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Politico
POLITICO
21 Jul 2023
Ben Leonard


NextImg:The VA’s new medical records system has gone haywire. Congress is alarmed

The Veterans Affairs Department’s fumbling effort to replace its decadesold electronic health records system has strained its relationship with Congress to the breaking point.

Anger about the project — billions over budget, tied to at least four veterans’ deaths, and now, on pause — is responsible for a spate of bill introductions, some aiming to shut the project down, others to boost oversight and accountability. The problems also led Iowa GOP Sen. Chuck Grassley to hold up a confirmation vote on President Joe Biden’s nominee for one of the VA’s top posts.

Key lawmakers, including Senate Veterans Affairs Chair Jon Tester (D-Mont.), are trying to give the VA one more try to get it right after the department halted the system rollout this spring and renegotiated its contract with the vendor, Oracle Cerner.

“Modernization of the electronic health record is not optional — one way or another it has to be done,” Tester told POLITICO. “I will keep demanding results.”

But if more veterans are harmed by mishandled records, or the VA announces more multimillion-dollar cost overruns, the lawmakers who just want to shut it down could gain the upper hand, and that could leave vulnerable veterans who are unable to afford private care stuck in a system that’s stuck in the past.

Bills pending in Congress would end the program, require the VA to make substantial improvements before expanding the new system or mandate the VA to update lawmakers on progress.

“It has been a nightmare,” House Veterans’ Affairs Chair Mike Bost (R-Ill.) said in an interview. Bost is among those threatening to pull the plug, saying the old system could instead be improved. “I carry the carrot and the stick … The stick got their attention. That is good because we need to wake them up on how bad this has gotten.”

Bost is working on a checklist describing what he needs to see to assuage his concerns.

“It’s a government thing,” said Bost. “Good idea, bad rollout. The company can’t get it figured out. We as Congress have got to take control.”

In April, the VA put the system on pause indefinitely after the agency acknowledged that the system had contributed to the deaths and “catastrophic harm” to others.

An assessment commissioned by the VA from the Institute for Defense Analyses last year found that the initial cost projection from 2018, $10 billion over 10 years, had grown to $50.8 billion over 28 years.

More than a dozen officials who have been involved or intimately familiar with the project told POLITICO the system’s problems are myriad.

They bemoaned a lack of leaders with relevant experience, a failure to prepare for deployments, a rushed initial rollout and a lack of buy-in from VA clinicians wedded to the current system, VistA, which dates back at least 40 years.

“The program was never designed to be successful,” said Peter Levin, a former VA chief technology officer. “Not making difficult choices and not making good choices is costing, at the very least, taxpayers billions of dollars.”

Oracle declined to comment on the record for this story. But Executive Vice President Mike Sicilia previously told POLITICO the company supported the VA’s decision to pause the rollout after the company had pledged to restart operations in June.

Sicilia said it would allow time “to improve the operation of the EHR at the current sites and take the necessary time to institute governance, change management and standardization changes to ensure the success of future VA deployments.”

‘We need to modernize’

A health care organization’s electronic health records system does everything from keeping track of patient appointments to doctor’s notes, to new prescriptions, to surgeries, and allows patients to access their records through a portal.

A modern, interoperable system would allow any doctor in the VA to quickly call up a patient’s full medical history, including from military service. It makes it easier to share records with specialists, and plan care.

“We need to modernize,” said Neil Evans, VA’s EHR project director. “There is incredible value in having an enterprise electronic health record.”

Modern digital records systems are ubiquitous in private health systems.

But VA physicians often struggle to share patient data, since each VA medical center can customize the digital workflow in VistA, making it difficult for clinics to share records. That leaves providers with an incomplete view of a patient’s history.

And that can make it harder to deliver the right care and avoid errors. The system — which is expensive to maintain — is also more vulnerable to hackers than modern ones.

“Today’s regulatory requirements, the need for interoperability, and the pace of innovation are forcing the retirement of all self-built systems,” said John Halamka, president of the Mayo Clinic Platform. “There is not a choice to keep the systems of the past.”

‘The status quo was unsustainable’

In the summer of 2015, Cerner — which Oracle purchased last year — won a contract with the Defense Department to replace its electronic health records system.

That was a spur for the VA, which for years had discussed the possibility of a unified system with the military.

In June 2017, Trump administration VA Secretary David Shulkin announced that the agency was hiring Cerner to replace VistA.

“The status quo was unsustainable,” Shulkin said in an interview with POLITICO.

Shulkin proceeded with a special authorization that allowed the VA to skip the competitive bidding process, saying that the VA and DOD would continue to struggle to provide quality care if they had different systems. Then-President Donald Trump called it “one of the biggest wins for our veterans in decades.”

But the decision to skirt the normal process was controversial. An open bid could have provided valuable information about how to proceed, said Shelby Oakley, who oversees VA’s contracting activities at the Government Accountability Office, Congress’ investigative arm.

Some VA staff who’d helped build VistA and clinicians who relied on it also were skeptical, believing that Cerner had swayed the decision-makers.

VistA had its defenders. Edward Meagher, who was VA deputy chief information officer in the 2000s, said the agency should have stuck with what it knows.

“The greatest irony is that the VA has in VistA a system that solves all of its current problems and is the best path forward to real modernization,” he said.

White House adviser Jared Kushner added to the unease when he said the decision to make the change took just two weeks.

