The Department of Veterans Affairs, with the rollout of its new Electronic Health Record (EHR) on hold for now, is telling Congress that the system is currently “not even close” to meeting the needs of patients, and that fixes to patient safety problems may result in additional rollout delays.

Deputy VA Secretary Donald Remy told members of the Senate Appropriations Committee on Wednesday that the agency won’t proceed with future EHR go-lives until it addresses persistent outages and patient safety concerns.

“Right now, the bottom line is that the Cerner system is not delivering for veterans in the ways that it should. Not even close. It needs major improvements,” Remy told the subcommittee on military construction, veterans affairs and related agencies.

The VA recently postponed EHR launches planned for this summer, and has scheduled the EHR to go live at 25 VA medical centers in fiscal 2023. but the schedule is still subject to changes.

“We’re looking closely at this schedule, and we’re realizing that there are issues that need to be resolved before we can go live. Right now, our schedule would have us go to another installation in early 2023 — January, February. If we have to push that back, we’ll push that back,” Remy said.

Remy said the department is currently testing the EHR at some of its larger, more complex facilities, and improving usability for health care personnel.

“If any future sites fail to meet our integrated readiness criteria for any reason, we will not go live. We simply will not subject our veterans to avoidable risk,” Remy said.

The VA continues to face intense scrutiny from Congress over EHR patient health and safety concerns documented by the VA inspector general’s office.

Remy said these “problems are real enough that if that we’re not moving forward until we resolve some of them.”

VHA says EHR leading to employee burnout

VA Undersecretary for Health Shereef Elnahal told senators that after a recent visit to see how the EHR functions at VA facilities in Columbus, Ohio, he has “deep concerns about the system as it’s functioning for front-line employees in service to veterans.”

“Right now, I saw folks struggling with this system deeply. Among the most concerning things that I saw was a phenomenon whereby our front-line clinicians, when they put in an order, or tried to interface with the system, they were not confident in many cases, and in many clinical settings, that those orders were actually getting where they needed to go, on behalf of their veterans,” Elnahal said.

The EHR went live in Columbus in May.

Elnahal said he saw VA health care providers having to put in additional manual work and steps to “rework” and “recheck” the EHR to ensure the system was doing what it was supposed to.

While Elnahal said he received some positive feedback on the EHR from urgent care personnel and surgical staff, he concluded that he “did not see a system that was meeting most of the front-line clinicians’ needs.”

Elnahal said VA employees told him during his visit that the “system was stressful to use” and contributed to burnout. He said leadership also told him employees were quitting in part because of frustration with the EHR.

Elnahal said the VA needs to rework the EHR interface so that it’s more user-friendly for clinicians. He said the VA also needs to provide enough training to ensure that “we have a confirmation that the broad swath of employees being trained to know what to do in front of a veteran.”

Elnahal said he was surprised by how frequently he saw an “unknown queue” error in the EHR cause problems for VA employees.

The “unknown queue” issue in the EHR, as documented by the VA inspector general’s office,  has led to thousands of clinical orders disappearing in an unmonitored inbox, causing patients to miss follow-up care.

Mike Sicilia, the executive vice president for industries at Oracle, said Oracle delivered a fix to the unknown queue problem on Aug. 1. Oracle this week also launched a dashboard that catalogs its to-do list for EHR fixes and progress being made under those changes.

“We know we have a lot to prove with deployments next year at larger, more complex sites. We view the next year as a key window for building momentum and turning the corner,” Sicilia said.

‘I don’t know that we’ve got a return on investment’

Remy said the VA has developed a  site readiness deployment checklist along with Oracle-Cerner that outlines criteria a VA site will need to demonstrate before a scheduled go-live can proceed. Those criteria include adequate training for the VA personnel who interact with the EHR system and patient safety protections.

Remy said the VA scrapped plans in July for the EHR to go live in Boise, Idaho, because the location didn’t pass the checklist.

“This is an iterative process. It’s not a static process. As we’re working with a site for potential deployment, we work through these issues to make sure that they have them covered,” Remy said.

The VA does not yet have a new go-live date schedule for Boise, but expects the rollout to resume at least by the second quarter of fiscal 2023.

