Few VA employees navigate the new EHR easily after training, months of use, auditors say

The Department of Veterans Affairs Inspector General dealt a double-edged blow to the massive effort to modernize VA’s electronic health records this week, detailing both employee training failures with the new system and estimates unreliable IT costs for the entire project.

A small percentage of VA employees at the first commissioning site in Spokane, Wash. Said they could easily use the Cerner Millennium EHR after taking training and using the product for two to three months, the IG said in a new report on Thursday.

And on Wednesday, the IG said VA’s cost estimates for IT infrastructure upgrades needed to support the EHR were unreliable. VA previously told Congress it would need $ 4.3 billion for upgrades to its IT infrastructure.

But the department did not identify an additional $ 2.5 billion in “critical program-related IT infrastructure upgrade costs,” auditors said.

The latest IG report, again, questions the full lifecycle costs of the EHR modernization effort. Auditors said in May that VA underestimated the costs of the physical infrastructure upgrades also needed to support the new EHR. These are potentially worth between $ 3.1 billion and $ 3.7 billion, costs that have never been reported to Congress.

These numbers are estimates, the IG said, because VA does not have a reliable method for reporting infrastructure costs. The VA’s Office of Information and Technology and the Veterans Health Administration are responsible for paying for IT infrastructure upgrades, but the department’s Office of Electronic Health Records Modernization is supposed to report these costs to the Department. Congress.

The role of VHA is “undefined”

The way these three entities – VA OI&T, VHA and OEHRM – interact with each other is in part responsible for the failure of employee training at the department’s first commissioning site in Spokane, the auditors concluded.

The IG said VHA does not have a defined role in the decision-making or oversight associated with the EHR project, even though its clinicians and employees are the primary users of the health record.

The Spokane Facility Manager and Acting VHA Undersecretary, for example, told VA OEHRM that they felt an operational readiness assessment was needed before initial commissioning. .

“In addition, also months before the initial commissioning date, the OIG found that the facility director and the Acting Under-Secretary for Health had raised significant concerns to VA OEHRM management regarding disturbing comments from staff about the insufficient training program, ”the auditors wrote. “With both issues, VHA has encountered resistance from VA OEHRM leaders or has not been included in decision-making discussions with VA OEHRM leaders. The OIG is concerned that not including VHA leaders and end-users of the new EHR in operational decisions may affect the success of the implementation. “

Perhaps this is the reason why training often did not teach employees how to use the EHR to perform specific tasks at the heart of their work.

“School leaders reported that the training did not provide an opportunity to test the skills needed to navigate a wide variety of clinical scenarios; instead, the instruction focused on the multiple steps required to accomplish specific tasks, ”the IG said. “Facility managers coined the term ‘button-ology’ to describe the content of application training because it focused on which button to press to get the desired result out of the system. A facility staff training coordinator said, “They were just people sitting down and learning to use the buttons without having any context for what they were doing.

A “total waste of time”

The auditors described a wide range of issues related to EHR training – and the controls used by VA to measure employee competence with the new system after instruction.

Employees did not have enough time for training exercises, and the platform they used for training did not closely mirror the real, live EHR, auditors said. Cerner classroom trainers often couldn’t answer questions from employees, the IG said.

In the winter months leading up to commissioning, VHA’s “super users” described the training as “a complete waste of time,” and the Spokane installation manager said he was “blown away. By their negativity. The IG said the department as a whole does not have a process to address the concerns of Spokane executives and employees.

Auditors asked VA employees at the Spokane plant about their experiences with the new platform. Only 5% of survey respondents answered yes to all four items, the IG said.

VA OEHRM leaders recognized employee training issues and suggested gaps in Cerner’s training work.

“VA OEHRM Change Management has completed ongoing evaluations of Cerner’s work on training and has identified frequent and recurring deficits in project timeliness, staffing, management and product quality,” said the IG. “Despite the detailed report on the gaps in Cerner’s training work, VA OEHRM contractors rated Cerner’s performance largely as satisfactory, the minimum score to meet contractual requirements. “

Notably, the auditors also expressed concerns about the proficiency check data provided by OEHRM officials to the IG – and at one point, suggesting that VA prepared the books detailing the number of employees who had passed the tests after the training.

“Worryingly, VA OEHRM Change Management executives withheld some training evaluation data requested by the OIG and modified other data before sending it to the OIG,” the report said.

The department told auditors that 89% of VA employees passed their proficiency checks with a score of 80% or more in three attempts or less.

But the IG said it found an earlier version of the VA proficiency check results, which were written but not sent to auditors. These results showed a significantly different result, where 44% of the employees passed their proficiency check with a score of 80% or more, and “27% passed the 1st attempt, 12% passed the 2nd attempt, 5 % succeeded on the 3rd attempt “.

When the auditors asked OEHRM about the differences, VA said they removed the outliers from the data later provided to the IG.

“The integrity and completeness of the information provided by VA is required by law and is essential to the OIG’s mission,” the auditors wrote. “The OIG has notified senior VA executives of this issue and is pursuing the case.”

EHR Strategic Review Results Coming Next Week

Auditors said they submitted findings and recommendations to Carolyn Clancy, acting assistant secretary of VA, and Richard Stone, acting deputy secretary for health, in May, expecting to receive responses from both. VA’s EHRM office responded instead.

Those responses from VA’s EHRM office did not reflect their views, Stone and Clancy said later in mid-June. They agreed with all of the IG’s findings and then provided action plans, which allude to the findings of VA’s recently completed strategic review of the EHR deployment.

VA recognized, for example, that it needs to create a training environment as close as possible to the actual EHR that clinicians will use. The department will also re-farm and repopulate its EHR boards with individuals with expertise in HAV operations. These tips will assess clinical workflows, VA said in its action plan.

The department first launched the review in March after hearing about systemic failures and concerns about EHR deployment by employees at the first commissioning site in Spokane, many of which reflect the findings of the latest report from Spokane. the IG.

Ministry officials will outline their findings from the strategic review of the EHR before the Senate VA committee next Wednesday, the panel said.

“This report makes it clear that the electronic health records modernization program must be closely monitored by VA and Congress to ensure that it provides reliable support to the department’s medical staff and the veterans they serve,” Sen. Jon Tester (D-Mont.), chair of the committee, said in a statement Wednesday. “While Secretary McDonough has taken positive steps to get this program back on track, the Senate must confirm a VA Assistant Secretary to help manage this effort, protect tax dollars and provide service to all veterans. This project is critical to the future of our veterans health care, and I look forward to hearing directly from VA next week about their plans to make sure it is implemented properly.

Members of Congress on both sides of the aisle have questioned the accuracy of VA’s cost estimates for some time. The VA House committee will hold its own hearing the following week, Democrats said Thursday. The committee invited McDonough to testify.

“Based on these reports and my previous conversations with VA, I continue to have serious concerns about the management of the EHRM program, including the lack of clarity regarding life cycle costs, failures in staff training. and inadequate change management practices, ”said the representative. Frank Mrvan (D-Ind.), Chairman of the technological modernization subcommittee, said Thursday.

Mrvan said the subcommittee hearing, scheduled for July 21, will focus on the current state of the EHR project, as well as the changes planned and the way forward for VA.