5 more takeaways from VA’s EHR strategic review

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The Department of Veterans Affairs this week revealed a wide array of findings about its electronic health record modernization project, a massive effort that began in Spokane, Washington nine months ago.

VA officials at the time said the initial roll-out went “extremely well,” but the department’s recent strategic review suggests otherwise.

The department released a comprehensive lessons learned report, a 36-page document that describes its findings and reactions from the 12-week review.

It’s packed with tidbits about the current status of the project, but anyone looking for specific dates about VA’s next deployments will walk away disappointed.

The department will no longer deploy the EHR based on its original, geographically-based timeline. Instead, it will make decisions about future deployments after reviewing data and evidence from individual facilities, which must first show they have the infrastructure in place to support the new EHR.

Initially, VA was planning to implement the new record next to its Columbus, Ohio facility and other locations in the Pacific Northwest.

But earlier this week, VA Secretary Denis McDonough told Congress the department won’t go live at any new sites until it resolves challenges with billing, access and patient safety.

“I hope to make that decision on that by the end of this calendar year,” he told the Senate VA Committee Wednesday. “The question you raise about patient safety, both defining it and identifying where concrete issues exist, and importantly, where mitigations are necessary, will be the principle basis on which I make that decision.”

“I think we can get our hands around those this fall, but it won’t go live at those next two sites fully until I have answered those questions,” McDonough added.

What’s a patient safety issue?

VA said it discovered “numerous patient safety concerns” in Spokane, but the department and Cerner haven’t yet settled on a clear definition of what that truly means.

The patient safety issues that arose stemmed from incomplete data migration, usability problems, complicated workflows, busy screens, manual workarounds, ineffective training and faulty data, VA said.

End-users didn’t always use the same definitions and severity scoring methods to report the issues they encountered, VA said in its lessons learned report.

“The same issue may be reported more than once,” the report reads. “This has resulted in different counts of the total number of safety issues and the status of the issues.”

VA and Cerner are discussing ways to streamline the patient safety reporting process, and a dedicated team is on the ground in Spokane to resolve previous problems, the department said.

A plan and timeline for resolving all patient safety issues at Spokane should be finished this month, VA added.

VA developing new lifecycle cost estimates

All told, VA understated the costs of the physical and IT infrastructure costs needed to support the new health record by at least $5.2 billion, David Case, VA’s deputy inspector general, told senators.

Those numbers are likely unreliable, the IG said, and VA is now developing a lifecycle cost estimate that includes figures not previously reported to Congress.

“We are now undertaking a lifecycle cost estimate to clearly identify total costs associated with the project, regardless of whether sources of funding currently exist within current programs,” McDonough said in his written testimony. “This includes all infrastructure costs related to the project, as well as those attributed to [the Veterans Health Administration] and VA’s Office of Information and Technology based on the recent OIG findings.”

Specifically, VA is conducting “current state reviews” of all of its sites concurrently, instead of on a site-by-site basis throughout the course of the entire project, the department said in its recent report.

Senators pressed both McDonough and the IG about who’s responsible for not reporting all EHR costs to Congress.

“It seems almost unfathomable that you would not know who the decision maker was,” Sen. Bill Cassidy (R-La.) said.

“Well, I think that’s part of the issue of the overall management of the EHRM to a degree is that decision making can be opaque,” Case said. “We have started an investigation that’s separate that goes into issues of candor and potential manipulation of information both toward the IG and Congress.”

Senators seek accountability for potential manipulation

Senators, Democrats and Republicans, also questioned VA and its inspector general on multiple occasions about potential manipulation.

In a report published last week on VA’s training challenges, the IG suggested officials in VA’s Office of Electronic Health Record Modernization doctored training proficiency data before sending it to auditors.

“Lying to [or] withholding information from the IG or from Congress for that matter is really outrageous and unacceptable,” Sen. Patty Murray (D-Wash.) said. “I know you agree with me on that. But I just want to say very clearly that I expect anyone found doing that to be found accountable immediately.”

McDonough said he would look into the matter himself.

“If it’s confirmed, obviously there will be ramifications for that,” he said.

The department told auditors 89% of VA employees passed their proficiency checks with a score of 80% or higher in three attempts or less.

But the IG said it found an earlier version of VA proficiency check results, which were drafted but not sent to auditors. Those results showed a significantly different outcome, where 44% of employees passed their proficiency check with a score of 80% or higher, and “27% passed on 1st attempt, 12% passed on 2nd attempt, 5% passed on 3rd attempt.”

When auditors asked OEHRM about the differences, VA said it removed the outliers from the data it later provided to the IG.

“We haven’t addressed motive yet,” Case said of the discrepancies. “We felt it was important to identify the issue. Our Office of Special Reviews is now taking an in depth review of that particular incident and the information we got.”

Unlikely all VA employees will be satisfied with final EHR

VA acknowledged on multiple occasions it needed to step up change management efforts if it wanted a successful EHR implementation throughout the enterprise.

If the experience of Intermountain, a hospital network based in Salt Lake City, Utah, is any indication, it’s unlikely all VA employees will be pleased with the final EHR once it’s deployed across the department.

Intermountain implemented Cerner’s platform back in 2018. The hospital network had previously developed its own health record applications, and its 40,000 employees were well-accustomed to them.

“That took 40 years of development, so these systems were very much modified to the specific needs of individuals and individual departments and individual clinical areas,” said Marc Probst, the former chief information officer for Intermountain. “When we went to a more standardized system like Cerner, it required a lot of people to meet us halfway. That goes back to managing those expectations. You can’t just bring the system to the people and say you’re going to do everything they want. There’s a give and take. They have to come to the system as well.”

The deployment was difficult, though ultimately successful, said Probst, who has more than 35 years of experience working with electronic health records and now serves as the chief information officer for ELLKAY, a healthcare technology services company.

No EHR implementation is ever simple, he told the committee.

“If you were going to do an assessment today as to how many people of those 40,000 actually like this medical record, what would that percentage be?” Sen. Jon Tester (D-Mont.), the committee’s chairman, asked.

“Wow, like it? Under 50,” Probst said. “Tolerate it, will use it, are finding advantage in it? 80-to-90%.”

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