Severe staffing shortages, infighting and lack of comprehensive planning for infrastructure improvements would have handicapped the multibillion-dollar project, the inspector general said.
The Veterans Affairs Department opted to delay the launch of the first instance of its new electronic health records system while the agency finished developing key functionality. However, even with those capabilities in place, the rollout likely would have been plagued by serious infrastructure problems, according to a report from the VA inspector general.
The VA initially planned to have significant infrastructure upgrades at the initial launch site—Mann-Grandstaff VA Medical Center in Spokane, Washington—long before the scheduled rollout. But poor organization, infighting and an extreme staffing shortage in the infrastructure-readiness office doomed those plans to failure, the IG wrote.
VA officials first announced in February that the rollout at Mann-Grandstaff would be delayed, later telling Congress the agency planned to launch the new EHR system in July. That deadline has since been pushed further as the VA deals with the ongoing COVID-19 pandemic.
At the time of the first postponement, VA officials told Congress—in letters and in hearings—the reason for delay was the need to build out additional functionalities so that medical center staff were able to train on a full system prior to deployment.
The Defense Department had similar training problems with the first round of deployments, ultimately deciding to completely reengineer the training regimen before starting subsequent rollouts. However, Defense officials also acknowledged issues with insufficient infrastructure at the initial launch sites, prompting the department to shift gears and require full infrastructure upgrades to be completed six months prior to deployment at a given site.
“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,” the IG wrote. “This caused the DoD to halt its implementation for two years while they corrected deficiencies and evaluated deployment actions.”
VA was aware of these hard lessons learned, according to the IG audit, and set a similar requirement to have infrastructure improvements finished at least six months ahead of rollout. For the initial planned launch at Mann-Grandstaff for March 28, that would have made September 28, 2019 the deadline for infrastructure improvements.
The agency fell well short of that goal, the IG reported.
“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,” the report states. “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.”
The IG also found nearly a third of end-user devices—computers, laptops, tablets, smartphones, etc.—had not been upgraded as of October 2019. Once those upgrades are completed, VA will still have to go through an additional vetting process with DOD before being allowed to connect with the latter’s EHR system. According to the IG, those authorizations had not been finalized as of January.
Overall, VA needs to ensure its medical facilities have a sufficient “underlying foundation that supports the system, such as electrical, cabling, as well as heating, ventilation, and air-conditioning,” the report states. “IT infrastructure includes network components such as wide and local area networks, end-user devices (e.g., desktop and laptop computers, and monitors), and medical devices.”
Despite these critical needs, acknowledged by leadership, the program management office—the Office of Electronic Health Record Modernization—has not been properly staffed, the IG said.
“As of November 2019, four of six staff positions on the infrastructure-readiness team were still unfilled, and the infrastructure-readiness director position was vacant until filled in August 2019, or approximately two months before VA’s goal of having infrastructure upgrades complete six months before the go-live date,” the report states.
Auditors noted the particular importance of the infrastructure-readiness director position: “Without this dedicated position being filled early in the infrastructure planning process, VA would be less likely to spot potential issues stemming from deficient infrastructure.”
All of these issues led to significant delays. For example, as of November 1, the Veterans Health Agency—one of three offices leading the project, along with OEHRM and the Office of Information and Technology—had yet to sign off on a critical document establishing requirements and standards.
“Disagreements between OEHRM and VHA leaders, such as those regarding the standard to be used for network cabling requirements, contributed to delays,” the IG added, noting the requirements document “was later signed on November 20, 2019.”
All of these issues combined led the IG to conclude there was no chance VA would be able finish infrastructure upgrades ahead of the original March 28 rollout date.
“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 IG wrote.
Auditors were able to distill the issues into four primary problems. According to the report, VA lacked: “Initial comprehensive site assessments that included physical infrastructure to determine a realistic go-live date; requisite specifications for infrastructure; appropriate monitoring mechanisms; and adequate staffing.”
Ultimately, the IG determined that deploying the Cerner systems at Mann-Grandstaff by the original target date—March 28—would have meant going live without sufficient supporting infrastructure.
“Deficient infrastructure for the deployment of the new electronic health record system has increased the likelihood VA will experience similar setbacks as DoD when it initially deployed its electronic health record system,” auditors concluded. “In addition, failing to have infrastructure ready for the go-live event reduces VA’s ability to adequately identify and resolve any issues before deploying the system at future sites, which can lead to VA experiencing additional delays. Those delays, if realized, may result in additional costs to continue supporting VistA, as well as increased costs for temporary solutions.”
The IG made eight recommendations—seven for the OEHRM executive director and one for the director of the Mann-Grandstaff Medical Center.
The OEHRM executive director should:
- Establish an infrastructure-readiness schedule for future deployment sites that incorporates lessons learned from DOD.
- Reassess the enterprisewide 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 Mann-Grandstaff VAMC director should ensure all access points to physical infrastructure are secured and inaccessible to unauthorized individuals.
The program management office and medical center leadership concurred with all of the IG’s recommendations.