By Jeffrey H. Brochin, J.D.
In transitioning from their 30-year-old health records system to a new commercial EHR system, the VA included a wide range of stakeholders from various regions; however, the VA did not always effectively communicate information to those stakeholders.
The U.S. Government Accountability Office (GAO) has issued its report to Congress on its audit of the Veteran’s Administration’s (VA’s) transition from their existing Veterans Health Information Systems and Technology Architecture (VistA) health records system to the new commercial system used by the Department of Defense (DOD). In making design configuration decisions, the VA had to assess the compatibility of the electronic health records (EHR) system with the processes clinicians and staff use to deliver care. However, despite the involvement such clinicians, staff, and other experts in various clinical areas, the audit noted the need for greater ongoing involvement of the various stakeholders in the modernization effort (GAO Report, GAO-20-473, June 5, 2020).
Why GAO conducted the study. In operating one of the nation’s largest health care systems, serving more than 6 million patients annually, the VA has relied on its VistA program to document the delivery of health care services to veterans. However, in its prior work, the GAO found that technically complex system, which has been in operation for more than 30 years, costly to maintain and did not fully support the VA’s need to electronically exchange health records with other organizations, such as the DOD and private health care providers. Furthermore, the customization of the system by VA medical facilities has resulted in approximately 130 versions of VistA across the VA health care system, raising questions about the consistency of the information collected.
Consequently, the VA has undertaken a modernization effort to replace VistA with a commercial EHR system, developed by Cerner Government Services, Inc., (Cerner)—a configuration of the same system the DOD is implementing. However, before transitioning from VistA to the commercial EHR system, the VA had to make design configuration decisions—such as, determining all the data that need to be incorporated into the EHR system—and they established 18 EHR councils in an effort to develop clinical workflows, design decision matrices, and data collection workbooks
How the study was conducted. In response to Congress’ request, the GAO reviewed the VA’s Electronic Health Record Modernization (EHRM) program’s process towards making decisions for configuring the new EHR system. To accomplish that task, the GAO focused on ongoing efforts to implement the new EHR system at the two medical centers where the VA plans to implement the commercial EHR system: Mann-Grandstaff VA Medical Center in Spokane, Washington, and VA Puget Sound Health Care System.
Specifically, the GAO examined how the VA made EHR system configuration decisions and assessed the compatibility of the Cerner EHR system with the work processes that medical facilities follow; they evaluated the extent to which the VA met its schedule for making EHR system configuration decisions; and they assessed the effectiveness of the VA’s system configuration decision-making procedures, including the extent to which the VA ensured that key stakeholders were involved.
As part of the study, the GAO reviewed available documentation on the process the VA developed to make system configuration decisions including establishing 18 EHR councils responsible for developing clinical workflows, design decision matrices, and data collection workbooks. The GAO also examined how configuration decisions may vary between VA medical facilities, and reviewed assessments performed by the VA’s EHR councils to determine the compatibility of the commercial EHR system with the work processes the VA medical facilities follow and efforts to address any incompatibilities.
What the study found. The GAO study found that the VA used a multi-step process to help ensure that its future commercial EHR system was configured appropriately for, and would be compatible with, its clinical work processes. The VA held eight national workshops between November 2018 and October 2019, at which the councils decided how to design the functionality of the EHR software to help clinicians and other staff deliver care and complete tasks such as administering medication. The VA also held eight local workshops at both Washington medical centers to help ensure that the EHR configuration supported local practices. As of March 2020, the EHR councils were continuing to meet to complete configuration decisions. Furthermore, the VA has plans to hold local workshops in advance of the EHR system implementation at future VA medical facilities.
Although the VA’s decision-making procedures were generally effective as demonstrated by adherence to applicable federal internal control standards for establishing structure, responsibility, and authority, and communicating internally and externally, the VA did not always ensure key stakeholder involvement. Specifically, the councils included a wide range of stakeholders from various geographic regions but, according to clinicians from the two initial medical facilities for implementation, the VA did not always effectively communicate information to stakeholders, including medical facility clinicians and staff to ensure relevant representation at local workshop meetings. As a result, local workshops did not always include all relevant stakeholders.
What the GAO recommends. The GAO study recommended that the VA ensure the involvement of all relevant medical facility stakeholders in the EHR system configuration decision process; and, that for implementation of the EHR system at future VA medical facilities, the Secretary of the VA direct the EHRM Executive Director to clarify terminology and include adequate detail in descriptions of local workshop sessions to facilitate the participation of all relevant stakeholders including medical facility clinicians and staff. The VA concurred with GAO’s recommendation.
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