VA wraps first-wave EHR fixes, but employees ‘strongly disagree’ it’s ready to move forward

The Department of Veterans Affairs has completed its first wave of fixes to its new Electronic Health Record (EHR), since hitting pause on the project’s rollout this spring.

The VA announced an indefinite freeze on new launches of the Oracle-Cerner EHR in April. The department says the current “reset” period won’t end until it addresses the system’s persistent outages, and until VA sites already using the Oracle-Cerner EHR show improved performance.

Neil Evans, acting program executive director of VA’s EHR Modernization Integration Office, said Thursday that there are “real significant advantages” to the VA having an EHR that’s standardized across its health care network and interoperable with the Defense Department.

The VA is considering resuming EHR go-lives next summer, but leaders of the VA medical facilities already using the Oracle-Cerner EHR told the House VA Committee they’re still not as productive as they were before the new system went into effect – despite hiring additional staff.

VA medical workers, they added, feel burnt out, putting in longer hours and going through more steps to complete routine tasks using the new EHR.

Robert Fischer, director of the Mann-Grandstaff VA medical center in Spokane, Washington — the first VA site to deploy the Oracle-Cerner system in October 2020 — said the facility has had to hire 20% more staff and 15% more clinicians to handle the same workloads under the EHR.

Fischer said that since implementation, employees have investigated 1,600 Oracle-Cerner-related patient safety events, 15,000 “break-fix” IT help tickets and 28,000 medical orders that “did not execute successfully as anticipated.

“I would say one of the root causes is related to Oracle-Cerner’s lack of appreciation for the complexity of VA operations,” Fischer said.

During the current recent period, Fisher said Mann-Grandstaff VA Medical Center officials are holding more meetings with Oracle-Cerner.

“It’ll be hard to say what a month from now will look like, when we’re more into normal operations and improvements are being made,” he said.

Evans said VA’s EHR migration is “one of the most complex health IT projects ever undertaken,” and that its implementation was always going to come with challenges.

“One of the challenges that you face in deploying an electronic health record is the tension between the need to deploy the health record and needing to optimize it, such that it is fit for purpose for how you deliver care in your health care system,” Evans said.

“When you deploy an electronic health record, you’re never done. There is always a tension between pushing forward with the deployment, but doing the optimization,” he added. “And it’s really as part of this reset we’re choosing … to get some of that optimization work done now, to take the time to do that, so that we can deploy a more standardized EHR that will meet the needs of our facilities moving forward.”

Thandiwe Nelson-Brooks, associate director of the VA medical center in Roseburg, Oregon, said staff are more familiar with the EHR since its launch, and the time it takes to fill prescriptions has decreased – but the facility still hasn’t returned to its pre-deployment productivity levels.

In April, 86% of Roseburg VA employees “strongly disagreed” that the Oracle-Cerner EHR is ready for future deployments in its current state, “as it does not increase efficiency, improve patient safety or meet expectations.”

“The training that our staff initially received from Cerner was not what we expected, and did not adequately prepare staff to be able to function effectively and efficiently in the medical record system,” Nelson-Brooks said.

Nelson-Brooks said the Oracle-Cerner EHR, A commercial, off-the-shelf product, does not take into account VA-specific programs. She added that the rural Roseburg VAMC has a 40% vacancy rate among its primary care provider positions, and isn’t able to surge staffing the same way that other VA facilities have been able to.

“Each medical center is different and unique, and their capacity to handle change of this scale is very individualized,” Nelson-Brooks said. “We are moving in the right direction. However, the system in its current state is not ready for additional deployments.”

Meredith Arensman, chief of staff of the VA Ambulatory Care Center in Columbus, Ohio, said clinicians are “exhausted, sometimes tearful, and frankly distressed,” that they’re unable to provide the level of care that they could in 2019, prior to the EHR’s rollout in 2020.

“Imagine being a doctor in Columbus, and receiving a critical message about a patient you have never seen, who’s been admitted to a Department of Defense site thousands of miles away, because his provider has a similar name,” Arensman said. “Imagine being an optometrist and finding an eyeglass prescription that has your signature, that you know you never signed … These are not possibilities. It has been the reality.”

Arensman said her facility has seen less total downtime and fewer outages with the new EHR system in the past six months, but staff are still seeing incidents at least once a month, incidents that require them to fall back on “downtime procedures” – taking patient notes using pen and paper.

She added employees have seen two outages in the past two weeks that have forced them to take patient notes by hand.

“We are taking care of the veterans in Central Ohio, and I think we’re doing an amazing job, but at what cost? It costs a tremendous amount, in terms of additional staff, in terms of additional overtime – and, I think, a degree of moral distress among our providers,” Arensman said.

Arensman said the facility is close to getting back productivity levels it saw pre-deployment, but only because “our staff continues to persevere, working longer hours, and manually completing workarounds to protect veterans every day.”

The current EHR strategy, she added, is “not adequate, nor scalable.”

“We understand we can’t flip the switch and go back to the legacy system, although there are days that would be our preference,” she said.

Committee Chairman Mike Bost (R-Ill.) said VA facilities using the Oracle-Cerner EHR have only managed to get close to normal patient volumes “by adding a lot more staff.”

“That’s more people to do the same amount of work,” Bost said. “But they still can’t trust the Oracle-Cerner EHR to be safe and accurate, so VA employees are being forced to double-check everything.”

Bost said he and Committee Ranking Member Mark Takano (D-Calif.) are working with Senate VA Committee Chairman Jon Tester (D-Mont.) to reach a bipartisan compromise on Tester’s EHR Reset legislation.

“Our staffs are going to be working together to hammer out an agreement,” Bost said. “It’s simple: the project has to deliver results, or end.”

The EHR Program RESET Act would prevent the VA from proceeding with EHR go-lives at additional facilities, until data from the five current sites using the system “demonstrates an ability to deliver health care to veterans at standards that surpass metrics” using VA’s 40-year-old legacy VistA EHR. 

Takano said Congress needs to take “legislative action to force some of the structural and accountability measures that are necessary to get this program on track.”

Bost said he’s also concerned greater volume of veterans enrolling in VA health care under the toxic-exposure PACT Act will push these centers beyond their breaking point.

“Your workload is going to get a lot bigger,” Bost said.

Scott Kelter, director of the Jonathan M. Wainwright VA Medical Center in Walla Walla, Washington, told the committee that the facility to getting close to the productivity levels it saw before the EHR’s rollout

But Kelter said employees are putting in long hours trying to use the system, and a “majority of staff” are still frustrated with the time it takes to complete routine tasks using the Oracle-Cerner EHR.

“What might have taken six-to-10 clicks before now takes 30 to 50. And so. the process time for many things is still double or triple what it was,” Kelter said.

Evans said VA and Oracle-Cerner are “focusing on delivering the improvements needed for current system users while also preparing the enterprise for future deployment.”

The VA during its reset is breaking up EHR improvements into three-month increments. Evans said the VA completed its first wave of improvements on Aug. 31.

During this first three-month period, VA focused on improving the technical stability of the system to prevent outages, system configuration, improved user support and IT ticket management, communications within VA and developing a “larger cohort of VA experts who can support the new system in the years to come.”

“This is much more than just a technology project,” Evans said, adding that the system will “profoundly impact” how the VA delivers health care, plans surgeries and transmits orders for prescriptions and follow-up care with specialists.

Switching to a new EHR, he added, gives VA an opportunity to standardize clinical processes and workflows across its health care network.

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