HHS’s Office of the National Coordinator for Health Information Technology (ONC), which released the draft Wednesday, establishes the following four goals: “promote health and wellness, enhance the delivery and experience of care, accelerate research and innovation and connect the health system with health data.” ONC said in a press release that it collaborated on the plan with 25 federal agencies that interact with health IT through purchasing, developing and regulating in order to improve health outcomes.

Among the overarching goals, the agency emphasized the need for a focus on “the policy and technology components needed to support” health IT users in connecting the system with data. 

Significantly, ONC states that the federal government plans to encourage “education, outreach and transparency” about artificial intelligence use so that both individuals and health care providers are informed about the performance and privacy practices of the technology. 

“The role of health IT and readily available access to health data have become increasingly essential to the administration of public health activities,” Jim Jirjis, director of the Centers for Disease Control and Prevention’s data policy and standards division, said in the release. “CDC appreciates how the draft 2024-2030 Federal Health IT Strategic Plan addresses the need to continue to advance the nation’s public health data infrastructure, while making sure that it is benefiting the communities that need it most.”

Additionally, Meg Marshall, director of informatics regulatory affairs at the Veterans Health Administration, said in the release that the VA is also seeking comments “so that veterans too can benefit from the goals of a coordinated federal health IT strategy.”

Marshall’s  statement follows a litany of problems with the VA’s Oracle Cerner-run electronic health record, including patient safety issues with EHR pharmacy software and a watchdog report about a veteran’s death tied to a scheduling error. The system was originally launched in 2020, in an effort to “establish interoperability of records between the VA and [Department of Defense] health care systems”.” EHR was later suspended in 2023 as part of a reset, and the department noted that it was working toward holding Oracle Cerner accountable for delivering high-quality services.

Marshall said in the statement that as the VA works to modernize its EHR system, ONC’s draft plan “provides direction towards a seamless health care experience” for patients and providers. 

“Not only that, the draft Federal Health IT Strategic Plan serves as an actionable roadmap for the federal government to align and coordinate health IT efforts in a transparent and accountable manner,” Marshall said.

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Testifying at a House Veterans’ Affairs Subcommittee on Technology Modernization hearing, VA Deputy Inspector General David Case said an upcoming OIG report will highlight “unresolved, insufficiently communicated pharmacy-related patient safety issues.” 

While the VA fixed issues tied to inaccurate medication information that was input to its Health Data Repository, OIG found that Oracle and the VA’s Electronic Health Record Modernization Integration Office “did not test for medication and allergy data accuracy after that information was transmitted” to the repository from new EHR sites. 

“As of September 2023, there have been approximately 250,000 veterans who either received medication orders and/or had medication allergies documented in the new EHR,” Case said. “They may be unaware of the potential risk for a medication or allergy-related event if they visit a legacy EHR site.”

In response to questions from Subcommittee Chair Matt Rosendale, R-Mont., Case noted that if a medication check is based on wrong information listed in electronic health records, then a patient could be prescribed something that results in side effects or is ineffective. 

Rosendale pressed Mike Sicilia, executive vice president at Oracle, on why the contractor hasn’t corrected every coding error associated with the Health Data Repository. Sicilia said that during the testing of enhancements to the system, “another issue” surfaced and Oracle made the decision to “not roll out anything that did not pass all final safety checks.” The Oracle team fixed the issue Wednesday and was set to resume testing Thursday. 

“So in other words, we’re still working on the same problem that you’re trying to tell me that was resolved last year,” Rosendale said.

The OIG findings on lingering issues with the VA’s EHRM program come less than a month before a critical test of the system is set to begin with the March 9 opening of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois. 

The Lovell center — the first fully integrated VA and Department of Defense joint health care system — will include the deployment of the EHRM program that was paused in April 2023 following myriad problems associated with the system’s rollout earlier that year.

