The Department of Veterans Affairs’ troubled rollout of a new Electronic Health Record always had its critics.
The same could be said of the VA’s three previous efforts to wean itself off the legacy, purpose-built EHR the agency developed about 40 years ago.
But congressional scrutiny is intensifying over the VA’s latest effort, a multibillion-dollar contract with Oracle-Cerner.
Five years into the contract, the EHR has gone live at five VA sites — with several pauses in deployments along the way. The agency’s goal is to bring the Oracle-Cerner EHR online at 171 VA medical centers across the country.
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The VA is back at the bargaining table with Oracle-Cerner, looking to renegotiate the terms of its contract.
“Obviously, inherent in the idea that there’s a five-year review is that you’re not just reviewing it to continue it,” VA Secretary Denis McDonough told House appropriators on Wednesday, when asked about the possibility of the agency switching vendors. “We’d be in a position to sustain what we have, and then see if there’s another technology.”
But House and Senate lawmakers say a renegotiated contract is only the start of what the VA needs to do to get the troubled Oracle-Cerner EHR contract back on track.
The toll of the EHR system crossed a new threshold this month, when members of the Senate VA Committee said the VA notified them of six “catastrophic events” related to a feature of the EHR modernization program over the last couple of years.
Senators said that four of the catastrophic events resulted in fatalities.
House VA Committee Chairman Mike Bost (R-Ill.) said in a recent interview that, according to the VA, those catastrophic incidents and deaths occurred because the EHR either dropped a possible appointment “that was vitally important” for a patient to receive, led to patients receiving the wrong medication or caused delays in care.
“It’s one issue like this after another that we’ve noticed,” Bost said in a March 22 interview.
Bost said those catastrophic events don’t include many other incidents where the EHR has “caused all kinds of trouble with our veterans trying to receive care.”
Those incidents include confusion in scheduling medical appointments, patients receiving the wrong medications, or not receiving any of their medications at all.
The VA’s inspector general has also flagged additional instances of patient harm.
“There are too many flaws in the system by itself. When you throw an electronic health record system in there that has failed over and over and over again — the danger to our veterans is out there, the frustration of our [VA] employees and our doctors is out there,” Bost said.
The VA recently released its EHR Modernization Sprint Report, which identifies four key issues leading to problems with the Oracle-Cerner rollout, as well as 14 issues with the system that need to be fixed.
VA health care executives recently told the Senate VA Committee that five of the 14 fixes have been partially implemented, and that some of the fixes probably require additional work from Oracle-Cerner.
Mike Sicilia, executive vice president for industries at Oracle, told the Senate VA Committee that recent fixes have allowed Oracle-Cerner to achieve the 99.9% uptime requirement for five of the last six months.
Oracle completed its acquisition of Cerner in June 2022. Prior to the acquisition, Sicilia said the average monthly downtime for the EHR was about 345 minutes, and that in January and February of this year, the system has only seen about 21 minutes of downtime per month.
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“The goal of every system should of course be as close to zero as possible, and we’re marching towards that,” Sicilia said.
Deployment of the same Oracle-Cerner EHR system is 75% complete at the Defense Department and Coast Guard. Sicilia said DoD will complete its deployment of the Oracle-Cerner EHR by the end of the year “on time and on budget.”
Bost, however, said the VA has yet to provide a clear picture to his committee of what a successful rollout of the Oracle-Cerner EHR looks like from here, given the system’s track record.
“The answer that we’re trying to get, is what is the long-term goal? What are the metrics that are put in place to make sure that it comes to an operating system that not everybody is afraid [to use] — that they’re going to lose important information or lose, of all things, veterans’ lives, because an electronic health record isn’t working correctly,” Bost said.
Bost said the VA has little to show for the $9.4 billion in congressional appropriations obligated to the Oracle-Cerner EHR contract so far, and that the vendor has yet to deliver on promises to bring the project back on track.
“Oracle made us all kinds of promises. They sat in my office and told me how great it was all going to be,” he said. “They made all these great promises. Those great promises haven’t come to fruition,” he said.
At the same time, Bost said the Oracle-Cerner EHR, which is currently only used by about 10,000 VA employees across five medical centers, has taken more of his time and attention than any other congressional issue.
