The Department of Veterans Affairs has technically finished a strategic review of its massive electronic health record modernization project, but the toughest work lies ahead.

The review, which VA initially launched in March after hearing concerns from employees at the first go-live site in Spokane, Washington, pointed to a whole host of tasks the department must complete to put the EHR modernization on a better footing — namely a new governance and organizational structure, as well as a new cost estimate and deployment schedule for the project.

VA Secretary Denis McDonough on Wednesday offered up his most concrete assessment of the initial EHR rollout to date, though some exact details are still up in the air.

The department uncovered “numerous patient safety concerns and system errors” with the Cerner Millennium system, which VA teams are still trying to mitigate and, in fact, define ahead of future deployments.

Veterans themselves were confused and frustrated with the transition to Cerner’s new patient portal, and Spokane employees didn’t train on the actual EHR before go-live. The training itself was ineffective, VA’s inspector general found.

The strategic review highlighted significant productivity declines and usability and data migration failures, which Federal News Network has previously reported and McDonough has hinted at recently before Congress and in the press.

During a hearing before the Senate VA Committee, McDonough described stories he heard from employees at the Mann-Grandstaff VA Medical Center, who found workarounds when, for example, the EHR generated duplicate prescriptions and confused patients.

“I heard from another clinician that help with the new platform wasn’t always easy to find, even when you asked for it,” McDonough said. “When she called the Cerner help desk, the person on the other end of the line told her he had just started a week prior. In other words, she had more experience using the platform than the person who was supposed to help her navigate it.”

To date, VA officials have managed the EHR modernization in “organizational silos,” McDonough said. He said the strategic review findings are “extremely disappointing,” though he’s optimistic about the project itself.

“Most challenges were not breakdowns of the technology, nor of the great people at Mann-Grandstaff who did the best they could in the worst of circumstances, implemented this program in the heart of a pandemic, dutifully shared findings that improved the system and ensured that our veterans were safe despite the challenges they faced,” McDonough said. “Instead the missteps were ours, at VA, and Cerner.”

Now, VA is “reimagining” its approach to the EHR modernization effort, starting with a new, enterprise-wide governance structure to manage the project.

McDonough didn’t detail exactly what that structure looked like. By law, the VA deputy secretary is in charge of the EHR project, and the Senate — at least at the time of Wednesday’s hearing — hadn’t yet confirmed nominee Donald Remy to the job.

“I want to talk to our deputy secretary, when confirmed, because statutorily he is in charge of this and will manage this as a management question and a budget question,” McDonough said. “I would just ask forbearance to spend a couple days talking with him about it, and then by next week we’ll be happy to come up and show that to you. I think you’ll see significant change, including a reduction of what I consider to be redundant positions, and most importantly, clear accountability among each of us to one another and to you, to ensure that decisions taken are decisions implemented.”

The Senate began voting on Remy’s nomination after Wednesday’s afternoon hearing.

Schedule of future deployments will depend on which facilities are ‘ready’

Clearly, the deployment schedule and timeline also need a refresh, McDonough said.

VA initially planned to deploy the EHR along a similar regional path as the Defense Department, which purchased the same Cerner Millennium product Genesis is based on. But the Pentagon is well ahead of VA, and their deployments are no longer synchronized.

That initial geographic deployment plan was a mistake, McDonough said.

The department instead will develop a new integrated master schedule for the EHR that will link to VA’s many other modernization efforts.

Moving forward, VA will make deployment decisions based on which facilities are ready, McDonough said. Facilities that have the infrastructure in place needed to support the EHR and properly trained employees and leadership will get the green-light to deploy.

VA is also developing a new budget estimate for the entire EHR project, which will include the costs of updating both physical and IT infrastructure needed to support the new record, the department told senators Wednesday.

Its previous $16.1 billion estimate for EHR modernization generally didn’t include those costs, and any estimates VA previously provided to Congress were unreliable and likely inaccurate, the department’s IG has said.

Senators question Cerner technology

VA’s review also pointed to other problems. The EHR deployment, for example, disrupted VA’s billing operations, the department said, because the Cerner product doesn’t have an “effective revenue cycle function.”

And while VA has deployed support to address billing problems, challenges persist. Today, many parts of the claims and payments process require manual entry, McDonough said in his written testimony.

“Actions are being taken to address and fix this major deficiency which, if not resolved, will limit future deployments,” the department said in its “comprehensive lessons learned report,” which VA shared with the press Wednesday afternoon.

McDonough, senators acknowledged, inherited VA’s current challenges. They confirmed him, they said, for his management skills.

“You’re a guy from Minnesota, great dairy industry. I’ve had the impression for some time there are folks out there milking the cow. Every day they go out and they see this cash cow, and they’re getting every dime they can get out of it. There’s been damn little accountability,” said Jon Tester (D-Mont.), chairman of the Senate Veterans Affairs Committee.

“I hope Cerner’s watching this,” he added. “If Cerner’s not up to making a user-friendly electronic medical record, and in fact what’s transpired here is we’re going in the opposite direction, then they ought to admit it and give us the money back so we can start over.”

McDonough reiterated multiple times: VA is still committed to the Cerner solution. The department has reviewed the contract, and it has since “clarified and reestablished contractual and functional metrics,” McDonough said in his written testimony.

VA has said it chose Cerner, in part, because it wanted to achieve interoperability with DoD, a long-desired goal. But the departments aren’t quite there yet.

“I’m told by the clinicians that all the data is available to that individual clinician, data from the DoD data pool, data from the VA data pool and then data from care in the community,” McDonough said. “Unfortunately I’m also told it doesn’t all populate [on] the same screen at the moment, and it’s not all apples to apples across those three data pools, which is kind of the point. One doctor reminded me today [that] the place where it’s all aggregated is in the clinician’s head. We obviously have to get to a place where that’s not the case.”

Multiple senators on both sides of the aisles questioned whether the Cerner product itself is the right fit for VA.

“I think the technology is basically sound,” McDonough said. “So much of these technology questions in terms of execution really end up being governance and management challenges, which is why I think it’s on me. I have not yet found and I don’t believe I will find an answer that says the technology is wanting. On this question of the three data pools, we have the best data scientists in government, and we’re going to fix that.”

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