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Introduction – VA EHR Modernization
The Veterans Health Administration (VHA) is the nation’s largest health system and is managed by the Department of Veteran Affairs (VA) (US Department of Veterans Affairs, 2009). The VHA provides care at nearly 1300 locations including 171 medical centers and 1,112 outpatient sites, which serves roughly 9 million Veterans each year (US Department of Veterans Affairs, 2009).
The VA was one of the earliest pioneers for the Electronic Health Record (EHR). The EHR is a digital version of the patient’s chart. The EHR captures patient information in real time and makes it instantly accessible to authorized providers (HealthIT, 2022). The EHR is crucial in a patient’s care because the information put into the record can be shared amongst providers across healthcare entities and other organizations (HealthIT, 2022).
Starting in the 1980s, the VA has worked on improving the EHR experience. They first transitioned from the paper health record to an electronic record through the use of the Decentralized Hospital Computer Program (DHCP) (Tong, 2015). The program served as a central location for patient data. The VA continued to work through several iterations of the DHCP until they landed on a tool that was much more comprehensive (Tong, 2015). The new tool was titled the Veterans Health Information Systems and Technology Architecture or commonly known as VistA (Tong, 2015).
The VistA system was implemented across all veteran healthcare sites and provides clinical, financial, and administrative functions. VistA was highly rated amongst physicians and providers in Medscape surveys done in 2014 and 2016 (Baker, 2022). VistA has also been the EHR system for the VA for over 30 years (Baker, 2022). Despite VistA’s notable achievements, the EHR system is outdated, expensive to run, and has quite challenging to maintain (Senate RPC, 2020). VistA also lacks interoperability with the Department of Defense (DOD) and other private health provider systems (SenateRPC, 2020).
The VA has tried repeatedly over the past 20 years to modernize VistA and make it interoperable with DOD. In 2008 Congress mandated it, requiring DOD and VA establish fully interoperable EHR systems that would allow for sharing health care data across departments. In 2013, the VA launched yet another plan to modernize the system, dubbed “VistA Evolution.” The program expanded the use of the “Joint Legacy Viewer,” a tool that allowed VA medical personnel to view a read-only display of patient data from DOD and other health care providers. While an improvement, the JLV was a far cry from true interoperability. (https://www.rpc.senate.gov/policy-papers/modernizing-vas-electronic-health-record-system).
In 2011, the VA enlisted an open-source community called OSEHRA (the Open Source Electronic Health Record Agent) to develop enhancements to VistA. This decision was part of a joint effort with the U.S. Department of Defense (DoD) to store all veterans’ and service members’ health records electronically using a single source. (https://ehrintelligence.com/news/ehr-and-the-va-part-i-history).
After years of failing to adequately modernize VistA or build a suitable EHR system, the VA decided to purchase Cerner as its EHR system in 2017 (SenateRPC, 2020). The VA selected this vendor because it is the same one that the DOD purchased back in 2015, hoping that using the same vendor would solve for some of the interoperability challenges (SenateRPC, 2020). The VA Electronic Health Record Modernization (EHRM) program was created to generate unification between the VA and the DOD by having both entities use a singular EHR system (Department of Veterans Affairs, 2021). Through the VA EHRM, VistA will be replaced with a commercial solution, Cerner Millennium (Department of Veterans Affairs, 2021).
Project Overview and Background
For the VA to continue delivering a high-quality experience for veterans, their clinicians and staff needed a modern platform that provided improved access to each veteran's health record (Department of Veterans Affairs, 2021). The VA is now undertaking one of the largest government transformation efforts ever; implementing a commercial EHR that will provide full interoperability with the DOD, the U.S. Coast Guard and Community Care providers, enabling a smooth experience for veterans (Department of Veterans Affairs, 2021).
The EHRM will finally give VA providers uninterrupted access to a patient's entire health record (Department of Veterans Affairs, 2021). The EHRM will also bring in improved health data analysis provided by advanced analytics. Equipped with tools to support decision making and improve patient outcomes, the new EHR system will give clinicians, providers, and staff members instantaneous access to the patient’s information they need (Department of Veterans Affairs, 2021).
The transition to the new EHR system will happen over the course of a 10-year period and is anticipated to end in 2028 (SenateRPC, 2020). The VA EHRM Integration Office will manage deployment of the new EHR system. The $16 billion contract to replace VistA and all of its instances was awarded to Cerner in May 2018 (SenateRPC, 2020). In 2020, the EHR program was allocated about $1.5 billion (SenateRPC, 2020). In 2021, the EHR program exceeded $2.6 billion (SenateRPC, 2020). The progress and allocation of funds will be monitored by the Office of Management and Budget’s Federal IT Dashboard as an IT investment (SenateRPC, 2020).