Shulkin — who also served as a high-ranking VA official for President Barack Obama — opted to delay finalizing the Cerner contract to make sure there was a proper approach to data-sharing and integrating it with the Pentagon system, he said.

But Trump ousted Shulkin in late March 2018, leaving the future of the Cerner deal in question.

Over at the Defense Department, the Cerner system was sending up red flags, with rising costs, data exchange and prescription issues.

An April 2018 memo from the Defense secretary found that the first stage of the Pentagon’s program was troubled with issues so significant they could kill patients.

Three weeks later, acting VA Secretary Robert Wilkie signed the deal with Cerner.

‘Everyone needs to be on board’

Wilkie set ambitious goals. But overhauling electronic health records systems is challenging, especially in the sprawling VA, which serves 9 million veterans and has more than 170 medical centers. Health care can’t shut down.

“[It’s] like trying to fix a plane while flying,” said Daniel Barchi, chief information officer at CommonSpirit Health, a private hospital system. “A project of this size is enormous, and the problems are far more than just technical. They’re about workflow, process and people.”

Evans, the VA’s program director, said that organizational change is more difficult than implementing new technology.

“Everyone needs to be on board,” said Bill Tinston, director of the DOD and VA’s joint Federal Electronic Health Record Modernization Office.

Leadership in the Trump administration was ill-equipped to handle the transition, given lack of experience in EHR overhauls, several high-ranking former officials in both the Trump and Biden administrations told POLITICO.

“VA’s infrastructure was built to support VistA. It wasn’t meant to support Cerner, which requires modern infrastructure,” said a former senior Trump VA official granted anonymity to speak candidly. “You needed somebody who really understood the health IT infrastructure.”

VA and Cerner pressed forward as reports of issues with the Pentagon implementation piled up.

The system lost prescriptions and it was hard for providers to log on, leaving them fearing patients would be harmed.

In April 2020, a VA watchdog warned that VA officials had set an “aggressive” and “likely unrealistic” initial rollout schedule with a March 2020 target — eventually moved to July — that potentially put patients at risk.

Issues are expected in these sorts of transitions, VA Deputy Inspector General David Case told POLITICO, but the VA didn’t put enough time into planning.

“It’s more than just putting dates on a calendar,” Case said.

Just two weeks before the 2020 election, the VA launched the system at its first location, Mann-Grandstaff Medical Center in Spokane, Wash.

The VA inspector general found that the facility lacked sufficient staffing to handle the transition and didn’t take enough steps to “mitigate known risks,” leading to substantial dangers to patient safety.

“There should be all this planning before an actual deployment,” the former senior Trump official said. “You don’t wing it.”

‘The VA is using veterans as guinea pigs’

Doctors tell Charlie Bourg he has a year or two to live, and he thinks it’s because of the Cerner system at Mann-Grandstaff.

In late 2020, doctors told the Vietnam veteran he might have prostate cancer and that he’d be referred to a specialist, according to a letter from Mann-Grandstaff to Sen. Patty Murray (D-Wash.) obtained by POLITICO and first reported by the Spokesman-Review. The new digital system routed the order to an unknown queue, and the appointment wasn’t scheduled properly. Four months later, he had another appointment with his doctor, who saw he hadn’t been to the specialist.

More system bugs meant that he wasn’t able to see the specialist and get a biopsy for nine months after he was initially referred, or get his prostate removed for more than a year after.

“The VA is using veterans as guinea pigs,” Bourg said. “The system needs to be shut down.”

Bourg sought damages from the VA and Oracle Cerner in an administrative claim and now plans to file a lawsuit.

VA declined to comment, saying it can’t discuss patients’ “specific medical information.”

‘It’s a government thing’

Alarmed by skyrocketing costs and reports of dead veterans, the bipartisan leaders of the House and Senate Veterans’ Affairs committees launched oversight hearings and proposed legislation.

Faced with the prospect of a congressional directive to kill the program, the VA responded this spring by pausing the rollout indefinitely, with the system in place at only five of the VA’s medical centers.

At Mann-Grandstaff, Director Robert Fischer blames the electronic health records system for most of a $35 million budget deficit that he said will require him not to fill 146 full-time positions when they become vacant.

House Energy and Commerce Chair Cathy McMorris Rodgers (R-Wash.) wrote VA Secretary Denis McDonough in May to ask him to use “every available dollar appropriated” to the system to avert reductions in staff and services.

It’s unclear when the VA will resume the project.

“Creating an arbitrary deadline for moving forward is not in anybody’s best interest,” VA project director Evans said. “Let’s take the time that we need to make things right.”

He said the VA will use the time to fix technical problems and optimize the system to meet clinicians’ needs.

But lawmakers are threatening more oversight.

“We need more than a reset,” said Murray, a former chair of the Senate Veterans’ Affairs Committee, in a recent hearing. “We need reforms to make sure that the problems with the EHR are not just fixed, but don’t ever happen again in the future.”

Pending legislation from the Tester, Murray and Sherrod Brown (D-Ohio) with companion House legislation from Veterans’ Affairs ranking member Mark Takano (D-Calif.) and Bost would prohibit the VA from implementing the technology at new facilities unless the five medical centers where it is in place meet performance criteria.

“The expectation should be success,” a congressional aide granted anonymity to discuss the situation candidly told POLITICO. “If it’s proven that Oracle Cerner can’t get there, maybe we have to ask some hard questions.”