The Department of Veterans Affairs is telling Congress it understands what went wrong in previous deployments of its new Electronic Health Record, and is confident short-term fixes will allow the agency to resume the project.
The vendors behind the project are also telling lawmakers recent EHR updates have made the system less prone to system outages.
But most members of the Senate VA Committee are wary of patient safety issues stemming from the multibillion-dollar Oracle-Cerner EHR rollout, and are asking for evidence the project is on the right track before the system goes live at any additional VA medical centers.
Committee Chairman Jon Tester (D-Mont.) said at a hearing Wednesday, VA notified the committee of several incidents where veterans were “fatally harmed,” and that each incident tied back “in some way to their care as delivered by the Oracle-Cerner system.”
Sen. Richard Blumenthal (D-Conn.) said his staff was told on Tuesday that “six catastrophic events related to a feature of the Electronic Health Record Modernization program in the last couple of years” and that four of those events “resulted in a fatality.”
Those patient deaths add to an increasingly grim toll that watchdogs say the Oracle-Cerner EHR has put on VA providers and patients. The agency’s inspector general has flagged previous instances of patient harm.
Neil Evans, acting program executive director of VA’s EHR Modernization Integration Office, told the committee “there are many potential contributors to patient safety, of which the EHR is one.”
“There have been cases where we have found that, frankly, with both our [legacy] EHR on the VistA side, as well as with the Oracle-Cerner EHR, the EHR has been a potential contributor to that harm,” he said.
The Oracle-Cerner EHR is currently only used by about 10,000 VA employees across five medical centers. Full-scale deployment would bring it to 171 total VA medical centers. VA is nearly five years into the rollout of the EHR.
Tester said Oracle-Cerner has refunded VA about $325,000 of the $4.4 billion paid through the contract so far.
Those payments, he said, are meant to compensate VA for EHR system crashes, “incomplete technology and poor training programs.”
Tester, however, said the VA doesn’t have much to show for its current contract, and is calling on the agency to renegotiate the contract by the time its current agreement with Oracle-Cerner expires in May.
While most committee members expressed frustration with the troubled rollout of the Oracle-Cerner EHR performance to date, Tester said he’s not on board with terminating the project — as top Republicans on the House VA Committee have proposed.
“Make no mistake about it, we need to right the ship. And for me, all options but one are on the table to fix this new EHR. I’m not going to end the effort to modernize VA’s health records. This is not in the cards. It’s not sustainable to, and quite frankly, our veterans need it,” Tester said.
VA’s Chief Acquisition Officer Michael Parrish said the VA is currently back in negotiations with Oracle-Cerner.
“There have been some challenges around system reliability and user adoption, and we’ve insisted for those improvements to be made. They’ve done some, but nearly not enough,” Parrish said.
Meanwhile, 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.
Evans said five of the 14 fixes have been partially implemented, and that some of the fixes probably require additional work from Oracle-Cerner.
“We need to know that we are ready to safely deploy a record that will meet the needs of the organization before we go live at sites,” Evans said.
Undersecretary for Health Shereef Elnahal said each of those issues “needs to, at the very least, be mitigated at the sites where the system already exists, and certainly addressed in anticipation of future deployments.”
“Ideally, the configuration of the system would ultimately change. We would hold Oracle-Cerner accountable for making those changes to eliminate the risk entirely,” he said.
The Government Accountability Office finds the VA has obligated at least $9.4 billion on the Oracle-Cerner EHR so far. The Oracle-Cerner project is the VA’s fourth attempt at replacing its legacy EHR VistA, which was purpose-built by the VA and has been running for about 40 years.
Carol Harris, director of information technology acquisition management issues at GAO, said the agency found the Oracle-Cerner EHR rollout, so far, has been “fraught with major issues,” including VA clinicians expressing dissatisfaction with the new system.
GAO found that in surveys from 2021 and 2022 that 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.
“These scores are among the lowest we have ever seen on a major federal IT acquisition,” Harris said.
Harris told the committee that the EHR contract “as currently written, has not sufficiently motivated Oracle-Cerner to perform better,” and that the current terms of the contract are “not necessarily in the best favor of the government in this particular case.”
Elnahal said he expects VA’s user satisfaction scores to improve once it implements all of the fixes outlined in its sprint report.
200 days ‘without a complete outage’
Evans said the Oracle-Cerner EHR has gone about 200 days “without a complete outage.”
Evans said the amount of time VA users experience no disruption in their use of the system “isn’t yet at its goal, though it is moving in the right direction.”
While the VA and Oracle-Cerner will implement the fixes outlined in the sprint report, the report made no mention of whether the VA will proceed with additional go-lives in June, as planned.