Project Objectives
The VA EHRM has identified 8 project objectives to ensure a successful EHR implementation (Department of Veterans Affairs, 2021).
Improving the Veteran Experience
Moving forward to create a seamless and harmonized VA digital experience using a Human-Centered Design approach.
Ensuring Patient Safety
Ensuring clinical and practice management systems are functional and providing staff with tools to deliver the safest, most effective, and timely, evidence-based care to Veterans.
Extended Training for Frontline Employees
Ensuring frontline employees have the right tools and training to make full use of the EHR features to provide world-class care to Veterans.
Building Confidence at VA Sites
Ensuring site and technical infrastructure is configured to meet system and user requirements is well-tested, and is fully operational to support the provision of care.
Implementing Organizational and Program Improvements
Establishing effective management and project oversight to optimize cost, schedule, programmatic performance, and governance.
Improving Operational Efficiencies
Ensuring productivity and clinical workflows are optimized and the system is configured to maximize operational efficiency.
Making Governance Effective
Channeling data-driven decisions through a single governance body, incorporating stakeholder inputs and ensuring that good management discipline is applied, and risk management is rigorous.
Centralizing Data Management for Workers & Veterans
Ensuring clinical and practice management systems are functional with a secure unified Veteran-centered data model.
Project Stakeholders
Successful implementation of the VA EHRM depends on key stakeholders from cross-functional areas. The VA EHRM project stakeholders are as follows:
Contractors
Cerner was awarded the contract to develop the new EHR system for the VA. Cerner is partnering with over 20 partners to ensure the EHR system is deployed successfully (Fischer, 2021). Cerner’s core partners include AbleVets LLC, Accenture, Forward Thinking Innovations LLC, Guidehouse, HCTec, Henry Schein Inc., Leidos, MicroHealth, and ProSource 360 (Fischer, 2021). Cerner has also partnered with other businesses, a few of them veteran-owned to assist in the implementation. These businesses are Cerner’s premier partners and include Sharpe Medical Consulting, Signature Performance, Thomas Riley Strategies, ACI Federal, B3 Group Inc., Blue Sky Innovation Solutions, Clarus Group, Forward-Thinking Solutions, Healthcare Resource Group, KRM Associates Inc., Liberty IT Solutions, MedicaSoft, MedSys Group, Holland Square Group, Program Management Solutions, and Point Solutions Group.
Project Work Breakdown Structure (WBS)
Project Budget
In 2018, the VA awarded a $10 billion contract to Cerner for the VA EHR Modernization Project (Sweeney, 2018). The $10 billion dollar deal, spread out over 10 years, is the largest health IT projects in the government’s history (Sweeney, 2018). The no-bid contract took approximately 6 months to negotiate and finalize details (Sweeney, 2018).
The estimates for the project were severely underestimated. The OIG performed an investigation in 2019 in which it found that there were two factors attributing to the project costs (Fischer, 2021). The first factor was the actual IT work (Fischer, 2021). The second factor was infrastructure upgrades that needed to occur at the VA’s medical facilities (Mitchell, 2021). Many of the facilities are over 50 years old and need significant work including heating, cooling, ventilation, and cabling to support the new EHR program (Mitchell, 2021). After the OIG concluded its investigation, it found that the project was $3.6 billion short of adequately launching the new EHR program (Fischer, 2021). In 2020, the VA asked for an additional $1.2 billion in its fiscal year to continue the EHR work (Landi, 2020). In 2021, the ask has increased to $2.6. billion for the fiscal year (Landi, 2020). Of that $2.6 billion, over $1 billion is for infrastructure upgrades, another $1 billion is for the Cerner EHR contract, and nearly $260 million is to add additional staff to the project management office (PMO) (Landi, 2020). Currently, the VA has estimated the increased initial project cost from $10 billion to $16 billion over the 10-year period (Landi, 2020).
Project Timeline
The VA EHR Modernization project is scheduled to run from 2018 to 2028. Figure 1 shows the general timeline of the EHR modernization.
Project Description & Status
Overview
In this case study our team will discuss the Department of Veteran Affairs, Electronic Health Record Modernization (EHRM). The purpose of the EHRM is to provide a single health care system that stores health information and tracks all aspects of patient care. The three major components to the EHR program are:
Since its inception in 2018, the EHRM was thought to be a well-organized, innovative and structured program. But, over the years the system has proved to be an issue with a broken data collection system, missed deadlines, and misuse of funds of over $16 billion dollars and counting. Our team will evaluate these issues and come up with recommendations for getting the program back on track.
Critical Questions
1) What are the major causes behind the failure of the VA's electronic health record mega-project?
2) What are the documented reasons by the Government Accountability Office for the failure of most of the government programs of the scale of EHRM?
