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VA Plans Cerner EHR Go-Live at Three Sites by 2020; Lawmakers Call for Close Project Oversight

June 27, 2018
by Heather Landi
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Cerner president Zane Burke said VA and DoD have an opportunity to lead on healthcare interoperability with EHR modernization projects
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The U.S. Department of Veterans Affairs (VA) plans to begin deployment of a new $16 billion electronic health record (EHR) system at three sites in the Pacific Northwest—Spokane, Seattle and American Lakes, all in Washington—in October 2018 with a goal of full capability by March 2020, according to VA officials.

During a House Committee on Veterans Affairs hearing Tuesday, Acting VA Secretary Peter O’Rourke updated lawmakers on the initial stages and planning for the VA EHR modernization project as the agency transitions from its aging legacy VistA system, which it’s been using for several decades, to a new Cerner EHR system.

The much-anticipated EHR modernization contract between the VA and Cerner was finally signed on May 17, after a delay of several months. A year ago, the VA announced that it would replace its aging EHR system by adopting the same platform as the U.S. Department of Defense (DoD), an EHR system from the Kansas City-based Cerner. The Cerner-VA project is a $10 billion contract, but the VA estimates that $5.8 billion will be needed for project support and infrastructure over 10 years.

“VA’s EHR modernization will be a flexible, incremental process, welcoming course corrections as we progress. Effective program management and oversight will be critical, it will be critical to cost adherence as well as to timelines, to performance quality objectives, and to effectively implement risk mitigation strategies,” O’Rourke said.

“We’ve designed a proactive and preemptive contract management strategy. We’re working closely with DoD, listening to advice from respected leaders in healthcare, and we’re fully engaged with Cerner, establishing governance boards and optimizing deployment strategy. We intend take advantage of lessons learned to mitigate risk, and strategy will adapt as we learn and technology evolves.


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In the midst of this project, President Donald Trump’s nomination to lead the VA, Robert Wilkie, has still not been confirmed; he faces a Senate confirmation hearing today. There has been tumultuous turnover among VA leadership in the past six months. Former VA Secretary David Shulkin was fired back in March and President Trump’s initial nominee, Navy Rear Adm. Ronny Jackson, withdrew his nomination amid damaging professional allegations.

O’Rourke reported to lawmakers that the VA was moving forward to establish appropriate governance and to tackle change management issues. “This is deep change, and this is a technical and cultural challenge; the human component is central to success. We’ll engage end users early to train facility staff and promote successful adoption. It’s a user-centric approach to veteran-centric change,” he said.

During the hearing, Congressional leaders voiced concerns on a number of issues and potential hurdles for the VA EHR modernization project.

Governance, Accountability and Leadership Vacancies

Committee chairman Rep. Phil Roe, M.D. (R-Tenn.) and ranking member Tim Walz (D-Minn.) announced last week the creation of a new subcommittee to focus on conducting oversight of the EHR modernization program and other technology projects at VA.

“Leadership will make or break this project, as will the oversight,” Rep. Walz said. “This panel will be a small group of three to five committee members who will focus intensively on these issues. EHR modernization is a big bet on the future of VA and we simply must make sure it succeeds.”

On the subject of governance and leadership, many committee members voiced concerns that there are still critical leadership roles that have yet to be filled, including a confirmed VA Secretary, a deputy secretary, an undersecretary for health and the CIO.

“I don’t see how this is going to end well unless we get top leadership positions in place,” Rep. Mark Takano (D-Calif.) said.

Committee members also questioned O’Rourke about media reports stating that Genevieve Morris, principal deputy national coordinator health information technology (ONC), will be leading the Electronic Health Record Modernization Program (EHRM) team. Morris was detailed to the VA earlier this year.

O’Rourke called those media reports “premature,” while acknowledging that Morris was a candidate for the position. “She has been instrumental in helping us in the past few months. She was loaned to us from HHS, and she has been critical to this team and helped us with broader perspectives of the industry and successful ways of implementing this project.”

DoD Cerner Implementation Issues

The DoD already is having issues with its Cerner implementations, according to a Pentagon report, and committee members pressed VA officials on these issues. Back in May, Politico detailed a Pentagon report which found that experts who have seen the DoD-Cerner deployments have cited highly damaging issues with that rollout, inclusive of problems so severe that they could have resulted in patient deaths. The DoD-Cerner EHR deal from 2015 is worth about $4.3 billion. 

One Congressional leader on the committee questioned O’Rourke about this report and whether it had any impact on the decision to adopt the Cerner platform. “We’re putting all eggs in one basket—every DoD and VA health record—did it give you pause?”

“We knew about implementation issues and how they have been resolved and we have integrated what we learned from them into our deployment strategy,” O’Rourke said. “We never had rose-colored glasses on; we knew that this would be an extreme challenge.”

Asked if he had any existing concerns, O’Rourke replied, “It’s cost scheduling performance, and our ability to track to the milestones that we’ve developed.”

Ashwini Zenooz, M.D., chief medical officer for the VA's EHRM program, said one of the biggest lessons learned so far from the DoD Cerner implementation has been the need to engage frontline providers early, which the VA is currently doing, she said. “Frontline providers have to be involved, and especially in the testing process. Users will be an integral component of user testing to make sure it works before go-live, to ensure patient safety,” she said.

Rep. Gus Bilirakis (R-Fla.) asked Vice Admiral Raquel Bono, director of the Defense Health Agency at DoD, to define the top challenges of the DoD EHR modernization project. “The two most challenging parts is governance and change management, and I’m gratified to see VA is working on this up front. The ability to make decisions needed at an enterprise level to maintain that interoperability and connection with VA is extremely important.” She added, “Being able to involve clinicians right from the start is an important part of the change management effort.”

