VA Secretary Outlines Structural Changes to EHR Rollout

As promised, significant changes are coming to management and deployment of the Veterans Affairs Department’s electronic health records, or EHR, program, including a new governance structure, new training regime and a rollout schedule based on readiness rather than geography.

The coming changes, as outlined Wednesday by VA Secretary Denis McDonough during a hearing before the Senate Committee on Veterans Affairs, were the result of a three-month strategic review and a pile of watchdog reports showing mismanagement, incorrect or misleading budgeting, and frustrated and burned-out employees at the first deployment site, the Mann-Grandstaff VA Medical Center in Spokane, Washington.

“At the time, VA officials described the rollout as ‘flawless,’” Committee Chair Jon Tester, D-Mont., said, panning then-VA Secretary Robert Wilkie’s glowing remarks on the deployment. “Since those statements were made, we’re hearing from VA medical staff who are frustrated and demoralized by a new system that is making their jobs far more difficult.”

Tester also cited inspector general and Government Accountability Office reports showing the agency did not fully prepare sites for deployment—including training, physical infrastructure, technology upgrades and more.

“While there are some who might describe this effort as a ‘flawless rollout,’ I think most people would use the word ‘alarming,’ or something far worse,” he said.

McDonough’s word choice trended toward the latter.

“VA’s first implementation of the Cerner Millenium … did not live up to that promise, either for our veterans or for our providers,” he said.

McDonough offered an anecdote from a staff pharmacist working at Mann-Grandstaff who heard multiple reports of patients getting duplicate prescriptions.

“The issue, it turned out, was that the veterans’ old prescriptions were not automatically being canceled when new ones came in,” forcing staff to create workarounds to protect patient safety while the problem was rectified, McDonough said. “Those efforts were largely successful, but they also demonstrate the lengths to which our staff in Spokane had to go simply to do their jobs and to care for our vets.”

Similarly, he retold another anecdote of a clinician who called in to the help desk with an issue, only to be told the support staff had been hired there the week before and that the clinician likely had far more experience with the system than the help team.

“Stories like that are what led me to launch the top-to-bottom review,” the secretary said.

After putting the program on pause for a three-month strategic review, VA leadership is making major changes to the EHR rollout, including a new governance structure, switching from a geography-based deployment timeline to one based on the readiness of individual medical facilities and building a simulated training environment to help users get comfortable with the new system.

“First, we’re establishing a unified, enterprisewide governance effort led by our deputy secretary,” McDonough said, speaking of Donald Remy, who was confirmed by the Senate Thursday.

The new governance structure will be designed to ensure previously left-out stakeholders were ingrained in the process, McDonough said, citing the Veterans Health Administration, which runs the full network of VA medical centers, as well as finance and acquisition leaders.

“Second, we will shift from site-by-site deployment of VA’s EHRM to an enterprisewide readiness and planning approach,” the secretary said. “This means that we will deploy the program based on evidence of readiness—evidence of which sites are most trained and technologically ready for it—therefore setting each new site up for success.”

Prior to the strategic review, VA was following the geographic lead of the Defense Department’s MHS Genesis rollout—DOD’s concurrent program, which includes Cerner’s EHR platform—which also began in the Pacific Northwest.

Going forward, VA’s deployment schedule will focus on individual sites, rather than arbitrarily matching DOD’s schedule, McDonough said. 

“That was a mistake for two reasons,” he told the committee. “One, we’re off-kilter with DOD, geographically. Two, we were not in a position to adequately prepare for the structural and maintenance requirements and, as a result, ended up not being as transparent as you all as we should have been in this process.”

The third major program change will be a “fully simulated training and testing environment so veterans and providers can properly evaluate and learn the system before it goes live, not during or after,” McDonough said.

Another recent IG report showed staff at Mann-Grandstaff did not feel prepared to use the new system, with:

• 62% saying relevant patient information was not readily available.
• 53% saying it was difficult to share patient information with other clinicians.
• 65% saying it was difficult to navigate the new system.
• 55% saying it was difficult to document patient care in the system.
• Only 5% of staff reported positively on all four metrics.

“Overall, the survey results showed that after training and two to three months of new EHR use, only a small percent of facility users reported facile use with EHR core functions,” the IG report states.

McDonough put the full responsibility for these failures on VA leadership and the agency’s commercial partners.

“Most challenges were not breakdowns of the technology, nor of the great people at Mann-Grandstaff,” McDonough said. “Instead, the missteps were ours at VA and Cerner. Now that we’ve identified those problems we can solve them.”

That said, McDonough stated unequivocally that VA would be sticking with the Cerner platform.

“We took a real hard look at [switching vendors] and the technology,” he told the committee. “We think that the technology is sound. There are technological challenges for us to fix … But really what we face here are management and structural changes—governance changes—and those are on me.”

Tester—who noted he has been dealing with this issue his entire tenure in office—made a direct plea to Cerner during the hearing.

“I hope Cerner is watching this,” he said. “If Cerner is not up to making a user-friendly electronic health medical record and, in fact, what’s transpired here is we’re going in the opposite direction, then they ought to admit it and give us some money back so we can start over.”

Despite these changes and two IG reports suggesting the program is currently underbudgeted by at least $5.1 billion, McDonough said the department would not be revising its budget request for 2022.

Editor's Note: This article has been updated to reflect that Sen. Jon Tester represents Montana.