Congress's Competing Proposals to Fix VA's Ailing EHR Program

Leading Democrats and Republicans on the House and Senate Veterans’ Affairs committees have introduced legislation to enhance oversight of the Department of Veterans Affairs’ beleaguered rollout of its new multi-billion dollar Oracle Cerner electronic health record system. 

The slate of bills comes as VA’s Electronic Health Record Modernization program has faced significant challenges in its effort to upgrade the department’s legacy system, known as the Veterans Health Information Systems and Technology Architecture, or VistA. 

Oracle—which acquired Cerner in June 2022—won a $10 billion contract in 2018 to replace VistA, but the new EHR system has been plagued by patient safety concerns, technical and performance glitches, cost overruns and deployment delays since the software first went live in 2020 at the Mann-Grandstaff VA Medical Center in Spokane, Washington. These challenges have included reports of significant patient safety issues associated with the new software, such as deaths tied to the software’s deployment and clinical orders being routed to an unknown queue without alerting clinicians. Thus far, the Oracle Cerner EHR system has only been deployed at five facilities across the VA’s national network of 171 medical centers. 

Last October, VA announced that it was pausing future deployments of the Oracle Cerner software at additional VA medical facilities until June 2023 so the department could “address challenges with the system and make sure it is functioning optimally for veterans and for VA health care personnel.” 

The department announced on April 6, however, that it was further extending its pause on future rollouts of the software by holding off on the planned deployment of the system at the VA Saginaw Healthcare System in Michigan that was scheduled for June. That decision was made after VA announced in February that it was delaying a planned July rollout of the new system at the Ann Arbor Healthcare System in Michigan until later this year or in early 2024. 

One factor in the department’s rollout pause is the ongoing negotiations between Oracle Cerner and VA over the current contract, with VA officials reportedly waiting to see how discussions play out before resuming deployments of the new system. The current contract is set to expire May 16, and VA Secretary Denis McDonough previously told lawmakers during a March 29 House Appropriations Committee hearing that, “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.”

Challenges lead to bipartisan outrage

Lawmakers have already taken steps to address issues with the EHR system’s rollout, but continuing concerns with the modernization program have spurred calls for even more oversight. 

Last June, President Joe Biden signed into law the VA Electronic Health Record Transparency Act—bipartisan legislation that strengthened transparency around VA’s management of the deployment by requiring McDonough to “submit periodic reports to Congress regarding the costs, performance metrics and outcomes.” But ongoing issues with the software have led lawmakers to push for greater accountability standards and oversight of VA’s and Oracle Cerner’s management of the EHR system’s rollout. 

Congressional Democrats have largely voiced support for VA to continue its EHR modernization efforts with enhanced oversight standards, while Republicans have been more open to the idea of scrapping the effort and continuing to use VistA, with needed financial support to bolster the existing system. 

Rep. Mike Bost, R-Ill., chair of the House Veterans’ Affairs Committee, introduced legislation in January that would prevent VA from rolling out the Oracle Cerner system at additional medical facilities until the sites provide written certification to McDonough that they have met outlined performance and facility readiness standards. McDonough would then be required to submit written certification to the House and Senate Veterans’ Affairs committees verifying that the software has met the requirements prior to its deployment. 

The bill, which has 10 Republican co-sponsors, would require that sites certify “a monthly uptime for the electronic health record system of 99.9% for four sequential months,” as well as the completion “of all improvements or modifications of the electronic health record system required to be completed pursuant to a contract, task order, modification or other similar instrument.”

The directors and chiefs of staff of VA medical facilities—along with the the directors of the Veterans Integrated Services Network in which the facilities are located—would also be mandated to certify in writing that the proposed “build and configuration” of the Oracle Cerner system is “accurate and complete,” that facility staff and infrastructure are “adequately prepared” for the software’s rollout, and that the new EHR system “will not have significant, sustained adverse effects on patient safety, patient wait-times for medical care or health care quality.” 

Republicans float termination

Bost is also a co-sponsor of legislation introduced by Rep. Matt Rosendale, R-Mont.—chair of the panel’s Subcommittee on Technology Modernization—that “would end the Oracle Cerner electronic health record program at VA if it cannot demonstrate significant improvement but is nonetheless introduced to additional medical centers.” The bill was introduced the same day as Bost’s legislation. 

