VA expects its legacy EHR to be ‘around for a long time’ as it troubleshoots replacement

The Department of Veterans Affairs will need to rely on its legacy electronic health record, VistA, for another five-to-10 years, if not longer.

The Department of Veterans Affairs is telling Congress a new multibillion-dollar Electronic Health Record is the best way to provide care for its patients — despite a troubled rollout and House lawmakers threatening to pull the plug on the project.

Whether or not the VA is able to get the rollout of its Oracle-Cerner EHR back on track this summer as planned, agency officials told members of the House VA Committee that the VA will need to rely on its legacy EHR, VistA, for another five-to-10 years, if not longer.

“In essence, we are supporting two EHR systems simultaneously, until the Cerner implementation is complete,” Daniel McCune, VA’s executive director of software product management, told the technology modernization subcommittee in a hearing Tuesday. “In the interim, VistA remains our authoritative source of veteran data.”

VA officials told the subcommittee that VistA is not suited for meeting the agency’s long-term health care needs, but McCune said the VA plans to modernize VistA over the coming years to provide “uninterrupted care and continually improve the veteran service.”

McCune said the VA has moved 20 instances of VistA to the cloud this year, and plans to migrate another 54 instances of VistA to the cloud later this year.

“The version of cloud migration that’s taking place today is what we call a lift-and-shift, meaning we’re not changing VistA, we’re simply taking it out of our data center and moving it into a virtual cloud environment,” he said.

McCune estimated that each migration of VistA to the cloud costs the VA about $70,000.

The VA originally intended to complete the rollout of Oracle-Cerner EHR over 10 years. It first went live in October 2020 in Spokane, Washington.

The EHR is currently running at five VA sites, but its rollout has been delayed several times to address patient safety issues documented by the VA’s inspector general, as well as persistent system outages.

The VA, since October 2022, has been in an “assess and address” period, to address known issues with the EHR, and to determine whether it’s ready to launch at additional sites.

The EHR delays and disruptions have frustrated congressional leaders. Technology Modernization Subcommittee Chairman Matt Rosendale (R-Mont.) is leading two new bills that would alter the course of VA’s EHR rollout.

One bill would prevent the VA from implementing the Oracle-Cerner EHR at additional facilities, until the system has achieved 99.9% uptime at VA medical facilities currently running on the new system.

Another separate bill would force the VA to completely pull the plug on the Oracle-Cerner EHR.

“The reality is regardless of whether the Oracle-Cerner implementation can be accomplished, and regardless of how we feel about that, the VA will probably continue to rely on VistA for at least another decade,” Rosendale said at Tuesday’s hearing. “And some of the elements of VistA will probably never go away because no replacement even exists.”

While Rosendale is urging the VA to keep modernizing VistA, rather than proceed with the Oracle-Cerner rollout, agency officials say the Vista system is reaching its limits.

McCune said VistA is “an old technology ill-suited for the modern digital age,” and that modernizing the legacy EHR beyond its intended lifespan would require it to be rewritten “almost from scratch, at a great cost and great risk.”

McCune said the VA will need to keep the VistA system running for at least another 5-to-10 years, although the agency may need to keep VistA running longer than that.

“That end date is indeterminate at this point. We are making investments in VistA to make sure that it is resilient, that we maintain the level of performance that we have today. So we are not stopping work on VistA. We realize it’s going to be around for a long time,” McCune said.

McCune said VistA has served the VA well for over 40 years, but said the system doesn’t have  capabilities that providers and veterans “expect and deserve from a modern cloud-native EHR,” including mobile and web access, as well as artificial intelligence and machine learning tools.

The graphics interface VA added to VistA in 1997 runs on an outdated programming language called Massachusetts General Hospital Utility Multi-Programming System (MUMPS).

VA employs a team of MUMPS programmers supporting Vista, but about 70% of them are eligible to retire.

“MUMPS is not taught in computer science classes, and the pool of MUMPS programmers shrinks every year as they retire,” McCune said.

The VA has yet to see those retirement-eligible programmers leave the agency. The VA had 1,129 full-time employees working on VistA in 2022, nearly the same level of staffing it had a decade ago.

“We have been fortunate. Our employees are committed to the mission, and they’ve stayed long beyond what a typical workforce would stay,” McCune said.

However, he added that the retirement eligibility of its workforce has been “creeping up year over year.” McCune said the VA is also struggling to keep VistA integrated with the rest of its network.

“MUMPS programmers are increasingly challenged keeping VistA integrated in a growing ecosystem that is architected very differently from the system designed 40 years ago,” he said.

VA clinicians have also complained about the functionality of the Oracle-Cerner EHR, and have relied on workarounds to complete routine tasks.

In a survey of VA employees currently using the Oracle-Cerner EHR, 78% of respondents said the new system didn’t help them deliver high-quality care, but 64% agreed that the legacy VistA system did help them provide quality care to veterans.

“It’s like a stable old family car,” Subcommittee Ranking Member Sheila Cherfilus-McCormick (D-Fla.) said about the VistA EHR. “Everyone knows you need to jiggle the clutch when it gets stuck in third gear.”

“I’m not here to say that the Oracle-Cerner approach in EHRM is going well, but I’m not sure returning to VistA is correct either,” she added.

McCune said the VA workforce is accustomed to how the VistA system operates, and that more training is needed for employees to feel comfortable with the Oracle-Cerner system.

With VistA, we have a relatively stable system, one that’s been in production for 40 years. So our clinicians, our users are very, very familiar with that system,” McCune said. “We also have happening a brand-new system, the Cerner system. I think there is some element of change management there. There’s some element of newness that has to be considered.”

McCune added that the VA has been able to ensure high reliability of the VistA system because the agency has had “decades to work out the bugs [and] fine-tune performance.”

Thomas O’Toole, VA’s deputy assistant undersecretary of health for clinical services, said the VistA EHR isn’t able to provide functions that are available in more modern health care systems. But he said the VistaA system is very familiar to VA clinicians.

“There is a muscle memory associated with using it for quite some time, that I believe providers are comfortable with,” O’Toole said. “They know how to use it. They know how to navigate the system and it’s worked well for us.”

VA Secretary Denis McDonough told reporters in January that said the VA still has a “particular need” to migrate to an EHR that’s interoperable with the Defense Department.

“We want to be in a position where we can easily access a service member’s records, going back through all of her years in active duty. So our ability to be able to do that with DoD is extraordinarily important,” McDonough said.

Both DoD and the Coast Guard are much further ahead than VA in their implementation of the Oracle-Cerner EHR. The VA has implemented the Oracle-Cerner EHR at five of its 171 medical centers since 2018, and spent about $5 billion on implementation so far.

While House Republicans have asked the VA to explore alternatives to the Oracle-Cerner EHR, McCune said the VA is “100% focused on the current [Oracle-Cerner] EHR implementation,” and doesn’t have the capacity to keep modernizing VistA beyond its current plans.

“We don’t have extra people working on a plan B, so we are fully committed to this, until such a time as we need to change course,” McCune said.

The VA expects to resume EHR go-lives this June. Undersecretary for Health Shereef Elnahal told reporters last week the VA is close to releasing a revised execution plan for upcoming EHR go-lives.

Meanwhile, O’Toole said the VA has “learned a lot” from the launch of the Oracle-Cerner EHR at five VA sites.

“I think it has exposed a lot of challenges in both product and product development, refinement, our staff training and stresses to the system. It is a learning curve. Some provider groups have fared better than others in terms of their adoption,” O’Toole said.

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