Neil Evans, acting program executive director for the VA’s EHRM Integration Office, said the Lovell health system was exempted from the deployment pause given the “deep interdependencies” between the Department of Defense and VA health care systems. The DOD, Evans said, “has been able to successfully deploy the record across the rest of their enterprise health care system.”

“One of the three primary goals of the reset was to put our focus on” Lovell, Evans said. “We’ve been working to improve the system and do the enterprise work that we need to be able to successfully move forward with this program. But we’ve also been able to put a significant amount of attention on [the Federal Health Care Center] and we will benefit from the DOD’s experience in support of all of our users.”

Evans confirmed that the “core system” of the Defense Department’s EHR is the same as the VA’s, though some of the workflows are different. Pharmacy benefits are different in the VA compared with the DOD, Evans noted, but “having a single record will be important.”

Sicilia said the providers and pharmacists at the new facility will be ready to use the EHR system “with the current enhancements” once the doors open in North Chicago next month. A visit last week from the VA and Oracle team to provide training to those clinicians yielded positive feedback and “readiness for using the new pharmacy system,” he added.

“We are anxious to evaluate the deployment and get feedback from the pharmacists at Lovell,” Sicilia said. “It will provide valuable insight, along with the continued review with the feedback from other live sites for other enhancements that may be required as we seek to continually improve the system. Oracle looks forward to continuing to provide VA with a pharmacy module in the new EHR that enables veterans to receive their medication when they need it, and safely.”

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“Overall we still think there’s a ways to go. I don’t want to present the system as all set and ready to go,” Kurt DelBene, the VA’s chief information officer, said during a House Committee on Veterans’ Affairs hearing on the implementation of the VA’s EHRM initiative with Oracle Cerner. 

Oracle Cerner did not send a representative to the hearing despite being invited to.

“There are places we have significant concerns that we’re working with Oracle on: the incident-free time, not hitting standards is important, the end user responsiveness we think still has a ways to go, we think there are still functional workflow issues that still have to be resolved,” DelBene added.

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.

Multiple members of Congress expressed 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. 

“[Oracle] training and change management are still woefully inadequate and user satisfaction is still critically low,” said Rep. Sheila Cherfilus-McCormick, D-Fla., the ranking member of the House Veterans’ Affairs Subcommittee on Technology Modernization. 

“I’m disappointed that Oracle Health isn’t here to participate in this conversation. I would like to stress that they are not present with us today. The fact that they didn’t send a representative raises major concerns for me and I expect better. I’m constantly losing faith in the process,” said Cherfilus-McCormick.

VA Secretary Denis McDonough will next year make the final decision regarding the exact timing of the continuation of the EHR rollout.

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

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“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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The department’s IG received an allegation that Oracle Cerner had submitted invoices for approximately $5.8 million between October 2019 and March 2020 with progress reports on deliverables that were not adequately detailed.

While the IG wasn’t able to substantiate those claims, it did report that the VA’s timeline for working with Oracle Cerner to correct issues with insufficient progress reports connected to invoices wasn’t adequate and could be improved.

“The complainant reported being told the progress report was just ‘a cover page, there’s an agenda, there’s six empty pages, there’s an ending. That’s what they turned in to get paid for this deliverable,’” the VA OIG management advisory memorandum issued Wednesday said.

The IG found there was actually detailed information in the progress reports, so it didn’t substantiate the allegation. However, the watchdog did conclude that “VA lacked timelines for when contractors needed to provide corrections to insufficient progress reports,” and therefore “the delays observed for contractors’ corrections to progress reports could limit VA’s ability to promptly and accurately monitor contractors’ progress on particular tasks.”

For 18 of the 48 Cerner progress reports reviewed by the IG, the VA required Oracle Cerner to resubmit the report with corrections, to which Cerner complied. But because there was no timeline in place, it impacted the VA’s ability to properly manage actions from the multiple and ongoing reports.

The IG requested that the VA inform it regarding what actions, if any, it plans to take to strengthen the deliverable review process in future contract requirements.