Within 180 days of its enactment, Rosendale’s bill would direct McDonough to abolish VA’s Electronic Health Record Modernization Integration Office, revert all medical facilities currently using the Oracle Cerner software back to VistA and prevent VA from exercising “any option periods or optional tasks under any contract” related to the software’s deployment.

In a March interview with Nextgov, Bost signaled that the committee would initially pursue his legislation establishing performance and facility readiness standards for future EHR system deployments before considering the bill to terminate the Oracle Cerner contract. 

“That's what these two bills are doing: we set standards, we ask the VA to make sure that Oracle Cerner does what we're requesting in the law and, if not, then we'll move on,” Bost said about the two GOP-sponsored legislative proposals. “And we'll either go back to the VistA system, or we will look at a different direction to go.” 

Competing accountability proposals

Democratic leaders on the House committee, meanwhile, have also introduced legislation that would address issues with VA’s IT initiatives, including the rollout of its new EHR system. The two bills—introduced in March by Rep. Mark Takano, D-Calif., the panel’s ranking member—are broader in scope than the Republicans’ proposals, but would similarly mandate enhanced oversight for major IT projects across the department.

The first proposal, known as the Manage VA Act, would create a VA under secretary for management position to “consolidate and standardize business functions across the department—from acquisition to IT.” The second bill, the Department of Veterans Affairs IT Modernization Improvement Act, would require VA “to enter into a contract for the independent verification and validation of certain modernization efforts,” including “the Electronic Health Record Modernization Program (or any successor program).”

The House Veterans’ Affairs Oversight and Investigation Subcommittee is holding a legislative hearing on Wednesday to discuss the Democrats’ and Republicans’ proposed bills, as well as legislation from subcommittee Chair Jen Kiggans, R-Va., that would address supply chain issues within the VA. 

The chair and ranking member of the Senate Veterans’ Affairs Committee also introduced separate legislation in March to enhance oversight of the EHR modernization program. Both of the proposed bills would, in full or part, delay future deployments of the Oracle Cerner software until VA medical facilities have met certain standards or metrics signifying that they are ready to go live. 

Sen. Jon Tester, D-Mont., who chairs the panel, and two other committee members—Sens. Patty Murray, D-Wash., and Sherrod Brown, D-Ohio—introduced legislation on March 30 that would “restructure, enhance and strengthen the entire EHRM program while also mandating aggressive reporting to Congress to increase oversight, accountability and transparency following a series of challenges with the system and program.” 

The bill would, in part, require that VA “develop clear metrics” to guide “whether and how” the department should move forward with deploying the new EHR system at additional VA medical facilities, mandate that the department and Oracle Cerner address health and safety issues identified in the EHRM Sprint Report that VA issued last month and hold off on future deployments of the new EHR system “until the data at the existing five facilities demonstrates an ability to deliver health care to veterans at standards that surpass metrics using VA’s VistA system or that meet national health operations standards as determined by the Under Secretary for Health.”

Given the ongoing contract negotiations between VA and Oracle Cerner, the bill would notably require that VA develop “an alternative ‘Plan B’ strategy for a new EHR in the event Oracle Cerner will not agree to new contract terms that protect taxpayers and increase accountability and penalties for poor performance.”

Despite the legislation, and the provision accounting for an alternative strategy in the event that negotiations between VA and Oracle Cerner break down, Tester has pushed back against calls to terminate the department’s EHR modernization efforts. Following introduction of the Republicans’ House bills, Tester told Nextgov in an emailed statement in February that “modernization of the electronic health record is not optional,” adding that “one way or another, it has to be done.” 

The Senate Republicans’ proposal, meanwhile, is similar to Bost’s bill, in that it would “establish a rigorous list of requirements that VA must meet before the EHR system can be implemented at more VA medical centers.”

Introduced by Sen. Jerry Moran, R-Kan.—the panel’s ranking member—and 12 Republican co-sponsors on March 29, the legislation would prohibit McDonough from approving deployments of the Oracle Cerner software at additional VA medical facilities until he submits written confirmation to the House and Senate Veterans’ Affairs committees that the system has met outlined “improvement objectives.”

These objectives include confirmation of “the achievement of a minimum uptime and system-wide stability standard for the electronic health record system,” as well as a report detailing “the completion status of corrections to the customization and configuration of workflow designs” and confirmation “that the staff and infrastructure of such facility are adequately prepared to receive such system.” 

“Without these changes, it would be irresponsible to continue implementing the system at additional VA centers,” Moran said in a statement.