Roll-out Remains on Hold Elsewhere; Legislators Concerned
Walla-Walla, WA VAMC
WASHINGTON, DC — As VA approaches the 3-year anniversary of the Cerner electronic health record system going live at its first site, the roll-out remains on indefinite hold as the department endeavors to fix problems at the five facilities where the system is active.
Currently, those facilities are working at a lower capacity, spending more money and sometimes hiring more staff because of difficulties caused by the HER, according to reports. In at least two of the facilities, clinicians are said to be hesitant to use certain modules because of fear the EHR could result in deadly medication errors.
While VA leaders and administrators at the affected facilities have testified to Congress that they believe the situation is improving, many legislators remain unconvinced that the Cerner EHR should not be scrapped entirely and those five sites rolled back to using the previous legacy system.
Testifying at a House VA Committee hearing last month were facility leaders from the Spokane, WA, Walla-Walla, WA, Roseburg, OR, and Columbus, OH, VAMCs—4 of the 5 areas where the Cerner EHR is currently in use. The system also has been rolled out in the Southern Oregon VA Healthcare System, which is based in White City. While their testimony differed in detail, the broad strokes were the same: Some problems have been fixed, but many remain; productivity remains diminished; and staff are still relying on time-consuming workarounds to use a system that was not designed with the needs of VA in mind.
“The training our staff initially received from Cerner was not what we expected,” explained Thandiwe Nelson-Brooks, associate director at Roseburg. “It did not adequately prepare staff to function effectively and efficiently with the medical record systems. In addition, there were specific things that were not included in the medical record to take into account the complexities of the care that VA delivers. Cerner is a commercial off-the-shelf product, not designed for VA. It does not take into account specific programs like caregiver support or our homeless program and other programs along those lines.”
Those deficiencies have had a demoralizing effect on many clinicians, who not only have to navigate it but deal with the mistakes that it can perpetuate.
“Imagine being a doctor in Columbus and receiving a critical message about a patient you’ve never seen who’s admitted to a Department of Defense site thousands of miles away because his provider has a similar name,” said Meredith Arensman, MD, chief of staff at the Columbus VAMC. “Imagine being an optometrist and finding an eyeglass prescription that has your signature that you know you never signed. Imagine being a social worker and being unable to print a transfer summary for a patient who is decompensating and needs a higher level of care. These are not possibilities. It has been the reality of our team in Columbus.”
In Spokane and Walla Walla, there was some word of improvement over time.
“We’re recovering toward our pre-Cerner productivity, but we’re still not as efficient,” explained Scott Kelter, director of the Walla Walla VAMC. “We’ve added a modest number of permanent staff (4%) to meet the demands of the Cerner platform, including nurses, pharmacy staff, charge analysts and an additional patient safety manager. VA-delivered care remains at 80% of pre-Cerner levels, but the number of Cerner-related patient safety reports have declined by 73% from the initial spike immediately after go-live.”
In Spokane, which has had three years to adapt to the new system, they have added 20% more staff, including adding 15% more clinical providers and tripling their informatics staff, explained Robert Fischer, MD, director of the Mann-Grandstaff VAMC.
“We’re at 70% of efficiency prior to go-live,” Fischer said. “But a year ago we were at 50%, so we’re seeing incremental improvements. We’ve told our staff to move at the speed of safety.”
Reluctance to Use EHR
In some areas, staff are reluctant to use the EHR at all. Cerner’s oncology module, installed at Spokane and Columbus, includes a PowerPlan care-planning tool that allows physicians to manage orders. For chemotherapy patients, those orders can be complex, and delicate, and the stakes can be high if any errors are made.
“We have a very experienced medical oncologist in Spokane, and he is very reluctant to utilize multiagent chemotherapy currently,” testified Fischer. “He would like to test those PowerPlans in production [to] make sure there are no medication errors. Because they’re lethal with the use of these very significant medications.”
In Columbus, facility leaders have dedicated an oncologist and pharmacist so half of their workday is “essentially editing, correcting and validating PowerPlans,” Arensman said.
Adding more staff to address EHR problems is not a realistic solution for many facilities, including Roseburg, which has a 40% vacancy rate for primary care providers.
“The Roseburg VA is very rural and, as a rural site, we’re challenged with recruitment and retention of staff,” explained Nelson-Brooks. “In addition to that, as a facility, we’ve had turnover in our leadership team. I’m new to Roseburg … and our new medical center director began in April.”
Neil Evans, MD, acting director of the EHRM program, is also new—having been on the job seven months—and currently enjoys the goodwill of Congress, since his remit is essentially to undo the mistakes of the previous 5 years. Facility leaders also have said VA and Cerner have been more active in partnering with ground-level staff since Evans came on board.
Evans testified that many of the mistakes in rolling out the EHR could be laid at the feet of an underappreciation of how complex a job it actually is.
“Replacing the EHR by its very nature forces VA to revisit, reconsider and, where possible, standardize clinical processes and workflows,” he testified. “Electronic health records profoundly impact operations, including how care is delivered in the modern healthcare system; how orders are transmitted into and received by the hospital; how highly complex care is organized in our intensive care units; how surgeries are successfully planned and completed; how prescriptions are ordered and delivered. Getting this right requires a massive team effort across the VA enterprise.”
Many legislators remained skeptical as to whether that is possible and are putting their own timeline in place.
“VA leaders are going to have to make hard decisions they’ve been avoiding,” declared Rep. Mike Bost (R-IL), chairman of the House VA Committee. “Unfortunately, the previous directors of the project have wasted far too much money. VA has spent 50% of the budget and completed 3% of the roll-out. … Congress has been letting VA grade its own test for too long. We were too hands-off at the beginning of this project. … We need to establish clearly what our expectations are.”
Bost, along with other legislators in the House and Senate, are working on a bill that would attempt to address long-standing issues of management and delivery of the EHR roll-out. Along with a number of additional oversight rules, the current draft of the House version of the bill creates a requirement that VA must return its current five sites to a level that meets or exceeds performance baselines based on metrics prior to when the EHR was rolled out.
If VA and Cerner are unable to meet that requirement for all five sites within 180 days of enacting the legislation, the bill directs VA to consider terminating or canceling the department’s current contract with Cerner.