Interoperability and Sunsetting VistA

During the hearing, committee members also pressed VA and DoD officials about interoperability between the Cerner systems, once implemented. Interoperability between VA and DoD has been an ongoing issue, and something that agency leaders have assured Congress will occur with the adoption of the same Cerner platform.

“Our goal is to have seamless data transference,” O’Rourke said.

Zenooz said, “A complete longitudinal record is the ultimate goal. We have learned lessons from the DoD implementation, and external implementations, and when we go live at the Cerner sites, we will have a single system that will ingest all the records, not only from DoD, but also community providers. That will include clinical notes, lab exams and radiology exams.”

On the subject of interoperability with community providers, Zenooz said, “More than 30 percent of care within VA is provided in the community. Our goal is to not only have data be available to them, but to build on it." She added that the goal is to provide the ability for providers inside and outside the VA to have the "analytics tools and registries available to them, so that they participate and improve patient outcomes.”

Zane Burke, Cerner Corporation president, also testified about the EHR modernization project, telling lawmakers that the he estimates the cost of operating the new EHR platform will be less than the current cost of $1 billion annually that is spent to operate and maintain VsitA. “Today, VistA has 100 different instances, so it requires different training and the upgrades and updates are more expensive. We believe there will be taxpayer savings over time.”

Burke also testified that, from a technical perspective, there has been progress to address the challenges around interoperability.

“There isn’t as big a challenge on interoperability today as in the past from a technical perspective, but there are still business processes within communities that create a different experience on the availability of that information. One of those challenges is who owns the personal health record. We’re offering personal health records for free, that’s ultimately one of the ways we move past those business model challenges in that space,” he testified. “It’s a complex arena, and we have spent significant time on that. We’re committed to this process.”

Burke added, “There is an opportunity for the VA and the DoD to lead in this space and I’m convinced that we have the capabilities to do that.”

One committee member also pressed VA and DoD officials on whether there would be multiple EHR systems in use. “Modernization will result in one and only one EHR system? Can you confirm that once the Cerner Millennium EHR is deployed, VA will stop using VistA and the joint legacy viewer?”

“Our intent is not to use VistA,” O’Rourke said. When asked if the Cerner EHR system will completely replace the DoD’s legacy system, Bono replied, “We will sunset the legacy system and we will maintain some connection to the legacy database, but the applications and programs, those will be sunset.”

However, David Powner, director of IT management issues at the U.S. Government Accountability Office (GAO), testified that an analysis indicates the Cerner EHR may not replace all of VistA's functionalities. He reported that an application view of VA’s health IT environment identified over 330 applications that support healthcare delivery at a VA medical center. “About 128 of these are identified as VistA applications, and 119 have similar functionality to the Cerner solution. The bottom line here is it’s important to know how much of Vista the Cerner solution will replace. Some analyses say 90 percent, but the application view suggests a much lower percentage.”

He added, “We want to avoid a situation down the road where there are surprises as to exactly what the Cerner solution is replacing.”

Powner noted that the 10-year price tag for the Cerner EHR implementation would likely be higher than $16 billion. “Given the complexity and cost, and the fact that VA healthcare and IT acquisitions and operations are both on GAO’s high-risk list, this acquisition needs to be effectively managed.”

He outlined several key factors that would be critical to the success of the program, namely, Congressional oversight, business change management, building appropriate cybersecurity measures and interagency governance, noting, “This project needs a strong CIO role.”


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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.


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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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Montana Senator to VA CIO: “EHR Modernization Cannot Fail”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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Senate VA (Department of Veterans Affairs) Committee Ranking Member Jon Tester has urged new VA CIO James Gfrerer to avoid past failures as he helps to move forward the department’s EHR (electronic health record) modernization project.

Gfrerer, an ex-marine and former executive director at Ernst & Young, was recently confirmed by the Senate to serve as assistant secretary of information and technology and CIO (chief information officer) at the Department of Veterans Affairs.

One of Gfrerer’s top tasks will be helping to update hospitals’ infrastructures as the VA continues to work on replacing the department’s 40-year-old legacy EHR system, called VistA, by adopting the same platform as the U.S. Department of Defense (DoD), a Cerner EHR system. That contract was finally signed last May and the implementation project is scheduled to span over 10 years.

In a letter to Gfrerer, Tester, a Montana senator, noted that while many of the responsibilities for the implementation of VA’s new EHR fall to the recently created Office of Electronic Health Record Management, the CIO’s role “is critical to ensure that we do not repeat the mistakes of the past.”

The office that Gfrerer now leads, VA’s Office of Information and Technology, will still be in charge of managing infrastructure needs for both the patient care facilities that have received the EHR upgrades and those that have not, Tester stated. “This task will require significant resources and robust oversight as VA manages a decade-long rollout,” he said.

Tester further wrote, “EHR modernization cannot be allowed to fail, and your leadership is essential if VA is to ultimately achieve a truly interoperable health record for veterans.”

In regard to “past failures,” it’s possible that Tester is referring to media reports that have outlined some of the significant issues that the DoD has had with its own Cerner rollouts. In reports throughout 2018, the initial feedback on the four military site EHR rollouts has been less than ideal. A Politico report first detailed the first stage of implementations noted that it “has been riddled with problems so severe they could have led to patient deaths.” Indeed, some clinicians at one of four pilot centers, Naval Station Bremerton in Washington, quit because they were terrified they might hurt patients, or even kill them, the report attested.

Providing an update on Cerner’s progress with the DoD EHR implementations, a company executive recently noted that he is seeing “measurable progress” at the DoD’s initial operational capability (IOC) sites.

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