VA EHR leader calls for ‘accelerated delivery’ in fixes to pharmacy disruptions

The Department of Veterans Affairs is taking a closer look at how problems with the rollout of its new Electronic Health Record are leading to disruptions in veterans receiving prescription drugs.

The VA announced last month it is putting all future deployments of the Oracle-Cerner EHR on hold until it addresses problems at the five VA sites already using the system.

As part of this reset in the EHR modernization program, the VA and Oracle-Cerner are working to fix issues that have led to less productive pharmacy operations at VA facilities — as well as veterans sometimes receiving the wrong prescription medication in the mail.

Neil Evans, acting program executive director of VA’s EHR Modernization Integration Office, told members of the House VA Committee on Tuesday that the feedback he’s heard from VA clinicians and pharmacists is that recently deployed improvements to the Oracle-Cerner EHR “have been small and incremental.”

“Although these improvements are appreciated, VA pharmacy staff and providers need an accelerated delivery of upgrades to eliminate the burden of the more labor-intensive human mitigation strategies that are currently in place,” Evans told the Technology Modernization subcommittee.

Four of the five VA sites currently using the Oracle-Cerner EHR told the subcommittee in a questionnaire they have added, on average, 20% more pharmacy staff to carry out the same workload prior to the new EHR’s launch.

Pharmacy operations at VA medical centers in Spokane, Washington; Walla Walla, Washington and Columbus, Ohio, have had to deal with the increased costs of additional staffing and declining morale.

“The pharmacists are in distress, and they do not feel their concerns are being taken seriously,” Subcommittee Chairman Matt Rosendale (R-Mont.) said. “The situation they described is outrageous and dangerous. The pharmacists cannot trust the system, so they have to work in a constant state of hypervigilance.”

Oracle-Cerner released EHR pharmacy updates in February and late April. Another is slated for August.

Rosendale said VA employees have said some recent EHR pharmacy updates have led to incremental improvements. However, he said employees have complained that more significant updates “seem to have created as many new complications as they even resolved.”

The Government Accountability Office found in a recent report that, according to VA’s own post-deployment questionnaires, VA medical centers gave the Oracle-Cerner EHR average usability scores ranging between 23 and 32, out of a total score of 100.

“One user reported working 60 hours a week and trying not to drown in carrying out duties because completing chart reviews, which used to take 15-30 minutes using the old system, was now taking hours or even days,” the GAO report states.

Carol Harris, the director of information technology acquisition management issues at GAO, said the pharmacy department at one VA medical facility using the Oracle-Cerner EHR increased staffing from 15 to 60 employees to manage increased workloads associated with the new EHR.

GAO also found multiple instances of veterans receiving double quantities of their prescriptions and incorrect medication orders, after receiving care at VA medical facilities using the Oracle-Cerner EHR.

VA employees told GAO that processing prescriptions took much longer in the new EHR, causing increased backlogs and decreased efficiency, leading to patient safety concerns because pharmacies could not fill prescriptions in a timely fashion.

Harris said GAO has found has not established goals to assess user satisfaction with the Oracle-Cerner EHR system — an essential metric for the agency to determine whether the EHR is reliable enough for rollouts to resume at additional facilities.

“Having such goals in place would provide the department with a basis for determining when satisfaction has improved, and also help ensure that the system is not prematurely deployed to additional sites, which could risk patient safety,” Harris said.

VA concurred with GAO’s recommendations and expects to fully implement them by October 2023.

The recommendations focus VA on improving user satisfaction, prioritizing IT help tickets and getting an independent assessment of the EHR’s operational deficiencies.

Harris said the VA hasn’t set a realistic timeline to address GAO’s concerns with the Oracle-Cerner EHR.

“That’s five months away. To me, that suggests they’re unserious about our recommendations and what it’s going to take to implement it. But if they do effectively implement them, I think they’re going to be on a much better footing for success,” she said.

Harris said that the EHR’s rollout to date shows that it will take “a much longer runway for VA to change their culture.”

Evans said VA’s indefinite pause on the EHR rollout allows the agency to focus on improving the functionality of the Oracle-Cerner system, without having to balance that workload with preparing for new go-lives.

“Let’s stop flying the plane while also building it. Let’s build the plane as it needs to be,” Evans said.

Thomas Emmendorfer, VA’s executive director for Pharmacy Benefits Management Services, said an update in February fixed an issue where the Defense Department’s Defense Enrollment Eligibility Reporting System (DEERS) would sometimes override VA EHR records.

Emmendorfer said that error led to multiple instances where veterans’ medications were mailed to the wrong address.

“The ability for that to overwrite any VA data has been addressed, such that if the employees working on the EHR are recognized by the system as VA, it will no longer take DEERS information to overwrite the VA information,” he said.

DoD and the Coast Guard are rolling out the same Oracle-Cerner EHR as the VA. DoD expects to complete the implementation of the new EHR in fiscal 2024.

Mike Sicilia, the executive vice president for industries at Oracle, said the vendor is “not completely surprised” by the feedback from VA employees, and said pharmacy issues have been a “driver for a lot of the dissatisfaction with the EHR.”

“I’m not surprised to hear that right now. People don’t like it because it’s not complete. It’s not finished,” Sicilia said.

Oracle-Cerner is more than halfway through delivering updates to the EHR’s pharmacy functionality.

Sicilia said Oracle-Cerner has made three updates to the EHR’s pharmacy functionality and expects to complete four remaining updates by early 2024. The next set of enhancements is focused on updates that will improve the VA pharmacists’ experience.

“We believe that once delivered and implemented, then pharmacists will be in a position to provide very valuable feedback,” Sicilia said.

Sicilia said the five VA sites using the Oracle-Cerner EHR are filling more than 200,000 prescriptions a month, and that to date, they’ve filled nearly 3 million prescriptions that have been delivered to veterans through the mail.

VA first launched the Oracle-Cerner EHR in October 2020, at the Mann-Grandstaff VA Medical Center in Spokane.

The agency is now five years into its contract with Oracle-Cerner and is looking to renegotiate the terms of the contract to hold the vendor to a higher standard for system uptime and reliability.

The Oracle-Cerner EHR is VA’s fourth attempt at replacing its legacy EHR system, VistA, which VA clinicians have used for 40 years.

“Implementation thus far has been just as challenging as the last three attempts, if not even more so,” Harris said.

Oracle Vice President James Ellzy told the subcommittee that moving the VA — the largest integrated health care system in the U.S. — to a new EHR is an inherently big change for VA medical employees to manage.

“Whenever you change systems, you’re going to not be as comfortable as the system you’ve been working in for decades. It’s going to take time to learn the new system. Two years is not enough time to get comfortable in the pharmacy sphere with a new system,” Ellzy said.

“Is it satisfactory to meet all the goals of how the VA practices pharmacy right now? No, it does not,” he added.

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