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.
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.”