January saw the introduction of two new House bills related to the VA’s Electronic Health Record Modernization (EHRM) program, adding another decade to the on-again, off-again modernization attempts at the VA. One of the bills H.R. 608—the Termination Act—will kill the program quickly, and the other bill H.R. 592—the Improvements Act—will kill it slowly. Either bill would result in veterans being delayed or denied the benefits of a modern Electronic Health Record (EHR) and instead having to continue using VA’s decades-old VistA health record system. We previously wrote about the importance to lead and the impracticality of returning to VistA in this prior blog entitled Veterans Deserve Better than VistA.
For sure, the roll out of the new Electronic Health Record at the VA has had its problems, and there is a lot of blame to go around. We have spent the last six months working through the issues on the Oracle / Cerner side as detailed in our year-end report. And our partners at the VA are similarly focused on getting the program back on track and fully deployed. The timing of the first EHR deployment at the height of the pandemic did not help. Like changing a tire without bothering to stop the car, it’s hard to imagine medical centers over-run with COVID cases changing EHRs. But hindsight is 20/20, and nobody could have predicted a once in a century health crisis.
The problem with modernization is it is hard work—change requires work and leadership. The technology component of modernization is not that difficult. The hard part of modernization is process change, from antiquated, legacy processes to modern processes. In the case of the VA, the system they are using has its roots in the Carter Administration and has grown into nearly 130 unique systems. If you took a poll of users with familiarity with the system they will always vote not to change, because change is hard … all that time and training for a system they perceive basically does the same thing: keep track of medical records.
So why change? Because it’s not just about the users of the system (hospital administrators, network administrators and care givers) it’s primarily about the beneficiaries of the system (veterans). It’s about making certain veterans don’t have to try to recall past treatments, prescriptions, procedures, and tests. It’s about the veterans trying to navigate multiple specialists, some in the community care system. It’s about veterans’ test results and images being in the right place, at the right time, whether at a primary care facility, community facility or specialist. It’s about using analytics and data to ensure that precisely the right care is delivered to a patient at precisely the right time.
A modern EHR gives veterans all these benefits and more. When you think about the current system and then add in trauma, addiction, depression, memory, pre-existing conditions, poor eyesight, diminished hearing, and plain old age, it’s frankly a credit to the men and women of the VA medical system that quality care gets delivered at all.
I lost my father-in-law to COVID in a VA medical center. He was a Korean War combat veteran with Alzheimer’s. I am a relatively young, educated, well-resourced, tech-savvy care giver with flexibility at work. The good news is the honor, dignity and care he was given by the VA medical system was beyond first rate, and I am forever thankful. The bad news is that navigating the record keeping among a half dozen specialists, a dozen prescriptions, and numerous prior conditions—particularly when memory issues are involved—is literally not possible.
The point of the VA EHR modernization program is to provide a seamless longitudinal record from enlistment to end-of-life, so the burden of recall does not fall on the veteran. The point of a stateless cloud-based web EHR that Oracle will deliver is so that the burden does not fall on the veteran to pick up an image from one specialist and bring it to another (because we all know they are never where they are supposed to be). The point of a modern EHR is to end the endless filling out of the same form over and over. The point of a modern EHR is so that interacting with your health record is as easy as interacting with a Starbucks Barista.
But even that understates the opportunity for veterans because the real benefit of a modern EHR is to enable predictive care using analytics; to flag treatment options based on large datasets; and to alert caregivers when signs of opioid abuse or suicidal depression are present. To reduce the burden on caregivers. To reduce human error. And to put an EHR in every veteran’s pocket.
Now, for sure, the users of the system are clearly important. This country is indebted to the medical professionals and caregivers who are on the front lines serving our nation’s veterans. For them we need a system that is easy to use and navigate, that is intuitive, and that features voice recognition and self-service. Just in time delivery of health records will reduce just as much frustration for caregivers as it will for veterans.
We’ve shared previously why H.R. 608, the bill to terminate the modernization program and revert to VistA, makes no sense. Yet H.R. 592, the so called “improvements” act, ensures an end-state that would be worse than terminating the program and staying with VistA. H.R. 592 compounds the problem of 130 different VistA implementations by placing the go/no go decision to migrate to the new EHR to … 171 different medical centers. “Each medical center’s director, chief of staff, and network director would be required to certify that the EHR system has been correctly configured for the site, the staff and infrastructure are adequate to support it, and it would not negatively impact safety, quality or current wait times.”
With 171 medical centers’ separate decisions and certifications you’d have maybe 10 or 20 or 80 VA centers move to a modern system and the rest would stay with VistA. You’d have some centers moving this year, in two years, or in ten years. You would create an untenable patchwork, adding complexity, reducing interoperability, and increasing cost. The schedule would essentially be rendered obsolete. You’d balloon costs due to uncertainty. You’d have major questions of liability relating to “certification” and “safety.” Which Chief of Staff is going to sign and “certify” the system would not “negatively impact safety?” You eliminate the ability to standardize workflows across the VA system. And, most importantly, you abandon the point of the modernization project in the first place: to benefit veterans and provide them with a seamless record from enlistment at the DoD to end-of-life care at the VA.
Now that doesn’t mean that the program can’t be “improved.” We are working closely with VA leadership to improve the program and resume deployments in June by making sure users are well-trained, simplifying workflows, applying updates for system performance and capacity, and speeding the pace of technical fixes pushed out to users. We are ready to be held accountable and have no issue with improvements to the program so long as at the end of the day there aren’t 171 different decision-makers.
In June of last year, Oracle acquired Cerner essentially giving the VA two leading technology providers for the price of one. By the end of 2023, the Oracle Cerner EHR will be fully operational across the Department of Defense and the Coast Guard. We have committed to deliver the entire VA program on time and within the existing budget envelope. We have brought on Accenture to work through the challenges with training. We have accelerated and already delivered key components of the critically important pharmacy module. We have substantially decreased system performance issues. And we have delivered new features in the areas of opioid abuse and suicide prevention.The problem with modernization is it’s always hard and it’s always worth doing. If modernization relied on polling system users, it’s always easier to do nothing than to invest time and effort in change. The only thing worse than killing this program quickly—“the termination act”—is killing it slowly—the “improvements” act. Rather than give up and pull the plug, let’s lead and finish what we started. Remember, it’s about the veterans.