over 9 million veterans in order to avoid recognizing a series of multi-billion-dollar bad decisions made by the Department of Defense and the previous Veterans Affairs leaders. Why he would do this is unfathomable.

With the release of a statement describing an “updated plan to move forward with its systemwide Electronic Health Record Modernization program,” Secretary McDonough chose the path guaranteed to fail. It is apparently based on his belief that all problems can be solved by “heroic management.”

The announcement did not address a single technical, business process, patient safety, human resource, cost, schedule, employee morale, employee retention, training or veteran concern that have previously been raised. Instead, it detailed yet another reorganization and the onboarding of yet another Defense Department executive to drive home the notion that the problems that this program has encountered are the fault of VA personnel and VA organizational resistance to change. His solution is clearly to impose military discipline and organizational structure on a civilian organization and force compliance.

Secretary McDonough’s misappreciation of the organization he now misleads is staggering in its breadth and consequences.

He clearly does not comprehend the culture of the most highly educated and credentialed agency in government. He certainly does not understand the collaborative and consensus-based governance model inherent in the multiple hundreds of thousands of medical doctors, nurses, PhDs, hospital administrators, board certified medical specialists, medical informaticists, certificated technicians, experienced practitioners, medical technologists, information technologists and operational specialists who work together as a mission-driven ensemble that delivers the best care anywhere to over 9 million veterans.

He clearly has no concept of the pride, the dedication, the professionalism and the commitment to excellence of the organization he now misdirects. This organization simply will not tolerate the degradation of care for veterans to solve some political or contractual problems.

His “full steam ahead, dam the torpedoes” decision proves all of that. He is heedless of the several reasons why this decision is doomed to failure.

He has recent, reliable and specific data that indicates after a year of herculean effort implementing the new electronic health record, at the Mann-Grandstaff Veterans Affairs Medical Center in Spokane, Washington which included 44,000 hours of user training, that:

• There are still over 500 unaddressed, EHR related, patient safety issues;
• Clinician productivity is still at 50% of pre-implementation levels;
• 63% of the staff stated that they are considering leaving their job as a result of the imposition of the new EHR;
• that 83% of the staff reported worsened morale as a result of the imposition of the new EHR; and
• 78% of the staff reported lowered job satisfaction as a result of the imposition of the new EHR.

And yet he is determined to force this solution on other VA facilities as early as March 2022 without addressing any of the concerns of the Mann-Grandstaff staff.

He clearly does not understand the “central nervous system” role of the current VA medical management and electronic health record system, VistA. He is clearly unaware that, at very best, the proposed new EHR system will replace considerably less than half of the current functionality of VistA without any plan in place to replicate the remaining functions of VistA.

He clearly does not appreciate the differences in mission, culture, process and governance of the two organizations he intends to force a “one size fits all” solution on.

He clearly does not understand the implications, limitations and restrictions of a commercial-off-the-shelf (COTS) product decision. Once implemented there is virtually no way to change direction or approach. The degree of contractual and practical lock in is total. All future medical, technical and business process decisions will be at the sole discretion of the COTS corporate leadership and based on what is in the best interest of the corporation, not the VA.

He clearly is unaware of the loss of access to 30 years worth of data-driven, experiential best practice that is embedded in the VistA environment and that will not exist in the proposed EHR.

He clearly disregards the impact of the change from using a system that was designed by the clinical users of the system to support the medical needs of a specific population of veterans to a system that is focused on commercial insurance-based cost capture and revenue enhancement. The imposition of a tedious, time consuming workload on already over-burdened professional staff that provides no improvement to medical outcomes is apparently of no concern to him.

He obviously has no concept of the difficulty and complexity of imposing not one but three massive, interrelated, interdependent mission critical systems simultaneously. He is apparently unconcerned by the historic failure rate of large-scale systems development where three-out-of-four well-designed and well-managed systems fail based primarily on the limitations of change management. He seemingly has no ability to sum the odds of success of three poorly conceived, ill-advised, unfocused, unwanted mission critical “rip and replace” systems.

And he manifestly has no comprehension of the multiple, basic technology issues of communications, security and platform posed by this massive cobbling together of multiple environments to support an as yet unknown workload, across an as yet undetermined infrastructure and dependent on an as yet unspecified computational capability.

He continues to repeat the mantra that the new system is working despite all evidence to the contrary. He continues this misguided program without explaining why he is doing so. He stubbornly refuses to listen to anyone outside his inner circle and avoids dealing with the complaints, frustrations and concerns of the implementors.

The awful truth is that there is no possibility of any “success” for this program at the VA. This will end at some point in the future when it becomes manifestly clear that this system will not do the job. The only issue is how long that will take and how much damage will be done in the interim. If VistA is neglected long enough it will not be a reliable system to fall back on. If they discourage enough doctors and nurses and other critical staff who leave or reduce their involvement with the VA, the veteran will suffer. If they degrade the productivity and effectiveness of the staff who remain, that will severely impact the veteran. There is no win in this for the veteran, the VA or Secretary McDonough. The professional staff at Mann-Grandstaff have spoken. Many former and current senior executives have spoken or left. Congress members have spoken. The question is who is listening.

So it is truly a mystery why Secretary McDonough, a man known to be ethical, caring and experienced would choose this hill to die on. It is truly and certainly “a weird hill to die on.”

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. Meagher 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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