Both witnesses and lawmakers agreed that the Oracle Cerner EHR system at its current state is not satisfactory—but disagreed over how to fix it.
The Department of Veterans Affairs’ Electronic Health Records’ pharmacy component continues to face surmounting issues affecting veterans at the facilities using the Oracle Cerner EHR system.
Lawmakers on the House Committee on Veterans’ Affairs’ Subcommittee on Technology Modernization pressed witnesses at a hearing Tuesday about EHR modernization and the problems the new system is causing for pharmacies and veterans.
“Pharmacy is crucial to veterans’ health and well being and unfortunately, it’s one of the most error-ridden and dangerous parts of the system,” Subcommittee Chairman Matt Rosendale, R-Mont., said in his opening remarks, calling the program “dysfunctional.”
Facilities have faced issues with prescription orders not being filled either at all or on time, double orders, incorrect prescriptions, troubles with refills, needing to manually check for drug interaction and allergy information and long prescription processing times, among other things. There has also been an increase in patient safety reports and multiple events of patient harm, with the system contributing to the deaths of several veterans.
The Oracle Cerner EHR system has been implemented at five out of 171 VA facilities, though the agency has paused rollouts due to ongoing concerns. Rosendale called it “outrageous and dangerous” that pharmacists in each of these locations—Spokane and Walla Walla, Washington; Roseburg and White City, Oregon; and Columbus, Ohio— must be “in a constant state of hypervigilance,” that they cannot trust the system and continue to discover new problems each week.
According to Rosendale, facilities using the Oracle Cerner system have had to increase staff to perform the same workload. For example, the Columbus Medical Center has a pharmacist solely managing Cerner help desk tickets, and the facility added a management position to handle the EHR. Moreover, the Spokane, Walla Walla and Columbus medical centers have a $9 million deficit because of increased staffing costs, and fewer copays and collections.
While Rosendale applauded VA leadership for recognizing that the Oracle Cerner EHR is not working as-is—and he showed support for the delay and reset of the program—he noted, “we expect the VA pharmacist to give our veterans world class service and we owe them fully functional technology to do that.”
Witnesses were unable to provide a concrete deadline of when the delay would end, but noted it was when they were confident the EHR was highly functional.
“The new electronic health record is not meeting our expectations and VA is electing to take the time to get things right,” said Dr. Neil Evans, acting program executive director of the Electronic Health Record Modernization Integration Office.
According to Evans, the issues with the pharmacy component of the EHR are related to select aspects of the application called Med(ication) Manager Retail and its interaction with core Cerner software. Evans asserted that Oracle is working on improvements to address this.
“Overall, the system performance has significantly improved from where it was last summer,” Mike Sicilia, executive vice president of Oracle Global Industries, said.
Sicilia added that of the seven prioritized projects, three have been deployed and four will be deployed by early 2024.
“It’s early in the pharmacy process to judge as to whether or not the end product is not so good,” he said. “I’m not surprised to hear that right now. People don’t like it because it’s not complete. It’s not finished.”
But these changes do not address other issues with the system, according to VA officials. Thomas Emmendorfer, executive director of the Pharmacy Benefits Management Services at the VA said that it takes three times as long to process a prescription using Cerner software.
However, he noted that Cerner would provide value through features like a perpetual inventory system.
Evans and others stated that workflows would also need to be adapted to the new system. While several witnesses attributed the slow processing to staff having to adjust workflows, lawmakers generally disagreed with that assessment.
While praising VA’s healthcare staff, Rosendale gave an analogy of the old and new EHR systems to cutting wood.
“If you’re given new tools, somebody comes out and gives you a chainsaw and you’re a lumberjack and he doesn’t give you any gas, you’re better off using the handsaw that you used to have. You’ll actually be able to cut more wood than to sit there and try and make that chain drag across the log,” Rosendale said.
According to several witnesses, another challenge to the system is that, unlike a traditional pharmacy, the VA serves as both the ordering party and the pharmacy fulfilling prescriptions. As a result, the system must seamlessly work with both of these needs, which is creating challenges.
“The EHR needs to support the supplying components to fill prescriptions,” Sicilia said. “This fundamental difference is the reason that pharmacy enhancements were needed to tighten the integration between the outpatient pharmacy application and the provider ordering application.”
Evans asserted that the Oracle Cerner pharmacy and EHR would be fully functional before restarting a go-live. He noted that the system must work for the three stakeholders: the ordering party, the pharmacist/pharmacy staff processing the prescription, and the veteran receiving the prescription.
Ranking member Sheila Cherfilus-McCormick, D-Fla., questioned witnesses about a lack of a baseline Cerner EHR, noting that constant changes are negatively impacting staff.
Over the course of the new EHR’s rollout, there have been 79 business requirement change requests, but in 2.5 years, only six have been completed—something lawmakers deemed unacceptable.
Carol Harris, director of information technology and cybersecurity at the Government Accountability Office, said that the VA has had challenges to “effectively manage organizational change” and faces “extreme dissatisfaction among users and systems issues.”
Harris recommended that the VA create an agency-driven change management strategy based on best practices, instead of relying on a contractor-led change management; establish goals to assess user satisfaction; and conduct an independent operational assessment of the EHR system.
“The successful implementation of the new system across VA will require a level of program management, adaptability to change and sustained system performance that the department and contractor have yet to demonstrate,” Harris said.
She stated that in VA’s post-deployment questionnaires—which rate satisfaction on a scale of zero to 100, with 68 being average—users rated their ability to use the new system between 23 and 32. In the VA’s 2021 and 2022 user satisfaction survey, “about 6% of users agreed that the system enabled quality care and roughly 4% of users agreed that the system made them as efficient as possible,” Harris added.
“I’ve been auditing for over 20 years now across the federal government. These are the lowest scores that I have seen in government hands down,” Harris said.