The VA reported in July that the EHR has experienced at least 24 outages and 48 degradation events since the first EHR go-live in October 2020, and that resiliency of the EHR remains an ongoing challenge.

“Whether a system outage lasts for one minute, one hour or one day, that outage is unacceptable. So on behalf of veterans we serve and providers serving them, we couldn’t be more frustrated,” Remy said.

Remy said the VA continues to monitor sites that have implemented the new EHR, and applies lessons learned from previous go-lives to inform future deployments.

Lawmakers, meanwhile, are frustrated that the VA, nearly five years into a 10-year contract, has only deployed the new Oracle-Cerner EHR to five of VA’s 171 medical centers nationwide.

Senate VA Committee Chairman Jon Tester (D-Mont.) said the agency has spent about $7-9 billion on the contract so far.

“I don’t know that we’ve got a return on investment to speak of at all,” Tester said.

Sen. John Boozman (R-Ark.) said the VA EHR rollout to date has “fallen far short of expectations,” considering that Congress so far has appropriated $8.5 billion for the VA EHR over the last five years, and the agency is requesting $1.75 billion for fiscal 2023.

While the VA signed the EHR contract in May 2018, under the Trump administration, Tester told VA officials currently in charge of the rollout that “it’s your responsibility now to either figure it out and move forward, or figure it out a different way to go.”

“I don’t want anything implemented before it’s ready for prime time. On the same token, we’ve got an investment in a program that needs to start delivering at some time,” Tester said.

EHR cost, timeline remains murky

Sicilia said Oracle has shifted 2,000 Oracle employees onto the VA EHR implementation since it completed its acquisition of Cerner in June.

“This is the most important effort we have going on at the company,” Sicilia said.

Sicilia said the company will rewrite the Cerner EHR as a cloud application with new capabilities within the next six-to-nine months, in order to ensure better performance and stability for clinicians and patients.

Sicilia told the subcommittee that Oracle would provide this as a “cost-free upgrade under the current contract,” and that a beta version of the cloud application version of the EHR would be available in 2023.

Sicilia some of the EHR delays have been COVID-related but said “technical, functional and training challenges” at VA facilities have also led to delays.

Sicilia said Oracle will be ready, from a technical infrastructure perspective, whenever the VA wishes to resume go-lives. But he said the company needs more feedback from frontline VA employees on what usability changes they would like to see.

“What we need is the VHA councils to provide the content for how they want the system reconfigured, if so, because that’s not necessarily a programming change. We don’t have to change the code of the system, these are switches that need to be flipped,” Sicilia said.

Despite EHR schedule delays, Sicilia said Oracle expects to meet the scope of its VA contract with the $10.7 billion price tag.

“As we’ve examined the underlying causes for these delays and challenges our conclusion is that we have found nothing that can’t be addressed in reasonably short order to get us back on a workable schedule, and within budget,” Sicilia said.

Despite Oracle’s claims that the EHR contract can proceed on time and on-budget, an independent cost analysis from the Institute for Defense Analyses estimates the EHR, in terms of its lifecycle costs, will cost $50 billion to implement and maintain over a 28-year period.

Brian Rieksts, a research staff member with IDA’s analysis and research division, said there are  “notable differences” between the IDA analysis and the VA’s 2019 cost estimate of $16 billion.

The VA’s estimate, he said, only looks at a 10-year implementation period, and does not look at cost of expected productivity losses at VA facilities deploying the EHR.

“As the system is rolled out to more facilities, emerging information will provide additional insights regarding risk and uncertainty in the cost estimate,” Rieksts said.

The VA has not yet allowed IDA to publicly release its independent cost estimate, but has provided the full document to Congress.

IDA estimates it will take the VA 13 years to initially deploy the EHR, but Remy said the VA, for now, is still looking at a 10-year timeline.

“We’ve been looking at if we have to go beyond the 10 years, what does that look like? We don’t have here today a specific time period beyond the 10 years,” Remy said.

“We are looking at what it would take to make sure that we deploy this system in a safe, effective manner for our clinicians and our veterans. And if that needs to go beyond 10 years, we’re working through the process of determining what that time period might be,” he added.

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