VA sprint team outlines 4 key issues leading to EHR rollout problems

The Department of Veterans Affairs is outlining a plan to address some of the biggest problems to emerge from the troubled rollout of its new Electronic Health Record.

The VA, in its EHR Modernization Sprint Report, also detailed the steps the agency will go through to determine whether upcoming sites are prepared to make the migration to the new system.

The report, released late on March 10, doesn’t mention any changes to the VA’s timetable. The VA expects the EHR will continue to go live at additional medical centers this June.

The VA’s sprint report stems from a months-long review of the state of the EHR modernization program, and addresses problems VA clinicians have raised about the new system.

Two of the top VA executives overseeing the EHR rollout — Undersecretary for Health Shereef Elnahal and Acting Program Executive for EHR Modernization Neil Evans — thanked frontline VA clinicians “who have worked tirelessly to flag concerns with the system.”

“We acknowledge that the progress of this project has not met veteran or VA expectations,” Elnahal and Evans wrote in the report.

The VA has been in an “assess and address” period since last fall to troubleshoot problems with the system — some of which have led to patient harm. This is the second prolonged pause of the EHR rollout.

The agency has also sent letters to 42,000 veterans urging them to contact the VA if they “experienced a delay in medications, appointments, referrals or test results” at a facility using the Oracle-Cerner EHR.

The problems have frustrated members of Congress. Top Republicans on the House VA Committee have introduced legislation to pull the plug on the Oracle-Cerner project altogether, and have asked the VA to consider sticking with its legacy EHR, VistA, which has been in use by the agency for 40 years.

Senate VA Committee Chairman Jon Tester (D-Mont.) said in a statement that the VA is “far from where we need to be in using this new EHR to deliver health care for veterans,” and urged the agency to “aggressively renegotiate this contract with better terms for taxpayers” by the time the current agreement expires in May.

“The men and women who risk their lives to defend our country deserve to get the care they have earned when they return home,” Tester said.

The Senate VA Committee will hold its next EHR oversight hearing this Wednesday.

After the VA put a hold on upcoming go-lives on hold last fall, the agency launched an EHR Modernization Sprint Team.

The sprint team identified four key patient safety issues with the EHR — one of them being the “unknown queue” issue flagged by the VA’s inspector general office.

The “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.

The team also found that the EHR failed to follow up and reschedule appointments for veterans who canceled or didn’t show up for their appointments. It also found the EHR didn’t adequately handle referrals for patients.

The team found usability issues with the EHR, such as the system inadvertently only billing patients for medical imaging, but not actually ordering the clinical imaging for the patient.

The sprint team expects the VA will be able to implement many of the solutions it identified later this year, and will be included in the EHR modernization program’s integrated master schedule.

The VA said some of the remedies outlined in the report are already complete, while in other cases, it will pursue interim solutions — since  “durable solutions may take many months.”

The VA said it’s also restructuring how the agency makes upcoming go-live decisions.

“In 2022, it became more and more evident that our structure and our processes were not optimal for successful deployments or to fix issues identified after deployments,” the report states.

The VA is developing an Enterprise Site Readiness Dashboard that will help the agency determine if a particular site is prepared to migrate to the Oracle-Cerner EHR.

The VA acknowledges that most of the sites that have implemented the Oracle-Cerner EHR “have not returned to baseline productivity,” and that most sites have hired additional employees in an effort to achieve the same level of productivity prior to the go-live.

The VA also found that VA sites that have implemented the Oracle-Cerner EHR have generally seen a decrease in revenue, compared to the period before the go-live.

“Deployment decisions for future sites should be informed by success in addressing these causes and evidenced by improvement in operations at current facilities,” the report states.

The sprint team reviewed more than 450 submitted issues from VHA and prioritized 30 to address during the sprint.

“The EHRM sprint team obtained honest, open opinions and insights through field input that helped inform process changes across VA to ensure a more consistent experience for veterans,” the report states.

The sprint team conducted an “orders audit” to flag instances when the EHR wasn’t correctly routing orders from clinicians.

The team also heard from VA medical center staff who identified instances where the EHR system is difficult for them to use, “which can lead to user errors that cause inefficiencies, delays in care and patient safety concerns.”

“This sprint was a direct result of your efforts, and we thank you for your unwavering commitment to veterans,” the report states. “Working together to modernize the EHR system, we will create a lifetime of safe, reliable and seamless care — and ensure the best possible experience at VA for both veterans and VA health care personnel.”

As for next steps, the report recommends a different approach to training front-line VA clinicians on the EHR, adding that clinicians who have completed their training still “have had trouble applying this software knowledge to the accomplishment of their jobs.”

The sprint team recommends “more over-the-shoulder or at-the-elbow support than is already provided, including by peers, to help users make the transition from VistA to Cerner and to understand new ways of getting work done with the new EHR.”

The report also identifies EHR workarounds for VA medical centers that conduct medical research.

“VHA’s ability to retain faculty is foundational for success against VA’s goals across all four of its missions, to include high-quality and timely delivery of health care. Research faculty must maintain their clinical research studies to retain funding and meet timelines outlined in grants,” the report states.

The VA recently delayed a go-live of the Oracle-Cerner EHR at a VA medical center in Ann Arbor, Michigan to not put the facility’s research grants at risk. The facility is one of many VA medical centers that partner with academic institutions on veteran clinical trials.

The EHR is now scheduled to go live in Ann Arbor in late 2023 or early 2024. The EHR was previously scheduled to go live in July 2023.

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