The VA’s EHR modernization office concurred with the information in the memorandum and had no additional comments. In addition, the VA’s Office of Information and Technology agreed with the memorandum without comment.

Veterans Affairs CIO Kurt DelBene told FedScoop last month that he is “cautiously optimistic” that Oracle Cerner can turn around EHR modernization after years of grave performance issues since it was rolled out in October 2020, including repeated outages that, according to the agency’s watchdog, have resulted in serious harm to veterans.

In May, the department announced it had reached a revised contract agreement with Oracle Cerner that it said “dramatically increases” the government’s ability to hold the contractor accountable for reliability, responsiveness and interoperability.

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“I guess I’d say I’m cautiously optimistic,” DelBene told FedScoop on an episode of the Daily Scoop Podcast this week.

DelBene reasoned that the schedule the VA took in its initial attempt at rolling out the $16 billion EHR modernization program was “pretty aggressive” but that the department “learned a ton from the five sites that we’ve deployed to” in terms of the functional usability of the system as well as its resilience and reliability.

The VA in April suspended the rollout of the EHR as part of a major reset, saying it wouldn’t be brought back online until it is “highly functioning.” Then in May, the department announced it had reached a new agreement with Oracle Cerner — the contractor that is developing and delivering the EHR platform — that it said “dramatically increases” the government’s ability to hold the contractor accountable for reliability, responsiveness and interoperability.

“I feel good about the fact that we have taken a pause, that we have very concrete requirements, a number of them are actually put into the update to the contract. So we now have lots and lots of SLA, or service level agreement, dimensions that are actually spelled out with penalties,” DelBene said.

DelBene, a former senior executive with Microsoft, continued: “Coming from the commercial world, I looked at it from the vantage point, if we were the recipient of this contract, how would I feel about … the difficulty of meeting these expectations and how much I’m being held accountable? And I feel very good. We took all dimensions of the performance of the system.”

So why the caution? DelBene understands the reality that this is an extremely complex system the VA and its partner Oracle Cerner are attempting to deliver to clinicians.

“It’s really complex to change your health record system. I think we’ve done the right thing in getting to the pause, getting to criteria to launch again, and I am optimistic,” he said.

The Pentagon’s success in rolling out its modernized EHR, which is based around the same Oracle Cerner platform, gives DelBene hope as well — though it didn’t face quite the same scale and complexity as VA’s system.

“I think that’s a signal that that we can make it work. But there’s been a certain uniqueness and variability of the way healthcare is delivered in the VA. And we’ve had to do more customizations to actually just facilitate how physicians and caregivers work in the VA,” he said.

With those challenges in mind, things are getting better and VA is getting “further along” on the journey to be at a point where it will decide to resume the rollout of the EHR, DelBene said. However, “We’re not going to start our resume from the pause until we feel good about where we’re going next,” he added.

During the wide-ranging conversation with FedScoop, DelBene also discussed how he’s approaching digital transformation within the VA, the changes he’s ushered in in getting IT and cyber professionals better pay, and how he’s thinking about artificial intelligence.

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Language included in the VA appropriations bill provides $1.2 billion for the Oracle Cerner-operated electronic health record contract, as well as $424 million for infrastructure readiness preparations associated with the system. It would also allocate $253 million for program management.

The proposed fresh funding comes amid increasing scrutiny from Congress over the troubled EHR rollout and wider scrutiny of technology procurement at the department. Last month, lawmakers in the Senate introduced a bipartisan bill that seeks to create an oversight board to review major acquisitions by the Department of Veterans Affairs.

Following passage by lawmakers in the House, the Military Construction, Veterans Affairs, and Related Agencies Appropriations Bill now moves forward to be considered by Senate lawmakers after they return from recess.

In its current form, money allocated to the EHR for fiscal 2024 is contingent on the agency providing a quarterly report of obligations, expenditures and the technology deployment schedule to Congress. The initiative will be administered by the Office of the VA Deputy Secretary.

