“In the summer of 2024, we should be having, and even before that we should be having real discussions about whether we’re ready to move forward with [the EHRM] restart,” Dr. Neil Evans, acting program executive director of the VA’s EHRM Office, said during a House Appropriations Oversight hearing on implementation of the VA’s EHRM initiative with Oracle Cerner.

The VA partnered with Oracle Cerner in 2018 to lead the development and implementation of its EHR modernization under a 10-year, $16 billion contract. But since then, the program has faced a number of significant challenges, some of which have reportedly brought harm to veterans. This led to bipartisan congressional criticism of the program and, ultimately, the decision in April by the VA to stop the rollout of the system at veteran hospitals until major patient safety issues are remediated.

The VA also renegotiated its contract with Oracler Cerner in a way that it believes “dramatically increases” its ability to hold the technology company to account for the system’s performance.

Speaking at Wednesday’s hearing, Mike Sicilia, executive vice president at Oracle, said: “I would concur with Dr. Evans’s time frame. It seems to me next summer we should be in a position, particularly if the go-live is trending well in March, that we should be in a position to resume [the rollout]. That is our expectation.” 

VA Secretary Denis McDonough will next year make the final decision regarding the EHR rollout timeframe, according to Evans and Sicilia.

The VA currently uses the Veterans Health Information Systems and Technology Architecture (VistA) EHR system in almost all of its VA hospitals. The modernized EHR system was delivered to five VA facilities before the department halted its nationwide rollout. VistA has faced its own issues including a lack of interoperability and nationwide access for veterans who change hospitals or move between states. 

Evans also said there are major issues in having two different EHR systems operating within the VA rather than one central, functioning EHR system.

“I wake up every day wondering are we moving in this direction? We don’t want to stay in reset forever. In fact, I would argue that we’re at higher risk the longer we maintain a healthcare system that’s running two different electronic healthcare systems. So we need to feel an urgency to move forward with a single electronic health record system,” he said.

Multiple members of Congress expressed strong frustration during the hearing that the VA and Oracle Cerner were not moving fast enough with improvements to the EHR system while spending billions in taxpayer dollars. 

“$10 billion dollars of taxpayer dollars. What the hell has that gotten us? What if we cut funding? What if next year it was zero? Would that light a fire in terms of fixing this program?” said Rep. Tony Gonzales, R-Texas.

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Montana Republican Rep. Matt Rosendale, who is chairman of the House Veterans’ Affairs Subcommittee on Technology Modernization, is bullish on removing Oracle Cerner’s EHR system and instead wants the VA to continue using its precursor, the Veterans Health Information Systems and Technology Architecture (VistA).

“If it was up to me, not only would Oracle Cerner be gone, but we would be clawing back some of the money that we’ve already spent on them,” Rosendale told FedScoop earlier this week during a brief interview after a hearing on the VistA and Oracle Cerner EHRs.

The Oracle Cerner EHR has faced grave performance issues since it was rolled out to five VA hospital locations in October 2020, with repeated outages that, according to the agency’s watchdog, have resulted in serious harm to veterans.

The implementation of the VA’s new EHR system is expected to be delayed from its original estimates by at least one to two years while the cost has ballooned by billions.

“If it’s up to Matt Rosendale, we would claw back every dollar from them,” the Republican said.
“We have a bill out there to terminate the Cerner contract but I think we should take it a step further. I do listen to the recommendations of my staff and so I haven’t done that but I think that they [Cerner] have done an absolute disservice.”

Instead, Rosendale said that the incumbent VistA EHR system still used in most VA hospitals today is much better than the Oracle Cerner system and could be improved and strengthened in certain ways if needed.

“Every time that I have the VA in front of me and the more information that I get, I get more convinced that VISTA is absolutely a system that can accommodate the needs of our veterans in the best fashion possible,” Rosendale told FedScoop.

“There’s not even a comparison between Oracle Cerner and VistA. When we’re talking about delivering safe, quality health care to their veterans, nobody can refute it. The numbers just don’t lie,” he said, referring to the high rates of dissatisfaction with the Oracle Cerner EHR system. 

Rosendale cited a recent survey of VA medical staff who use the Oracle Cerner EHR that showed 78% are dissatisfied. Meanwhile, Rosendale said over 70% of VA medical staff surveyed approve of the VistA EHR system.

