VA official has 'deep concerns' about agency's electronic health record project

Senators pressed officials from the Veterans Affairs Department to address cost and usability issues hindering the rollout of VA’s multi-billion dollar Oracle-Cerner Millennium electronic health record system during a Senate Appropriations Subcommittee on Military Construction, Veterans Affairs and Related Agencies hearing on Wednesday.

Dr. Shereef Elnahal, VA’s undersecretary for health, said he has “deep concerns about the system as it’s functioning for frontline employees and service to veterans,” noting that he visited the VA Central Ohio Healthcare System in Columbus earlier this year following the medical center’s EHR deployment and “saw folks struggling with this system deeply.”

“Among the most concerning things that I saw was a phenomenon whereby our frontline clinicians, when they put in an order or were trying to interface with the system, they were not confident in many cases and in many clinical settings that those orders were actually getting where they needed to go,” Elnahal said, adding that the experience led to a broader review within VA of how workflows and the configuration of the EHR system could be improved. 

Sen. Martin Heinrich, D-N.M., who chairs the subcommittee, reiterated his support for VA’s EHR modernization efforts, calling it “an extremely important effort to solve a decades-long problem.” But Heinrich expressed concern about VA’s transparency throughout the EHR deployment process, citing cost overruns that were not initially conveyed to Congress when the program was launched and an implementation process that has been hindered by delays and functionality concerns. 

“I am glad VA is not rushing deployments until there’s more confidence in the likelihood of success, but the department needs to be straightforward with Congress about what is reasonable and achievable,” Heinrich said. 

VA signed a $10 billion, 10-year contract with Cerner in 2018 to implement new, interoperable EHR software across the department’s national network of 171 medical centers, replacing its legacy system. The EHR system rollout, however, has been plagued by software outages, logistical delays and patient safety issues that have hampered the deployment process. A highly critical watchdog report released by the VA Inspector General’s office in July found that the EHR system deployed at the department’s initial rollout site—the Mann-Grandstaff VA Medical Center in Spokane, Washington—routed more than 11,000 clinical orders for veterans to an “unknown queue” without alerting clinicians. 

Sen. John Boozman, R-Ark., the subcommittee’s ranking member, noted that approximately $8.5 billion has already been appropriated to launch the EHR system over the past five years, and that VA is seeking another $1.75 billion for the program for fiscal year 2023. 

“At the outset, we were told that this program would cost no more than $16 billion and would be complete in 10 years,” Boozman said. “In the years since, VA has deployed the new system at only a small handful of sites, and those rollouts have been challenging, to say the least.”

VA’s beleaguered EHR deployment has garnered bipartisan criticism from lawmakers, who passed legislation—the VA Electronic Health Record Transparency Act—earlier this year requiring that the VA Secretary submit reports to Congress on cost, performance and patient safety issues related to the system’s deployment. President Joe Biden signed the bill into law in June. The Senate subcommittee hearing was held one day after lawmakers on two House Veterans’ Affairs subcommittees faulted VA for its major acquisition failures, including its EHR system deployment. 

Sen. Jon Tester, D-Mont., who chairs the Senate Veterans’ Affairs Committee, criticized VA’s lack of progress deploying the new EHR system and said “I don’t know if we’ve got a return on investment to speak of at all.”

“We're into this damn near five years—it’ll be five years in May—and we still haven't done a damn thing,” Tester said. “I mean, we've implemented, and it's been a trainwreck, in my opinion."

The VA had rolled out the EHR system at five medical sites, before announcing in July that it was postponing future deployments of the software until next year. VA initially delayed a planned EHR rollout at Boise VA Medical Center in June, before indefinitely postponing the site’s rollout in July after an assessment determined that “more could be done to ensure a safe and successful deployment.” VA’s EHR deployment schedule currently has the software slated to go live at 25 medical sites, including Boise, in fiscal year 2023. 

VA Deputy Secretary Donald Remy said the department is “looking closely at the schedule” and that “there are issues that need to be resolved before we can go live.”

Remy said that VA uses a site readiness checklist—which includes issues related to training, infrastructure and patient safety protections—to determine whether or not the EHR system is ready for deployment. That review process, he said, will largely guide future rollouts. 

“As we’re working with a site for potential deployment, we work through these issues to make sure they have them covered,” Remy added. “An example of the effectiveness of that checklist was Boise recently, where we determined we weren’t going live as we went through the checklist.”

A cost estimate provided to Congress by the Institute for Defense Analyses—or IDA—in July estimated that the lifecycle cost of the EHR system’s implementation would be more than $50 billion over 28 years, with the EHR deployment process at all of VA’s medical centers taking 13 years. As was noted during the hearing, VA has not yet allowed IDA to publicly release its cost estimate. 

Dr. Brian Rieksts, a research staff member in IDA’s cost analysis and research division, said that VA’s 10-year, $16 billion implementation and cost estimate did not take into account assumed productivity losses at medical centers deploying the EHR software, as well as sustainment costs needed to keep the EHR systems operational. And Rieksts told Boozman that IDA’s additional three-year deployment estimate was based on risk analysis.

“We estimate a range of one to five additional years over the 10-year period that will be required, and that’s based on both looking at historical programs and the challenges that they’ve had, and then events that have happened with the current program that have led to delays that don’t indicate that this program would behave differently than historical programs,” Rieksts said. 

Remy said, however, that VA still believes it can accomplish the EHR rollout within the 10-year contract period—although he added the caveat that the department is committed to doing so in a “safe, effective manner for our clinicians and our veterans.”

“If that needs to go beyond 10 years, we’re working through the process of determining what that time period might be,” Remy said. 

Mike Sicilia, executive vice president for industries at Oracle, told the senators that proper implementation of the EHR system was Oracle’s “most important” priority and added that the company has moved 2,000 employees onto the project to complement the existing Cerner team. Sicilia said Oracle—which acquired Cerner in June—still believes it “can deliver this system within the budget envelope and without the need for any additional funds.” 

Sicilia cited Oracle’s recent partnership with Accenture to “evaluate the current training program,” as well as the launch this week of a new dashboard “that catalogs our to-do list and progress being made” on the project, as examples of the company’s commitment to ensuring the success of the EHR system’s deployment moving forward. 

“As we have examined the underlying causes for these delays and challenges, our conclusion is that we have found nothing that can’t be addressed in reasonably short order to get us back on a workable schedule and within budget,” Sicilia said. “We know we have a lot to prove with deployments next year at larger, more complex sites. We view the next year as a key window for building momentum and turning the corner.”