VA’s electronic health record system for scheduling patients requires training

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The Department of Veterans Affairs has been laboring for years now to build and install the Cerner electronic health record system. The Office of Inspector General took a close look at the patient scheduling component VA installed last year at two locations. With highlights of what they found, Deputy Assistant Inspector General Leigh Ann Searight joined Federal Drive with Tom Temin.

Interview transcript:

Tom Temin: Ms. Searight, good to have you back.

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Leigh Ann Searight: Thank you, Tom. I’m glad to be back.

Tom Temin: I guess people may not realize at first glance that Cerner, the system they’re trying to install, is more than purely a record of a given veterans health. But it also has administrative components, including scheduling.

Leigh Ann Searight: Correct. The Cerner suite is a very complex suite of tools. And scheduling is just one of those, along with the primary electronic health record.

Tom Temin: And of course, scheduling was an issue for VA a few years back when it got into trouble because of scheduling and the inability to schedule people reliably.

Leigh Ann Searight: Right. The whole access to care issue that came about during the Phoenix error in, what, 2016 – that really put a big highlight on the visibility VA has over scheduling, yes.

Tom Temin: Alright. And so far VA has put in installations of the new system in a couple of locations. And that included the scheduling component. Tell us what you looked at and what you were specifically going after here.

Leigh Ann Searight: So the implementation of the EHR, the electronic health record, occurred on a full scale at Spokane, and then also in Columbus, we looked at it, but Columbus only actually implemented the scheduling solution and not the full EHR M suite. So we looked at the implementation of both of those locations and how the challenges identified. So we looked at whether training was provided to those schedulers, whether there were any system process weaknesses, and then what VHA and the Office of Electronic Health Record Modernization, and Cerner, did to fix those identified issues.

Tom Temin: And I want to talk about the training issue for a moment, because you would think that in this century, I mean, I guess I’m maybe introducing some bias here, but that software systems are designed to be so intuitive, that you don’t need a lot of training for something as basic as letting someone come in for an appointment at 2:30 a week from Tuesday.

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Leigh Ann Searight: From the layman’s perspective, scheduling seems very direct, right. But in terms of a healthcare system, it’s really pretty complicated in terms of identifying all the clinics that a patient might need to visit or all the different pieces of an appointment that need to occur. Like if you think about being scheduled for surgery, you have post-up, pre-op, blood tests, all those scheduling issues. So for training, it really was about getting the hands on training, and for their specific clinics, because each clinic has its own complexity level, and how they handle patients how they’re able to schedule. And then adding telehealth to that and the complexity of scheduling for telehealth as well.

Tom Temin: But in some ways, isn’t that a legacy of VistA in the sense that it was a different instance for each medical center, complex. And isn’t this supposed to, through Cerner and the larger effort they’re doing, an attempt to unify all of that?

Leigh Ann Searight: Yes, definitely. It is trying to unify that and standardize the processes in terms of scheduling. But even with that standardization, going from a legacy system that’s been around and had a lot of challenges, and maybe a scheduler might have to look at seven different systems to be able to schedule appropriately and really, completely changing processes and how they do business for scheduling. So it was a learning curve for the scheduling staff.

Tom Temin: And with all of the locations possible, and all of the procedures that might be associated with a given appointment, therefore, the system for scheduling it has to be able to pull in all those variables to be able to make an effective appointment, I would think.

Leigh Ann Searight: Exactly. And what they found when they implemented the system is that some of those clinics weren’t implemented. Schedulers went to schedule for a specific clinic and found that that clinic wasn’t even available. So that implementation process was critical. And the pre testing that needed to occur to make sure everything was up and running, really they didn’t allow for enough time for that to occur.

Tom Temin: We’re speaking with Leigh Ann Searight, she’s Deputy Assistant Inspector General at the Veterans Affairs Department. And your report found that the people doing the installation knew that there were issues but somehow all of these problems weren’t communicated to the people that would end up living with the system. Tell us about that.