Some Democrats, who are currently working on their own comprehensive legislation to fix the VA EHR, have argued that VistA is also plagued with its own issues including a lack of interoperability and nationwide access for veterans who change hospitals or move between states. 

Nevertheless, Rosendale, who has a history of slamming Oracle Cerner, said House Democrats have been very supportive in conversations with Republicans and during congressional hearings “in recognizing that Oracle Cerner is not delivering on the contractual promises that they made to us.”

During an interview with FedScoop in February, Oracle senior executives said the company would take a little less than a year to correct issues with the Cerner EHR system, after it acquired Cerner in June 2022, and said the IT giant would need another 9-12 months to right the ship. 

Oracle also highlighted that EHR system transitions, like the one from VistA to Oracle Cerner, are notoriously challenging and require significant training, culture adjustment, and major technical problem-solving. 

“The clock is running, now. Oracle has said they’ll come up the curve quickly within a year and time will tell,” Rep. Rosendale’s staff told FedScoop.

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The VA last week announced a further delay of the EHR rollout within the Ann Arbor Healthcare System until late 2023 or early 2024 due to concerns about how well the health record system would interact with the Ann Arbor hospital’s vital medical research mission.

During a media roundtable, VA Under Secretary for Health Dr. Shereef Elnahal told FedScoop that if the medical research issues with the EHR are not fixed, similar concerns could arise at other other VA hospitals.

“So there are many VA medical centers that are heavy with clinical research because of their academic affiliations,” Dr. Elnahal said. “And so those centers will need this research functionality. It’s not just an issue with the Ann Arbor Hospital.” Dr. Shereef Elnahal, VA Under Secretary for Health

He added the full EHR deployment schedule was still being deliberated within the VA.

When asked about the current state of cybersecurity and veteran health data security within the VA, Dr. Elnahal told FedScoop that the VA’s Office of Information Technology has a special team focused on such issues led by Chief Information Officer Kurt Delbene. 

“He has a team focused on this and our agency is regularly engaged with interagency discussions after major cybersecurity incidents. And we are always trying to be proactive in limiting that risk,” said Dr. Elnahal.

He highlighted that the VA’s use of two different EHR systems has created additional difficulties and complexities to security within the agency. Most VA hospitals currently still run on the Veterans Health Information Systems and Technology Architecture (VistA) while the VA has rolled out the new Oracle Cerner EHR to five VA hospitals in the past two years with more rollouts expected later this year.

“Right now, as you know, we’re dealing with two different EHRs currently in place in our system. And so we have to contend with those risks, instance by instance, and make sure that the entire network is secure,” Dr. Elnahal said.

The Oracle Cerner EHR has faced grave performance issues since it was rolled out to five locations in October 2020, with repeated outages that, according to agency’s watchdog, have resulted in serious harm to veterans.

The implementation of VA’s new EHR system is expected to be delayed from its original estimates by at least one to two years while the cost has ballooned to be tens of billions more than originally estimated.

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Speaking with FedScoop, Oracle Executive Vice President Ken Glueck said Oracle-owned Cerner had determined it needed additional support from consultancy firm Accenture after identifying this as an area where program improvement is needed.

“About three months ago, we did an assessment of the training and we decided that this was an area that needed accelerated investment,” he said.

Glueck added: “We signed a contract with Accenture probably a month ago. So they are part and parcel of the training procedure for the continued rollouts when they resume in June of 2023.”

The Oracle EVP said the Accenture contract was within Oracle’s current budget envelope. The VA’s EHR modernization rollout implementation tag for Oracle Cerner was about $10 billion over 10 years.

Accenture is one of several companies working as part of the Leidos Partnership for Defense Health group of contractors to implement the Pentagon’s iteration of the Oracle Cerner system, MHS Genesis.

The Oracle Cerner EHR system is a key platform used by doctors to access the medical records of current and former military personnel. It is being rolled out at the VA as a replacement for the open-source Veterans Health Information Systems and Technology Architecture (VISTA) health information system.

The VA’s EHR modernization program has attracted controversy since it was deployed at certain VA hospitals in 2020. A report published last year by the VA’s watchdog found that at least 148 veterans were harmed at a health center in Spokane, Washington, during the agency’s rollout of the EHR system. Last October, the VA decided to delay future rollouts of the EHR system to new locations until June 2023.

