A pair of newly-released inspector general reports shed light on the reasons behind the Department of Veterans Affairs’ February decision to delay the initial rollout of its new electronic health record — a project that’s now on hold indefinitely because of the COVID-19 pandemic.
VA’s inspector general said the department had been pressing toward an EHR deployment that would have caused “significant potential patient safety risks,” and that those risks will still exist whenever the department decides to move ahead, unless it solves key underlying problems.
The IG said VA failed to heed the lessons the Defense Department learned when it deployed an EHR based on the same commercial software, Cerner Millennium, in the same Pacific Northwest region of the country.
DoD’s experience showed, for example, that IT infrastructure upgrades needed to be finished six months before the system went live at any particular site, and that additional staff would need to be hired, since existing employees time would be occupied training on the new system and employing manual workarounds while new capabilities came online.
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Based on those lessons, VA officials knew the first EHR site — Mann-Grandstaff VA Medical Center in Spokane, Washington — could expect to suffer a 30% decrease in patient care capacity unless they took steps to mitigate the problem. But many of those steps were never taken, or were taken much too late.
For example, as early as September 2018, local officials in Spokane estimated they would need to hire 108 new clinicians and administrative staff in order to keep up acceptable levels of patient care while the EHR transition took place.
But those hiring plans were stymied when the medical center’s parent organization, Veterans Integrated Service Network 20, implemented a hiring freeze several months later. It wasn’t lifted until October 2019, when VA’s Office of Healthcare Transformation stepped in. The seven-month pause in hiring meant fewer than half of the needed employees had been hired by February 2020, a month before the system was set to go live in Spokane.
And despite VA officials’ earlier acknowledgement that network upgrades would need to be done six months ahead of the “go-live” date, the IG found officials were planning to press ahead before they were completed. By the end of 2019, 31 percent of the end user devices that would be needed to run on the new system still hadn’t been replaced, contracts needed to complete “critical” upgrades to networks hadn’t even been awarded yet, and equipment rooms needed to support the new system were still filled with mazes of antiquated wiring.
“By not having the proper infrastructure ready for the deployment of the new system, VA has reduced its ability to identify the root causes for any system performance issues, as DoD experienced during its electronic health record system implementation. DoD’s experience also portends that going live with deficient infrastructure can lead to diminished user experience and low adoption rates, in particular if there is system latency or other unresolved performance issues,” auditors wrote. “[VA’s] aggressive but seemingly unrealistic deployment schedule increases the risk of unnecessary program costs if future deployment sites are forced to make deadline-driven temporary fixes, only to have to pay for permanent solutions later.”
But Spokane employees told the IG that VA’s approach had generally been to simply reduce the number of features that would be available on the “go-live” date, and then introduce more capabilities in “waves.”
In some cases, that would mean patients and clinicians ending up with less capability than they have with the current system, VistA.
For example, since 2003, veterans have been able to order prescription refills through the MyHealtheVet online portal, and it’s since become the most popular way to do so. 10,000 prescriptions are refilled via the online system each month in Spokane alone.
But officials determined in late 2019 that the Cerner online prescription module wouldn’t meet VA’s needs, so they decided to press ahead without it — a measure that would force patients to order refills in person or by phone for the foreseeable future.
“Facility leaders and staff told the OIG of safety concerns related to the loss of the MyHealtheVet electronic refill portal and that mitigation strategies seemed insufficient to meet patient needs,” according to the report. “This mitigation plan requires patient involvement, and as of January 15, 2020, facility leaders had not deployed any communication to patients pertaining to their role in the change to the electronic prescription refill process.”
Between the two reports, the IG made 16 recommendations, including that the department provide clear guidance to medical centers on what capabilities they’d have available on their go-live dates, and exactly what steps they’d need to take to ensure a successful transition. VA leaders agreed with all of them in full, or “in principle.”
“As VHA continues to operationalize mitigation strategies, user and patient experience is at the forefront of our considerations,” wrote Dr. Richard Stone, the acting head of the Veterans Health Administration. “Prior to any go-live decision, it is of the utmost importance that Veterans Integrated Service Network 20 facility staff and leadership are 100 percent comfortable that go-live will not negatively impact patients and users…VHA is committed to doing no harm and implementing the electronic health record (EHR) in a thoughtful way. We realize this is a significant undertaking with multiple complexities. Secretary Wilkie, with feedback from many of our clinical and technical stakeholders, postponed training events and the initial go live date until we are fully confident that the new EHR system is as complete as possible.”