Rising costs estimated for the Veterans Affairs Department to fully migrate to its new Electronic Health Record (EHR) system are making the project a tough sell to Congress, as lawmakers consider alternatives.

House VA Committee Ranking Member Mike Bost (R-Ill.) said Wednesday that an upcoming cost analysis from the Institute for Defense Analyses found the new Oracle-Cerner EHR system will now cost $39 billion to implement over 13 years, and $17 billion to maintain over the next 15 years.

The EHR migration is currently expected to cost $16 billion over 10 years.

“What the VA is getting today would be a bad investment at any price,” Bost said at a technology modernization subcommittee hearing.

Bost said the Oracle-Cerner EHR could cost as much as $63 billion over this 25-year period, “if everything goes wrong.”

“And I see a lot of things going wrong,” he added.

Chairman Frank Mrvan (D-Ind.) said the new cost estimate appears to be a major cost overrun, but said it’s difficult to assess, because the VA has yet to conduct a comprehensive lifecycle cost estimate.

“To me, this is yet more evidence that this program has lacked and rushed through their strategic planning from the very beginning,” Mrvan said.

Terry Adirim, executive director of the EHR Modernization Integration Office, said the VA is still planning for a 10-year deployment, and that the agency expects to release an EHR schedule this fall.

“There have been delays, and so it’s reasonable to expect that it could go beyond, and we’re doing that kind of contingency planning,” Adirim said.

The EHR rollout is already two years behind schedule. The EHR has gone live at five of the VA’s 171 medical centers so far.

The agency recently postponed EHR go-live dates for the rest of the year, and expects the EHR to launch at 24 VA medical centers in fiscal 2023, starting in the second quarter.

Bost said the agency’s legacy VistA EHR has its flaws too, but said the Cerner-Oracle EHR is now 10 times more expensive than what VA would have spent on a proposal to modernize VistA.

“If we don’t see major progress by early next year, when VA says they intend to roll Cerner out to larger sites, we will have to seriously consider pulling the plug,” he said.

House VA Committee Chairman Mark Takano (D-Calif.) said the committee will demand fixes from VA leadership before it allows deploying the Oracle-Cerner EHR to any more medical centers.

“VA needs a modernized EHR. Continuing with VistA is not sustainable long term.  Despite this, and I want to be absolutely clear, I will not sit idly by and allow this program to endanger veterans,” Takano said.

Subcommittee Ranking Member Matt Rosendale (R-Mont.) said the VistA legacy EHR still works, and is much less expensive than any of the alternatives.

“The responsible thing to do is to stop throwing money at Oracle-Cerner and make targeted investments to shore up VistA. Medical centers all over the country and the veterans they serve cannot be left in limbo,” Rosendale said.

Adirim said the upcoming Institute for Defense Analysis cost estimate looks at a 25-year cost horizon, compared to the VA’s 10-year budget planning, which focuses on just deployment.

She added that the new cost estimate identifies a range of risks, namely “if things go 100% right versus if there are problems and delays occur.”

“We do want to get it right, and we have changed our deployment strategies and our approach,” Adirim said.

But the costs don’t end there.

Rep. Dan Newhouse (R-Wash.) said new cost estimates show it will cost VA more than an additional $5 billion to increase staffing at medical centers that implement the new EHR, as well as prepare for a decline in revenue, as a result of seeing fewer patients during a period of lower productivity.

“The centers in our district should not have to choose between staffing up to continue safely caring for veterans, and blowing a hole in their budgets, forcing painful cuts in the future,” Newhouse said.

Adirim said regional Veterans Integrated Services Networks can supply additional staffing to medical centers moving to the new EHR.  She said research shows that a new EHR can lead to a loss of revenue and a reduction in operations for up to six months.

“I’ve experienced that myself, having worked out in the commercial sector, gone through these types of deployments. As you’re learning the system, you’re slower. You can see fewer patients, so it’s not surprising,” Adirim said.

The VA inspector general’s office in a report this month found nearly 150 instances of patient harm at the site of the first EHR go-live in Spokane, Washington.

An “unknown queue” issue in the EHR has led to thousands of clinical orders disappearing in an unmonitored inbox, causing patients to miss follow-up care.

Rep. Cathy McMorris Rodgers (R-Wash.) said the IG’s findings show that the Oracle-Cerner EHR “turned Mann-Grandstaff upside down.”