Accenture was contacted for comment.

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A new bill is expected to take a fresh approach to the IT crisis that has dogged the agency’s Oracle Cerner electronic health record (EHR) system in recent years, according to two senior congressional sources.

The legislation from Democrats on the House Veterans’ Affairs Committee aims to provide a comprehensive solution for long-running problems with the IT system and an alternative to two Republican bills introduced last week. 

The sources told FedScoop that the legislation is supposed to provide a more holistic approach to solving issues with the EHR system while not resorting to its precursor system, the Veterans Health Information Systems and Technology Architecture (VistA).

VistA was also plagued with issues including a lack of interoperability and nationwide access for veterans who change hospitals or move between states. 

Precise details and the timing of the legislative proposal were not immediately available, however it is expected to land in the coming weeks.

According to one person familiar with the matter, the proposal may have a wider scope than prior attempts at legislative oversight and could involve a complete rethink of how other IT projects are conducted within the agency.

“This proposal is focused at a higher level than just one program,” the person added.

News of the alternate proposals comes after GOP lawmakers late last week put forward a pair of bills that would either substantially alter the Oracle Cerner electronic health records system or scrap the project entirely.

Those bills were introduced after Rep. Mike Bost, R-Ill., was named chairman of the House Committee on Veterans’ Affairs, and after Rep. Matt Rosendale, R-Mont., was elected as chairman of the VA tech modernization subcommittee. 

Both sources speaking with FedScoop said it may be possible for an alternate proposal to win support from both sides of the aisle, with one describing the EHR as a “unifying issue.” 

The EHR has faced grave performance issues since it was rolled out to five locations in October 2020, with repeated outages that, according to agency’s watchdog, have resulted in serious harm to veterans.

The implementation of VA’s new EHR system is expected to be delayed from its original estimates by at least one to two years while the cost has ballooned to be tens of billions more than originally estimated.

Last week the system was hit with network issues that affected the system’s performance at hospitals where it is deployed by the Department of Veterans Affairs, the Department of Defense and the Coast Guard.

Representatives for Democratic lawmakers on the VA committee were contacted for comment.

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“[We’re] working super deeply with Cerner to hold them accountable for having a high-availability, high-uptime system,” DelBene told the Daily Scoop Podcast on Monday. “And that’s been some of the difficult parts, that we’re working very deeply with them to improve those aspects.”

VA is in the process of conducting root cause analyses of the electronic health record (EHR) system’s problems with Cerner, which built the commercial-off-the-shelf (COTS) product the department is moving to under a $10 billion contract.

Cerner agreed to credit VA for failing to maintain the minimum level of system uptime stipulated in the contract, Dr. Terry Adirim, program executive director of the EHR Modernization (EHRM) Integration Office (IO), told The Spokesman-Review earlier this week. Outages have hindered health care providers’ ability to access patient information and plan care at VA medical centers piloting the system in Washington State and Ohio.

A VA spokesperson declined to comment on the minimum level of system uptime specified in its contract with Cerner, or the amount of the credit payout expected, but said uptime is reviewed on a “regular” basis.

The EHRM program remains in the “early stages,” DelBene said. Migration away from the 40-year-old Veterans Health Information Systems and Technology Architecture (VistA) system began in 2018.

“There’s certainly a lot of complexity coming from using such a COTS product in a new environment, and the thing to emphasize here is it’s as much about process change as it is about the systems that support that,” DelBene said. “And it’s also about adapting this commercial product to the particular environments that we have at the VA.”

The department has had “some successes” like bringing the Columbus, Ohio, facility on board a week or so ago and learned lessons from its first Mann-Grandstaff VA Medical Center implementation, DelBene said.

Meanwhile the Coast Guard completed its transition to Cerner’s system, and the Department of Defense is halfway through migrating its Military Health System.

Cerner’s system is different than when DOD began its rollout, and VA is working to limit the number of user experience roles like patient intake, increase training participation and involve “super users” in answering questions, DelBene said.

VA is also reconciling the need to connect medical devices with requirements to simplify infrastructure and not connect every system with Cerner’s, he added.

The Office of Information and Technology only recently joined the technical element of the VA Data Governance Council, which meets regularly to discuss the EHRM program. And Leslie Sofocleous was brought on as acting executive director of the EHRM IO program management office, in charge of user experience, in February.