According to the bill, the VA is not expected to request the release of the 25% of funds set aside for fiscal 2023, and it plans to pause new deployments of the system in fiscal 2024. In April, the VA announced that it had stopped all further implementation of the project as part of a major reset. 

In a statement at the time, the agency said that the system would not be brought online at any further locations until it is considered “high functioning” and issues at current locations are resolved.

Within 30 days of the appropriations bill being enacted, lawmakers are seeking a report of each new EHR requirement and customized interface added in fiscal years 2022 and 2023, to establish whether they were outside of the scope of the contract. And within 45 days, lawmakers want a briefing on the department’s plan to set enterprise standards, according to the bill.

Previous legislation also requires the Department of Veterans Affairs to provide Congress with updates on steps the agency has taken to revise and enhance the EHR training program, ensure proper medication management and the accuracy of patient data, and that the system is properly identifying veterans who may be at high risk for suicide. 

In May, the VA struck an agreement with Oracle Cerner to renew the technology giant’s contract for the electronic health record modernization program. In a statement at the time, the agency said the renegotiated contract “dramatically increases” the agency’s ability to hold the company to account.

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Senate Veterans Affairs Committee Chairman Jon Tester, D-Mont., and Ranking Member Jerry Moran, R-Kan., last week introduced the Acquisition Review Board and Cost Assessment Act of 2023. The legislative proposal was introduced on July 20 and has been referred to the full committee.

The bill comes amid continued scrutiny of major procurements undertaken by the agency, including its troubled Electronic Health Record Modernization Program. In May, the VA struck an agreement with IT vendor Oracle Cerner that according to the agency “dramatically increases” the agency’s ability to hold the company to account.

If it passes into law, the new legislation would create an independent oversight board to review major acquisitions early in the agency’s decision-making process, and also if a contract is not in compliance. 

The bill was introduced two days after the VA published a request for information as it seeks to appoint an independent third party to validate that requirements for major IT modernization programs have been correctly defined by the agency.

That RFI came in response to a House bill introduced by Rep. Mark Takano, D-Calif., in May, which directed the VA’s Chief Acquisition Office to enter into a contract for the independent verification and validation of certain modernization efforts at the department.

“The challenges we’ve experienced with the new electronic health record system and other major contracts have made clear we need better oversight of major VA contracts before they’re made. That’s why Senator Moran and I are introducing our bipartisan legislation to establish an acquisitions review board that will help ensure VA is being a good steward of Americans’ taxpayer dollars when it comes to programs that serve veterans,” Sen. Tester said of the new proposals.

Moran added: “This legislation will help ensure that the procurement of goods and services at the Department of Veterans Affairs is carried out responsibly, efficiently and effectively to support veterans and prudently spend taxpayer dollars.”

The VA awards large contracts for products and services to assist in the delivery of health care to more than nine million veterans, distribute benefits to 5.5 million veterans, and operate more than 150 cemeteries. 

VA programs that have experienced significant challenges include the EHR Modernization program, the replacement of VA’s financial and accounting system, and VA’s modernization of its human resources services.

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The Republican chairman and Democratic ranking member of the House Veterans Affairs Committee as well as the top leaders of the Senate Veteran Affairs Committee issued statements of approval.

“We support Secretary McDonough’s decision in the strongest possible terms. The best way to get out of a hole is to stop digging, and we’re encouraged that VA and Oracle Cerner have finally realized that,” House Committee on Veterans’ Affairs Chairman Rep. Mike Bost (R-Ill.), and Subcommittee on Technology Modernization Chairman Rep. Matt Rosendale (R-Mont.) said in a joint statement. 

“I’m pleased that the Secretary is ensuring that no future “go lives” will occur at any new facilities until these issues are addressed,” said House Committee on Veterans’ Affairs Ranking Member Mark Takano (D-CA). He added: “I introduced Senator Tester’s EHR RESET Act to provide accountability for this program as they move forward. This program needs accountability and they must restore the current five sites to normal operating capacity before we even considering future deployments.”