“What really wild is, remember, it’s only five [sites] that we’ve turned this up, and all five have been terrible. I’ve been in Congress nine years, and I can say this: Over the last five years, this has been the biggest problem every day. Every day, people come up to me and mention the name Cerner. It’s like a cuss word to me,” Bost said.
The Government Accountability Office found in VA surveys from 2021 and 2022, only 6% of VA users of the Oracle-Cerner EHR agreed the system enabled quality care. About 4% of respondents agreed that the new system made them as efficient as possible.
Carol Harris, director of information technology acquisition management issues at GAO, recently told the Senate VA Committee that these approval scores are some of the lowest the agency has ever seen from a major federal IT acquisition.
“That’s the problem that ends up happening at each one of these facilities — the morale at these locations goes into the gutter just as quick as you turn it up,” Bost said.
Bost said that clinicians and administrators at the first few VA medical centers were open-minded about making the switch to a new EHR.
But with more VA clinicians complaining about the functionality of the Oracle-Cerner EHR, and having to rely on workarounds to complete routine tasks, Bost said the VA workforce, at all levels, is now more candid about its concerns.
“What really wild is early on, when we would go in, the administration there, I think, was kind of told, ‘Tell them it’s OK, we’ll get through it.’ In the last couple of places we’ve gone to, the administration just goes, ‘This is junk. It is trash, it doesn’t work, it’s causing trouble for us.’ So it’s not only the frontline workers, not only the doctors — it’s the people who are over them trying to keep a good operation going in their medical facility,” Bost said.
The VA medical center in Saginaw, Michigan is currently scheduled to be the first new go-live of the multibillion-dollar Oracle-Cerner EHR since the VA paused rollouts last October.
McDonough, however, told House appropriators that the VA has not yet finalized that decision.
“That’s a decision we’ve not yet made. We’ll make that [decision] based on where the technology is. But to be honest with you — increasingly, my question is, I need to see what happens in this contract before we make a decision about where we go next anyway, because the contract may not be what we need,” McDonough said.
Bost said the VA would have to demonstrate that its clinicians feel much more comfortable using the Oracle-Cerner EHR, and that the problems identified in the sprint report are corrected, before he’d approve of the VA resuming EHR rollouts.
“They would [have to] show how they’ve cured those problems in the existing five facilities, so that the people that operate those systems feel comfortable — that they, as the medical experts, know and understand that the quality of care will be delivered promptly. It’ll be delivered safely, and the records will be kept, so we know and understand that they’re receiving the best possible health care, because if you can’t track it through their records, then it doesn’t get done. And that’s how we lose lives,” he said.
Bost is a cosponsor of two EHR bills. The VA Electronic Health Record Modernization Improvement Act would require “significant improvements” from the EHR system before bringing it to additional VA medical centers.
A separate bill, led by Bost and Technology Modernization Subcommittee on Chairman Matt Rosendale (R-Mont.) would force the VA to completely pull the plug on the Oracle-Cerner EHR.
“The first bill says, look, here are some guidelines and some points, which you need to reach, so that we know that it’s safe, it is going to do its job, and the administration of that particular place when [the EHR] goes signs off that, ‘Yeah, we’re ready, and this is going to work.’ That’s pretty simple. And if they can’t do that, then the other bill can kick in, and then we go back. We start over,” Bost said.
Even if the VA EHR proceeds as planned, the VA expects it will still need to rely on its legacy EHR, VistA, for another five-to-10 years, if not longer.
Rosendale and former VA IT officials said at a hearing earlier this month that VistA is capable of being modernized to support the VA’s EHR needs for the foreseeable future.
Bost said VistA has been reliably providing health care to veterans for decades, and that the VA needs to make a stronger case for Oracle-Cerner being able to provide a better standard of care for veterans than what they’re already getting from VistA.
“The problem is that there’s a whole bunch of people say, ‘Well, we need to move into the future,’” he said. “And I understand that, but if you’re moving into the future just to be moving into the future, and you’re endangering lives to do it, that’s not a very wise way to go. So if we need to go back to the old system, and then rethink this and have the VA rethink this, then that’s what we need to do.”