“She’s the person who drives the specifics of the program so that everything is coming together, and we’re super excited to have her in the role,” DelBene said. “But it’s about getting that governance right; it’s about iteratively finding what works and what we need to change.”

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The cloud giant on Tuesday announced that it would extend its prior offer to purchase Cerner for $95 per share, or $28.3 billion, until 12 a.m. eastern time at the end of the day on April 13.

It is the second time the company has prolonged its offer, and comes as the Department of Justice and the Federal Trade Commission review the transaction.

Oracle on Feb. 11 previously extended its bid for the company until 12 a.m. at the end of the day on March 16, and the preliminary antitrust review period for the deal was prolonged until Feb. 22.

Cerner’s Millennium platform and its HealtheIntent cloud platform form the backbone of the VA’s health records modernization strategy, which relies on transferring patient data off the VA’s legacy Veterans Health Information Systems and Technology Architecture (VistA).

The modernization strategy has sustained criticism from lawmakers and clinicians over frontline patient safety concerns. A wide-ranging report by the Government Accountability Office last month found the department failed to sufficiently monitor the accessibility, accuracy and appropriateness of clinical information as it was transferred in segments from one system to another.

If the deal concludes, it will be the biggest ever for Oracle, which has a market value of more than $280 billion.

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Speaking at AFCEA Bethesda‘s Health IT Event on Tuesday, Sam Michael said the transition to Fast Healthcare Interoperability Resource (FHIR) Release 4 (R4) is “going well” but is essentially an “unfunded mandate.”

To allow for easy sharing of standardized medical data for reporting and research purposes, the 21st Century Cures Act gives health-care providers, information exchanges and IT developers until December 31, 2022, to ensure their applications comply with FHIR R4. That’s easier for large, technically advanced hospital systems than small, non-technical health-care providers.

“This is no judgment at all,” Michael said. “I think everyone realizes there are different degrees of technical skill at different sites that are even submitting the data.”

NCATS, one of the National Institutes of Health, keeps data ingestion basic for non-technical organizations by using a secure file transfer protocol, but that takes some five minutes to complete and others the entire day, he added.

The agency continues to tout the benefits of FHIR R4 as a research tool, because it holds more data, with the hope of convincing more partners submitting data to quickly adopt the standard.

Other Department of Health and Human Services agencies like the Centers for Medicare & Medicaid Services, as well as the Department of Veterans Affairs, are all-in on FHIR standards and have teams working toward implementation. But in the case of the VA, the department is currently more focused on improving data quality between its two electronic health records: VistA and Cerner Millennium, said Chief Data Officer Kshemendra Paul.

“Yes, we have to push on standards really hard but that’s a long-lead-time activity, and we need to create the space to do that by dealing with the dirty, messy work of data management across legacy systems,” Paul said. “That’s kind of what eats my lunch and where I’m focused more than the standards, not because it’s not important, but because I’ve got to create space, and I think that’s probably a pattern that exists in other places.”

The COVID-19 pandemic revealed the “terrible” quality of medical data in many cases due to a lack of standards or following those that did exist, Michael said.

NCATS, like much of HHS, undertook a successful effort to harmonize data to standards by adopting the Observational Medical Outcomes Partnership (OMOP) Common Data Model many hospitals were providing COVID-19 data in, but increasing cloud connectivity has enabled the transition to FHIR.

“The data movement problem has gotten easier in some regards,” Michael said. “I want to say there are still a lot of challenges with that, but I think the ability for us to really adopt standards at an enterprise level, a national level, a global level really has gotten much greater.”

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In a wide-ranging report published Tuesday, the watchdog found that the department failed to sufficiently monitor the accessibility, accuracy and appropriateness of clinical information as it was transferred in segments from one system to another.

GAO recommended that the department establish performance measures for migrated data and that it use a stakeholder register.

“Although VA performed data testing activities identified in its plans, the department did not ensure that the quality of data migrated to the new EHR system sufficiently met clinicians’ quality needs,” GAO said in the report. In some interviews conducted by the watchdog, clinicians reported being unable to access patient information such as allergies, medications and immunizations, and also reported data errors.