She said a homeless veteran’s follow-up appointment with a VA psychiatrist got lost in the unknown queue, and as a result, the veteran nearly attempted suicide.

“Fortunately, he called the Veterans Crisis Line and they got him to a local hospital. I want to commend the Veterans Crisis Line for the lifesaving work that they do. But that should never be allowed to happen,” Rodgers said.

Adirim said the VA resolved the unknown queue problem by the time the first EHR go-live happened in Spokane. She described the unknown queue as a “safety net for orders that could not be routed properly.”

However, she acknowledged that the EHR rollout to date has undermined confidence in the system.

“I don’t blame them for not trusting the system,” Adirim said about the EHR go-live in Spokane, which has seen the most severe challenges of any site to date. “The deployment did not go as planned, didn’t go very well.”

Adirim said the unknown queue problem is incorporated into the EHR training.

“If they write an order that cannot be routed, cannot be filled, they do get a pop-up that says this order cannot be filled,” Adirim said. “During training, staff should know or be communicated with to know that this queue exists.”

Adirim said a council of VHA personnel decided not to include a “hard stop” fix to the unknown queue that would prevent the clinician’s order from going through, but said the VA is revisiting the issue.

Deputy VA Inspector General David Case, however, said the unknown queue problem is still delaying care to veterans, and has not been fully addressed.

“It has the potential and does, in fact, delay care. That’s because the remediation that’s in place requires human activity to identify what’s in the queue, remove the order, and then reroute the order,” Case said.

Case said the VA’s current mitigation plan does not eliminate risk, and every new EHR go-live site must monitor the queue and address it in a timely manner.

Case said the IG’s office is also concerned with VA Deputy Secretary Donald Remy’s response to its findings has been “essentially silent in acknowledging the VHA identified patient harm.”

“Such acknowledgment by senior leaders is critical for VA to function as a learning organization committed to zero patient harm,” Case said.

Julie Kroviak, the principle deputy assistant IG for the Office of Healthcare Inspections, said her office has seen “quite a few shortcomings in the mitigation processes that are currently in place.”

“It’s not a hard stop, and it requires a lot of human labor to monitor and re-enter those orders than clinicians placed,” Kroviak said. “As a former EHR user, if I’m putting in the order, I should be aware of the system limitations that are in place. I expect that order to be carried through and if it isn’t going to be carried through, I need to know, in that moment that I’m placing that order that I need to recreate the order or notify that I need this care, and for some reason, the system is preventing it.”

Adirim defended the Oracle-Cerner EHR as a “mixed bag of burden versus improvements.” She said the new EHR has led to increased efficiencies in lab and radiology.

“VA is one of the largest, most complex health systems — actually the largest, most complex health system. You would expect that there’s going to be a reduction in our operations,” she said.

Adirim said the VA is working with MITRE to evaluate some of its most high-risk and prominent workflows, including concerns with pharmacy operations. She said MITRE will start in Columbus, Ohio and issue recommendations on how the agency can reduce the burden on its personnel.

Adirim said VA has contracted with Cerner to deliver the three most urgent “capability enhancements” by February.

“It just seems to me that every time that we talk about an issue with the system, the VA’s response is that it will put a mitigation strategy in place, which is just another workaround. I don’t think you can guarantee patient safety while asking staff to take on massive amounts of extra work to compensate for the shortcomings of the system,” Mrvan said.

The VA said there have been 24 outages and 48 degradation events since the first EHR go-live, and that resiliency issues are at the core of the EHR problem.

But the EHR encountered yet another problem last week at Roseburg VA Medical Center in Oregon.

VA spokesman Terrence Hayes said EHR users on the morning of July 21 began reporting a “webpage not found” alert when attempting to admit new patients. The issue took 323 minutes to resolve.

“During this time, clinical staff could not check-in, discharge or transfer patients,” Hayes said. “While staff may not have been able to register patients or transfer them to another unit within the EHR, patients were seen and treated. When the issue was resolved, patients were registered and transferred within the system to the appropriate patient unit.”

Hayes said the problem tracked back to a March 2022 deployment when the Java Enterprise Archive (EAR) did not properly clear older files.

“A combination of system load and load balancing issues caused limited functionality in the system. The issue was triggered by too much load on the system,” he said.

FedScoop first reported the EHR outage in Roseburg.

“We just keep falling down with this system. We keep changing people looking in this and it just keeps getting worse,” Bost said.

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