Two new reports from the VA Office of Inspector General (OIG) highlighted some potential patient safety risks from the transition to the new EHR system at the Mann-Grandstaff VA Medical Center in Spokane, Wash., as well as some deficiencies in infrastructure readiness for deploying the new system.
On May 17, 2018, the VA signed a $10 billion contract with the Cerner Corp. to transition to a new EHR system. The transition is one of VA’s top priorities and scheduled to occur over a 10-year period, beginning in the Pacific Northwest in 2020. Eventually, the new system will be implemented to VA’s 174 medical centers and 1,577 standalone sites. The OIG focused its review on the new EHR system’s implementation at the facility to evaluate the potential impact of the transition on access to care, as well as the capabilities that will be initially available.
Mann-Grandstaff was scheduled to be the first Veterans Health Administration (VHA) medical center to implement the new EHR system with an initial go-live date of March 28, 2020. On February 10, the facility’s go-live date was postponed.
The OIG said that Mann-Grandstaff VA leaders consulted with Department of Defense colleagues who had transitioned to the Cerner system in 2017 and experienced a 30 percent decrease in productivity 18 months following their transition. As a result, facility leaders used a 30 percent decrease in productivity over a 12- to 24-month period to generate a plan to mitigate the impact of the transition. The facility plan included adding staff, enhancing clinical space, changing clinic processes, and increasing the use of community care.
Facility leaders also worked with central VA health IT transformation groups to generate mitigation strategies to prepare for decreased capabilities. The OIG determined that, at the initially planned go-live date, facility staff and administrators would enact as many as 84 distinct mitigations for the 62 systems that were determined to be either at moderate or high risk for being unavailable.
The OIG determined that the multiple work-arounds needed to address the removal of an online prescription refill process presents a patient safety risk. Although the facility’s initial go-live date has been postponed, the OIG determined that going live at a later date with decreased capabilities and the need to employ necessary mitigation strategies still presents a significant risk to patient safety beyond the inherent risk of deployment of an EHR system.
The OIG made a series of recommendations to the Under Secretary for Health related to the impact of the new EHR system implementation on productivity and the provision of operational guidance and required resources to facilities prior to going live; identification of the impact of the mitigation strategies on user and patient experience when going live; and a reevaluation of the EHR modernization deployment timeline to minimize the number of required mitigation strategies when going live.
In the report on infrastructure readiness, the OIG noted that in addition to the almost $10 billion contract, the VA estimates another $6.1 billion will be needed for program management and infrastructure-related costs. In preparation for the new system’s deployment at VA healthcare facilities, significant upgrades are needed to VA’s physical and IT infrastructure.
The objective of this audit was to determine whether VA’s infrastructure-readiness activities were on schedule to facilitate the electronic health record modernization initiative, starting with the previously scheduled deployment of the new system on March 28, 2020, at the initial operating capability site—the Mann-Grandstaff VA Medical Center. Specifically, the audit team examined the state of physical and IT infrastructure to determine VA’s readiness to proceed with system implementation and to identify infrastructure challenges that could impact the overall system deployment schedule.
OIG noted that when the DoD implemented MHS GENESIS at its initial deployment sites, the department experienced significant setbacks such as an overwhelming number of help desk tickets, loss of initial system connectivity, and a low user adoption rate. This caused the DoD to halt its implementation for two years while they corrected deficiencies and evaluated deployment actions. As a result of this evaluation, among other lessons learned, DoD concluded that infrastructure upgrades should be completed at sites six months before deploying the system to help ensure an efficient and successful system rollout.
VA recognized the need to apply these lessons learned from the DoD experience to help avoid similar setbacks. VA officials have testified before Congress as recently as June 2019 that having infrastructure in place six months before deployment to sites was a program goal. This means that infrastructure readiness should have been completed by September 28, 2019. However, this audit found many deficiencies that increase the risk that VA could repeat DoD’s setbacks and potentially hinder performance when the system goes live. It could also delay the new EHR implementation in VA sites nationwide.
On Feb. 11, 2020, during the audit team’s exit conference held to discuss the results of this audit with VA officials and staff, the VA Office of EHR Modernization executive director stated the March 28, 2020, system deployment date at Mann-Grandstaff VAMC and its associated facilities would be delayed and that the future system deployment date at this site was unknown. Soon after, VA released a new targeted deployment date of July 2020. However, in early April 2020, VA announced this deployment date would also be delayed until an unknown time due to the COVID-19 pandemic. Since notice to postpone system deployment occurred after the audit team conducted its work and an updated deployment date has not yet been announced, throughout this report the team referred to the previously anticipated system deployment date of March 28, 2020.
The OIG found critical physical and IT infrastructure upgrades have not been completed, even as recently as Jan. 8, 2020, at the Mann-Grandstaff VAMC and its associated facilities. “The lack of important upgrades jeopardizes VA’s ability to properly deploy the new electronic health record system and increases risks of delays to the overall schedule. In fact, some infrastructure upgrades needed to help ensure end users do not experience diminished system performance on the deployment date are not projected to be completed until months later,” the report noted. For example, modifications to telecommunications rooms will not be completed until up to four months after VA’s previously scheduled deployment date of March 2020. Until modifications are complete, many aspects of the physical infrastructure existing in the telecommunications rooms (such as cabling) and data center do not meet national industry standards or VA’s internal requirements.
Infrastructure upgrades were not completed at the Mann-Grandstaff VAMC in a timely manner to properly prepare for deployment of the new health record system primarily because VA lacked:
• Initial comprehensive site assessments that included physical infrastructure to determinea realistic go-live date,
• Requisite specifications for infrastructure,
• Appropriate monitoring mechanisms, and
• Adequate staffing.
The audit team also found that, while not directly affecting system deployment, there were security vulnerabilities with some of the physical infrastructure at the Mann-Grandstaff VAMC.
The OIG report states that the VA committed to an aggressive, but likely unrealistic, deployment date of March 2020 without having the necessary information on the state of the medical center’s infrastructure.
The audit team made several recommendations, including the following:
• Establish an infrastructure-readiness schedule for future deployment sites that incorporates lessons learned from DoD.
• Reassess the enterprise-wide deployment schedule to ensure projected milestones are realistic and achievable, considering the time needed for facilities to complete infrastructure upgrades.
• Implement tools to comprehensively monitor the status and progress of medical devices at the enterprise level.
• Standardize infrastructure requirements in conjunction with VHA and the OIT and ensure those requirements are disseminated to all necessary staff.
• Evaluate physical infrastructure for consistency with OEHRM requirements and monitor completion of those evaluations.
• Fill infrastructure-readiness team vacancies until optimal staffing levels are attained.
• Ensure physical security assessments are completed and addressed at future electronic health record deployment sites.
• The final recommendation calls on the Mann-Grandstaff VAMC director to ensure all access points to physical infrastructure are secured and inaccessible to unauthorized individuals.