Evans said the VA will “continually evaluate the readiness of upcoming deployment sites, as well as the EHR system itself to ensure success.”
“It’s important to take the time now to get things right, to provide a strong foundation for an accelerated deployment schedule later as the project proceeds,” he said.
Mike Sicilia, executive vice president for industries at Oracle, said 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.
“The goal of every system should of course be as close to zero as possible, and we’re marching towards that,” Sicilia said.
Sicilia said Oracle-Cerner will work with VA in the lead-up to June to evaluate other critical factors that will impact readiness for the resumption of go-lives.
“We believe though, from a performance and scalability standpoint, the system is ready for the resumption of deployments,” he said.
Lawmakers, however, are calling on the VA to fully correct the 14 problems — and not just mitigate them — before new EHR go-lives take place.
“Until the 14 technology fixes outlined in the EHRM sprint report are developed, tested and placed, this should not move forward at any other facility,” Sen. Sherrod Brown (D-Ohio) told VA officials.
The Biden administration in its fiscal 2024 budget recently proposed spending an additional $1.9 billion on the Oracle-Cerner EHR rollout.
But Senate Appropriations Committee Chairwoman Patty Murray (D-Wash.) said she’s heard from VA providers who are “burnt out” trying to navigate the new EHR while trying to care for patients.
Murray said she’s also heard from veterans who have received late cancer diagnoses “because of the flaws in the system.”
“I’m not sure it makes sense, Mr. Chairman, to continue to fully fund the budget request for this system until I can see that the system is working and not putting our veterans in harm’s way,” Murray said.
The VA states in its sprint report 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.
“The need to restore productivity isn’t an end in and of itself. It has everything to do with access to care. And it’s also a marker about the degree of workarounds and issues that our clinicians have to go through to work around the system rather than having the system function for their needs,” Elnahal said.
Elnahal said VA medical center in Walla Walla, Washington recently returned to pre-deployment productivity levels, which he called a “ray of hope.”
“They have strategies for their workflows that have been able to achieve that. We are learning deeply from that experience, and we plan on having that experience be taught and shared in terms of those best practices,” he said.
‘Who will be leading this program 3 months from now?’
Committee Ranking Member Jerry Moran (R-Kan.) said the five VA medical centers that are using this system are “struggling with delays, disruptions and rising costs.”
“I’ve yet to see what has fundamentally changed in the system training or program management that will make the implementation more successful,” Moran said.
While Moran said VA and Oracle-Cerner are making improvements, he said those fixes have been gradual and that “most fixes are many months or even years away.”
Moran also expressed concern about turnover in the VA leadership team overseeing the EHR.
Evans is serving in an acting capacity to replace Terry Adirim, the top executive leading the EHR rollout who left the agency at the end of February.
Meanwhile, Deputy VA Secretary Donald Remy is leaving the agency in April.
Moran said recent changes in EHR leadership “suggests to me that the whole effort may be sleepwalking toward an extremely destructive result.”
“Due to changes in leadership at the VA. It is still an open question, who will be leading this program three months from now,” Moran said. “To justify additional spending on this program we need assurances that every penny is spent focused on creating and implementing a system that serves veterans and provides them with the high-quality care they deserve.”
VA and DoD: ‘A tale of two departments’
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.”
Unlike DoD, however, the VA has not conducted an independent assessment of its implementation of the new EHR. GAO found that, as of this January, the VA had no plans to do so.
“The successful implementation of the new system across VA will require a level of program management adaptability to change and sustain system performance that the department and contractor have yet to demonstrate,” Harris said.
Evans told the committee the VA is “open to having those discussions to figure out what that could look like.”
DoD conducted an independent review shortly after its first go-live of the EHR. Based on those findings, it paused deployment to other sites until major issues were resolved.
Sen. Bill Cassidy (R-La.) said the VA would do well to follow some of the lessons learned by DoD.
“It’s kind of a tale of two departments. It apparently has gone kind of swimmingly in the DoD [with] high provider satisfaction. And it’s obviously not going very well in VA, with very low provider satisfaction,” Cassidy said.
Harris said the VA has also struggled to oversight the implementation of a commercial EHR, rather than building one, like it did with VistA.
“They have for 40 years been in the business of building systems like VistA, and it’s a completely different skill set in building it versus buying,” she said.
VA Chief Information Officer Kurt DelBene said the agency is beholden to some of the decisions DoD has already made, in terms of the EHR contract, such as login and patient safety features.
“It’s just a matter of history that they started this deployment, and then we’ve added on as kind of a second tenant,” DelBene said. “We need to get to a place where we share and all those kinds of decision-making and we’re working with them on that.