Beyond the next steps for the EHR rollout, Bost also outlined his other legislative priorities for the VA.
Bost said he’s looking at possible reforms to the Defense Department’s Transition Assistance Program (TAP), to ensure service members understand what veteran benefits they’re eligible for, before they leave active-duty military status.
“The job of the DoD is to make active-duty personnel that can make sure they deliver a bullet downrange. They’re never real good about returning them to civilian life,” he said.
Bost said he’s also prioritizing oversight of how the VA is implementing the PACT Act, which expands eligibility for VA health care and benefits to veterans exposed to toxic burn pits during their military service.
The bill also expands recruitment and retention bonuses for VA employees, including merit awards and pay incentives for employees that have a “high-demand skill or skill that is at a shortage.”
Bost said he worked with other congressional VA leaders to ensure the PACT Act contained the funding VA needed to expand its health care and benefits workforce.
“Every health care system out there is having trouble finding nurses and keeping nurses, and so we’ve got to be able to compete in that market,” Bost said.
Congress last year also passed the RAISE Act, which set higher pay caps for about 10,000 VA nurses.
The VA CAREERS Act, recently introduced by Tester and Sen. John Boozman (R-Ark.) would set higher base pay caps for VA physicians, podiatrists, optometrists and dentists. Specialists in some of those occupations are currently at a $400,000 pay cap — the current salary of the president.
Bost, however, said the VA should first focus on implementing the workforce authorities received in the PACT Act.
“I think the VA needs to implement what they’ve got. We need to continue to take away some of the unnecessary red tape and get people into the door who want to serve our veterans, and we want to make sure that we don’t hamper their ability [and] desire to work at the VA,” he said.
In addition to greater flexibility for the VA to hire, Bost also wants to make sure the VA has the authority it needs to fire employees accused of poor performance and misconduct.
Bost challenged a recent legal decision that limits the VA’s ability to fire employees, under a law Congress passed more than five years ago.
The 2017 VA Accountability Act and Whistleblower Protection Act gives the VA secretary the ability to fire, demote or suspend employees covered under the law, based on misconduct or performance issues.
But the Merit Systems Protection Board, in a decision in January, ruled that the VA can’t use the 2017 law to expedite the firing of “hybrid” Title 38 employees.
“The secretary has a responsibility to guarantee that the VA workforce is top-notch, and if they’re not, he needs the tools to fix it. Right now, the MSPB’s decision is standing in the way of that,” Bost said. “Why the MSPB has made this ruling makes no sense to me whatsoever. You cannot improve the quality of the delivery of service … if you don’t have the ability to understand that there are consequences if you don’t do your job. I think they’re dead wrong,” Bost said.
The VA, however, is proceeding in the opposite direction, and directing managers and supervisors not to use its authority under the VA Accountability Act and Whistleblower Protection Act to fast-track the removal, demotion or suspension of employees accused of misconduct or poor performance.
In a March 5 memo, Gina Grosso, VA’s assistant secretary for human resources and administration/operations, security and preparedness, said the VA will not propose new adverse actions against VA employees under the 2017 law, effective April 3.
“Although VA will cease using this provision, management will employ other authorities to continue to hold employees accountable for their conduct and performance deficiencies and will defend actions that were previously taken” under the legislation, Grosso wrote.
VA leadership may proceed with and issue decisions on proposed discipline prior to April 3.
Grosso said rulings by the MSPB, the U.S. Court of Appeals for the Federal Circuit, and the Federal Labor Relations Authority led to the legislation being “inapplicable to a large portion of the workforce.”
As a result of these decisions, Grosso said “there are few remaining practical differences” between what the VA is able to do under the VA Accountability Act and the traditional process for disciplining Title 5 employees.
McDonough told reporters on March 23 that VA’s use of its Section 714 authority, as provided under the VA Accountability Act and Whistleblower Protection Act, wasn’t helping the agency effectively manage its workforce.
“To be honest … the exercise of Section 714 wasn’t really helping us necessarily manage our workforce, as much as it was getting us in front of federal judges and in front of administrative bodies,” McDonough said. “So we just want to make sure that we’re exercising the authorities that we do have.”
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