3) What is the track record of VA with the large-scale system development and deployment?
4) What is the role of accountability for the success of the program?
5) How does lack of change management negatively impact the project's progress?
6) Does resistance from the employees create difficulties in implementing the system?
7) Is hiding the truth from the last three years regarding the issues that occur one of the major reasons behind the project's failure?
The VA EHRM program failure may be attributed to many factors. Although the program has witnessed several shortcomings, we believe that hiding the truth about the program for the last three years is a major contributor to the failures being witnessed now. When the project to replace VistA was rolled out a few years ago, it immediately showed signs of failure which was not communicated. The truth about the success of the early stages of the implementation of the project was hidden from the stakeholders, (ALLEN et al., 2022). A lack of openness during project implementation is a major concern that may lead to disastrous failures. Hiding the truth may have been convenient for the project’s managers in the short run, but impacts are now emerging.
Hiding the truth may be the major cause of the current failures of the VA EHRM project. The handlers of the project concealed several important truths from the stakeholders, which may have contributed to the failure. First, the project lied about the success of the training process. Replacing VistA with Cerner’s EHRM implied that healthcare workers, who are the primary users of the program needed to undergo training to learn how to use the new system. During the first deployment at the Mann-Grandstaff V.A. Medical Center in Spokane, the employees complained about the training program. Although the project reported that the user’s training was successful, reports emerge that almost two-thirds of the participants failed the accompanying test, ("Hidden Costs and Flawed Training Plague the V.A.’s Huge Software Upgrade", 2022). Office of the inspector general found out in an investigation that the proportion of employees who passed the training was 44% contrary to the 89% figure reported by the project.
The lack of honesty contributed to the current setbacks because if the training results were honestly reported, proper mitigation measures could have averted the current situation. The training’s honest results could have helped the project improve the training program and the system at large. The project management could have identified flaws at a very early stage and improved as necessary.
8) How does the training program for hospital staff impact the project's progress?
9) Is improper budget estimation during the project the main reason behind the shortfall of the project budget?
Apart from the issue of hiding the truth, another potential major cause of the failure is the improper estimation of the budget. The report by OIG in 2019, revealed that the project budget was severely underestimated. The report identified two factors as the major contributors to the budget cost. The OIG notes that apart from the actual IT work which the contractor is assigned to undertake, the VA’s medical facilities need serious infrastructure upgrades. It seems the upgrading process was not factored in during the budget estimation. The project is requiring more budget than planned when it’s only about three years old. The estimated total budget for the VA EHRM project is $16 billion for the whole work.
The funding of the project was planned to be distributed throughout the project's lifespan. But from the early years of the project, it is revealed that the actual cost is way beyond the estimated annual budget. For example, Cerner asked for an additional $1.2 billion in 2020 to complete the year,s IT work. The additional funding in part was supposed to facilitate the infrastructure upgrades, which seem to have been neglected for over 40 years, (ALLEN et al., 2022). Although the project was estimated to cost $16 billion, reports reveal that it could cost over $21 billion.
The budget underestimation may be the reason for the failure. When the cost of a specific activity becomes excess than expected, it may lead to delays. Underestimation of the cost may tempt the management to utilize less experienced and skilled staff to try to cut costs. Again, the number of staff may be little than the appropriate number needed to complete certain tasks at the right time. The report by the OIG shows that there was understaffing because $260 million of the additional funds was used to employ additional staff. Thus, the understaffing caused by the budget restrain could be the cause of the failure.
10) Why has the project missed almost each of the set deadlines?
11) What can be done in order to mitigate potential causes of failure?
There are several potential causes of failures for the VA’s EHRM project. The project is just about three years into its lifespan. It is estimated that the project will run until 2028 when the existing contract with Cerner will expire. Although several signs of failure are being witnessed, including missing almost every major timeline, there is still room to rectify the flaws and have a smoothly running project as planned. One of the actions that need to be implemented to mitigate some of the causes of failure is to undertake a new budgeting and scheduling process. Based on the report by the OIG, it is revealed that the project sought an additional budget in 2020 because the allocated funds were insufficient, (ALLEN et al., 2022). Thus, a new budget that includes all items needs to be developed. The current budget did not factor in the issue of the infrastructure upgrade. The new budget should include all factors that will affect the cost of the project.
Secondly, the project needs to observe integrity by upholding honesty in its operations. Hiding the truth has been a cause of failure. Challenges during the implementation of the project were hidden from all the stakeholders. The project management should thus improve the communication culture within the project. Honest progress results should be communicated to the entire stakeholder so that appropriate actions will be taken on time. The project should acknowledge any shortcomings and work on improving poorly performing operations. Communication is crucial for the success of any project.
12) What is the likelihood of project failure?
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