Senate Veteran Affairs Committee Chairman Sen. Jon Tester, D-MT., said also that the reset was a “step in the right direction”. He said: “The EHRM system is simply far too important to the future of our veterans’ health care. That’s why I’ll keep pushing VA to implement these much-needed changes and finalize a new contract with Oracle Cerner that better serves veterans, medical professionals, and taxpayers.”

The agency’s decision to halt implementation of the system comes during contract negotiations between the agency and Oracle Cerner over a potential extension of the initial $10 billion IT modernization contract that was first signed in 2018 but has faced a number of significant challenges and crisis that have harmed veterans in the past few years. 

In its statement announcing the program stoppage, VA said the agency would work with Congress on resource requirements for the modernization program and estimated that costs for fiscal year 2023 will be reduced by $400 million.

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The system will not be brought online at any further locations until it is “highly functioning” and issues at current locations are resolved, according to the VA. No timeline has been set for the continuation of the rollout.

The agency’s decision to halt implementation of the system comes during contract negotiations between the agency and Oracle Cerner over a potential extension of the initial $10 billion IT modernization contract that was signed in 2018 as it nears the end of its base period.

In a briefing call with reporters, VA official Dr. Neil Evans declined to give specific details about ongoing contract negotiations but noted that “everything has been on the table.”

“The original contract was a five-year base period with a five-year option, but everything has been on the table as part of the contract negotiations. I anticipate we’ll be able to share more as we near the end of those negotiations,” Evans said.

He added: “We are working towards an amended contract that will hold Oracle Cerner accountable to delivering the high-functioning, high-reliability EHR system that veterans deserve and will lay the groundwork for our expectations around improvements to the system that we think are necessary.”

In its statement announcing the program stoppage, VA said the agency would work with Congress on resource requirements for the modernization program and estimated that costs for fiscal year 2023 will be reduced by $400 million. 

One exception to the implementation freeze will be at the Captain James A. Lovell Federal Health Care Center in Chicago, which houses the only fully integrated VA and Department of Defense healthcare system. This go-live remains scheduled for March 2024. 

According to the department, system readiness at the five existing locations will be measured by clear improvements in clinician and veteran experience, sustained high performance and high reliability of the system, and improved levels of productivity.

The Oracle Cerner platform is currently in use at Spokane VA Health Care System, VA Walla Walla Health Care, Roseburg VA Health Care System, VA Southern Oregon Health Care, and VA Central Ohio Health Care System.

Commenting on the decision, VA Secretary Denis McDonough said: “We’ve heard from Veterans and VA clinicians that the new electronic health record is not meeting expectations – and we’re holding Oracle Cerner and ourselves accountable to get this right.”

“This reset period will allow us to focus on fixing what’s wrong, listening to those we serve, and laying the foundation for a modern electronic health record that delivers for veterans and clinicians,” McDonough said.

Details of the decision to halt further implementation of the system follow a five-hour incident earlier this week, during which clinicians using the platform experienced latency issues and freezing, according to an internal briefing note. 

“For the past few years, we’ve tried to fix this plane while flying it – and that hasn’t delivered the results that veterans or our staff deserve,” Evans said.

“This reset changes that. We are going to take the time necessary to get this right for veterans and VA clinicians alike, and that means focusing our resources solely on improving the EHR at the sites where it is currently in use, and improving its fit for VA more broadly. In doing so, we will enhance the EHR for both current and future users, paving the way for successful future deployments,” he added.

In a statement, Oracle Global Industries Executive Vice President Mike Sicilia said: “Oracle is proud to continue working together with VA to modernize its Electronic Health Record system.  We support VA’s plan 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, similar to what DoD did a few years ago.”

“DoD’s modernization is now nearly complete, on time and on budget. We will continue to closely coordinate with VA to provide enhancements and updates to the EHR. We appreciate Secretary McDonough’s leadership on this project and reiterate our commitment to providing VA and our nation’s veterans with an EHR that exceeds expectations,” he added.

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