The concerns were raised in relation to a staging environment used as data was transferred from the VA’s National Data Center in Austin, Texas, to a data center operated by contractor Cerner in Kansas City, Missouri. GAO’s performance audit was conducted over the period August 2019 to February 2022.

A greater-than-required volume of certain patient data, such as medication data, was also selected for initial migration, according to the watchdog. It found also that while VA implemented a feedback system to address concerns, it did not use a stakeholder register to help identify and engage all relevant stakeholders for reporting continuity.

“A stakeholder register is intended to help identify and engage all relevant stakeholders. Until VA uses such a tool, the department risks overlooking EHRM stakeholder needs for reporting on patient care, operations, and research functions,” the watchdog said.

The Office of Management and Budget’s Federal Data Strategy highlights the importance of validating data quality, including their accessibility, accuracy and appropriateness.

The new findings come after sustained criticism from lawmakers late last year following the department’s decision to push ahead with the rollout of the EHR platform at a new location despite safety concerns from frontline staff.

Last month, the VA announced a further delay to the rollout of the program, citing surging COVID-19 cases at its medical network in central Ohio. The system will now go live at the location April 30 instead of the previously set date of March 5.

Cerner’s Millennium platform and Cerner HealtheIntent cloud platform form the backbone of VA’s health records modernization strategy, which relies on transferring patient data off the VA’s legacy Veterans Health Information Systems and Technology Architecture (VistA).

In a statement, VA said that it concurred with the recommendations in GAO’s report: “The Electronic Health Record Modernization (EHRM) Integration Office will establish and use performance measures and goals, aligned with and integrated into the VA Data Strategy, to ensure the quality of migrated data meets stakeholder needs for accessibility, accuracy and appropriateness prior to future system deployments.

“This aspect of EHRM will meet enterprise data quality and reliability standards. The EHRM Integration Office will also use a stakeholder register to improve the identification and engagement of all relevant EHRM stakeholders and address their reporting needs,” the agency added.

In a statement, general manager of Cerner Government Services Brian Sandager said: “Supporting the VA in its efforts to provide veterans with safe, effective, holistic care is our top priority.” He added: “We are committed to working with our VA partners to quickly identify and aggressively address any concerns, as they implement a new electronic health record system that will give veterans and their providers a single record to support a lifetime of seamless care.”

Editor’s note: This story was updated to include additional comment from VA and Cerner.

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The VA issued a request for information Wednesday in search of a managed RPA tool to “streamline the flow of external clinical document sets” into its EHR systems — both the existing Veterans Health Information Systems and Technology Architecture (VistA) and the forthcoming Cerner Millenium-based modernized platform it is planning to roll out in the near future.

This is particularly important as the VA since 2014 has allowed veterans to seek care outside of its facilities under the Veterans Access, Choice and Accountability Act. When that happens, those non-VA facilities generate records and send them, often as paper copies, to the VA to be integrated digitally with a veteran’s electronic health record.

Such a tool would “help eliminate backlog, reduce the number of manual scanning/indexing tasks, and increase quality and quantitative traceability with both VA’s existing VistA and newest Cerner Millennium platforms,” the RFI says. The VA inspector general reported last year that the department’s backlog of health records awaiting digitization “measured approximately 5.15 miles high and contained at least 597,000 individual electronic document files dating back to October 2016.”

Likewise, as veteran care in the community increases even more under the 2018 MISSION Act, “the automation solution must be scalable to satisfy new and increased workloads, throughput, and digital exchange capacities,” the RFI says.

The VA included some must-haves for a potential solution: automated scanning that can link documents to a veteran’s EHR, a flagging system that alerts any issues in automated processing, and the delivery of metrics. The tool should also be able to access medical documentation from a variety of sources, including an internal shared VA folder, email, electronic fax, paper, electronic exchange, and via API in the HealthShare Referral Management platform.

For now, VA medical facilities continue to use VistA as their primary EHR system. But soon, the VA will roll out the modernized Cerner platform at hospitals, starting in the Pacific Northwest. The department had planned the launch for March, before delaying the go-live until July due to a need for more training. But since the coronavirus struck, the VA has put the launch on pause indefinitely to prioritize resources for pandemic response.

The modernized EHR will cost the VA more than $16 billion and take a decade to roll-out

The VA is asking interested vendors to pitch RPA solutions by July 30.

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