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WASHINGTON -- The new electronic health record (EHR) system in the veterans healthcare system still leaves a lot to be desired, witnesses said at a Senate hearing.

The VA signed a $10 million contract for a new EHR system with Cerner Millennium in May 2018. This system was supposed to modernize the VA's EHR and financial record-keeping, as well as establish a common EHR platform across VA and the Department of Defense. The contract was originally supposed to go live in March 2020, but the launch was delayed and the system finally went live in October.

Secretary of Veterans Affairs Denis McDonough addressed this on Tuesday at a held by the Senate Committee on Veterans' Affairs.

"The mission of VA HRM [health records modernization] has always been to create a platform that seamlessly delivers the best access and outcomes and the best experience for our providers, but the VA's first implementation of the Cerner Millennium, which occurred in October 2020 at Mann-Grandstaff VA Medical Center in Spokane, Washington, did not live up to that promise, either for our veterans or for our providers," he said.

Duplicate Prescriptions

As an example of the problems with Cerner's system, McDonough cited an issue with the pharmacy at the Spokane facility: "We began hearing disquieting reports from ... the pharmacy team that they were receiving duplicate prescriptions. It turned out that the veterans' old prescriptions weren't automatically being canceled when new ones came in."

In addition, "I heard from another clinician that help with the new platform wasn't always easy to find, even when you asked for it," McDonough continued. "When she called the Cerner Help Desk, the person on the other end of the line told her he had just started a week prior. In other words, she had more experience using the platform than the person who was supposed to help her navigate it."

Because of stories like that, McDonough said, he launched a top-to-bottom review of the new EHR implementation program. A by the VA inspector general found that at the Mann-Grandstaff facility there were significant gaps in training, including trainers' inability to answer users' questions and limited usefulness of "adoption coaches," among other issues.

Committee members on both sides of the aisle were not happy with this state of affairs.

"The electronic health records modernization program's organizational structure seems to me to be dysfunctional," said Sen. Jerry Moran (R-Kan.), the committee's ranking member. "Will we see a comprehensive reorganization of the program, and when will it happen? I ask this because based on your written testimony, it doesn't appear anything is changing."

McDonough asked committee members to give him a few days' forbearance on this issue so that he could confer with Donald Remy, the deputy secretary of the VA who was confirmed by the Senate on Thursday by a vote of 91 to 8. Once the conversation about reorganizing the program happens with Remy, who will be in charge of the reorganization, "we'll be happy to come up and show that to you," McDonough said.

"I think you'll see significant change, including reduction of what I consider to be redundant positions. And most importantly, clear accountability among each of us to one another and to you, to ensure that decisions taken are decisions implemented," he added.

Patient Safety Concerns

Sen. Patty Murray (D-Wash.) asked about patient safety. "Since the implementation of the Cerner program last October, I've heard ... about a number of serious patient safety issues that could put our veterans at risk," she said. "And I'm also very troubled by reports of exhausted staff struggling to use a system because of the workload design issues and lack of adequate training, and I expect those issues to be resolved."

"I know you inherited this multi-year, multi-billion-dollar electronic record health modernization program and all the challenges that come with it," Murray continued. "I know we confirmed you for this position because of your management skills and the ability to tackle hard problems, and I know you know we need leadership to get this back on track ... I'd like to ask you who's responsible for reviewing the EHR workflow designed specifically for patient safety."

"We sent a patient safety team to Spokane, but at the end of the day, I guess with my presence here today I'm telling you that I'm taking responsibility for these decisions," McDonough responded.

Sen. Marsha Blackburn (R-Tenn.) continued the focus on leadership, noting misrepresentations by VA staff in previous appearances before Congress.

"With the inadequacies that have been pointed out, has anybody been removed from their position?" she asked. When McDonough answered in the negative, Blackburn said, "Why has that not happened?"

"Any suggestion of withholding information to an [investigator] or not being fully candid with Congress I consider to be a uniquely important development, so I'm getting to the bottom of those," said McDonough. "And if I have confirmation of that, yeah, there would be consequences."

Cost Overruns Likely

Committee chairman Jon Tester (D-Mont.) expressed concern that the VA had not been entirely truthful about the cost of the EHR project.

"I don't need to tell you this is not acceptable," Tester said. "From the inspector general's work, we know the program likely will be at least $5 billion over budget when the VA infrastructure and other IT [information technology] costs are included. That will likely push this program to more than $21 billion."

He asked McDonough to provide the committee with all previous and projected costs, which McDonough agreed to do.

"I hope Cerner is watching this," Tester said. "If Cerner is not up to making a user-friendly electronic health record ... then they should admit it and give us the money back so we can start over." He noted that the VA and Congress have been working on the issue since about 2001, "and we've not gotten to where we need to go."

In the second panel at the hearing, David Case, JD, deputy inspector general at the VA, testified that his department had issued five reports on the EHR project since April 2020.

"While the VA implemented some of our recommendations from 2020, there's some work remaining," he said. "The VA needs to spend millions on physical and IT infrastructure upgrades."

Case also reiterated some of Tester's points. "We found the cost estimates were unreliable. They were not comprehensive, not well documented, inaccurate, and not credible. We also found that VA did not report accurate and complete information to Congress," he said.

He added that there had been some improvements in IT infrastructure cost estimates. However, "decision-making did not appropriately engage the VA staff who use the system."

The VA "also failed to effectively evaluate its training" on the new system, Case said.

"When we asked the OEHRM [Office of Electronic Health Record Modernization] to provide training evaluation data, they initially told us, '89% of proficiency checks were passed with a score of 80% or higher, in three attempts or less.'" However, Case's office found an earlier version of the data showing only a 44% pass rate.

"The Office of Inspector General concluded the data was removed and altered prior to submission. We are reviewing the issue more thoroughly after informing VA leaders," Case said.

Marc Probst, a health IT consultant who previously worked on Intermountain Health's EHR system, also appeared at the hearing. Moran asked him what Congress should expect from the VA regarding the EHR implementation.

"A clear vision of what this is going to do, the benefits that you're going to get from it -- I would hope that those are well defined, so that you understand the goal, what's at the end of the project," Probst said.

"You're going to need to see reductions in the number of complaints or tickets that come through." In addition, he said, "if I were in your seat, I would like to see real milestones, and are they hitting those milestones and if they're not, why are they [changing]? It's very common in these implementations for those milestones to change, but you need to have a rationale for why that's happening, so that everyone's aligned with what we're doing."

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