Leigh Ann Searight: There was an awareness that there was breakdowns in the appointment reminder letters. Veterans, while they can get email or text to give them appointment reminders, a lot of veterans rely on the paper appointment process. And this Cerner application didn’t allow for that, and the schedulers weren’t aware of that. So then they had to manually print off appointment reminders, manually address letters to send them out these clinics that have implemented this solution. They service up to 1,000 appointments a day, so that’s just not a feasible workaround. Through that process, one of the other issues was being able to change a modality of appointment. So I have scheduled you as a in person appointment, and then COVID hits, challenges with being able to come into the facility, we need to change you to telehealth. Under the old practice scheduler could make that change themselves. And with this, you have to go back to the provider to get a new order submitted to then make that change, or the scheduler can delete the appointment and reenter it. But then there’s a lot of complexity behind that, whether they do it correctly, we’re changing wait time metrics and how we’re tracking that. So there’s opportunities to sort of game the system a little bit.

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Tom Temin: Yeah, it strikes me that there’s a little bit of a catch-22 here. You need all of the complete data from all of the possible variables to be fed into the system. But you can’t have the system working until all the variables are available. And so without a comprehensive installation, it can never work. And so are they kind of going in circles a little bit here?

Leigh Ann Searight: To some extent. But I mean, for those clinics where it was implemented appropriately, the system is working very well, with some limitation exception, like we discussed. But it’s when you get the system into the facility, and you find you have gaps in terms of a clinic wasn’t built correctly, or the clinic can’t schedule certain types of appointments. That’s where the challenges come in. And then that’s where workarounds start being developed that maybe aren’t effective, or maybe lose sight of appointments. And so then we run a risk, or VA runs a risk, of really losing sight of that veteran and ensuring that that appointment actually occurred.

Tom Temin: Yeah, once you get into workarounds, then you’re kind of undoing what is supposed to be the goal of the system, which is a replicable, reproducible image, right, that can be eventually deployed to all of the visits and all of the subsystems that make up the VA as a whole, VHA.

Leigh Ann Searight: Exactly.

Tom Temin: Alright, so what were your principal recommendations then?

Leigh Ann Searight: So our primary recommendations were to improve the scheduling, which is pretty straightforward in terms of giving the schedulers an opportunity to really dig into their types of clinics and ensuring that it addresses all their needs. Also to develop a strategy to identify and resolve the additional scheduling issues. Making sure that all of the tickets that were submitted and the fixes that need to occur are addressed before they go forward and implement the EHRM scheduling package at additional facilities. And then being able to – one of the critical ones is the wait times, right. Coming up with guidance to allow for the facilities to appropriately track that wait times, because that is a critical piece in determining whether a veteran can go to community care or will remain within a facility. And so that directly impacts the veterans ability to make that choice.

Tom Temin: And by wait time, just to be specific, you mean the time from which they call or decide they need an appointment to when they actually can get one?

Leigh Ann Searight: Yeah. That or if a provider says I need you to go to ophthalmology, then if they can see you in ophthalmology within a certain period of time, then you will be seen within the facility. But if the wait time exceeds a certain threshold, then you will be offered an opportunity to be seen in the community.

Tom Temin: And just from a programmatic standpoint, this has grown to be a very complex affair, because you’ve got several offices in VHA dealing with it, and you’ve got lots of oversight. There was the VA review itself that Mr. McDonough initiated. There’s the OIG looking at it, there’s the GAO looking at it. So lots of oversight. To some degree Congress, which is driving what GAO does. And then you’ve also got the link to the Defense Department implementation, which has some of the same vendors, some of the prime vendors of its own, it all adds up to really a kaleidoscope of an effort here. Do you think that’s maybe one of the issues? Could the whole programmatic standpoint of installation be simplified, do you think/ Maybe that’s beyond the scope of your study, not to put you on the spot.

Leigh Ann Searight: That may be beyond the scope of this study. But it is definitely something to be studied, for sure.

Tom Temin: Because when I see a long list of abbreviations in the beginning of a report, that’s kind of a clue that there’s a lot of people working on this. So VA generally then agreed with what it is that you recommended in this case?

Leigh Ann Searight: Yes, VA agreed with all of our recommendations, and they set their implementation really to be complete by the summer of next year. We should receive our first update on the status of all those recommendations by February of this year.

Tom Temin: Got it. Sounds like maybe the first two or three installations will take eight years or something and then they’ll go bang, bang, bang, bang, bang and be done quickly.

Leigh Ann Searight: That is the hope, yes. I mean, with the pause that EHRM took to really figure out next steps, I mean, I think that VA as a whole would hope that that pause will result in some efficiencies moving forward.

Tom Temin: Leigh Ann Searight is deputy assistant inspector general at the Veterans Affairs Department. Thanks so much for joining me.

Leigh Ann Searight: Thank you, Tom. I appreciate the time.

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