Introduction.

On Tuesday, March 7^th 2023, the Technology Modernization Subcommittee of the House Committee on Veterans Affairs held a pivotal hearing entitled, “Veterans Health Information Systems and Technology Architecture (VistA)”. In the hearing, members of the subcommittee delved into the options to deliver improved Veteran healthcare outcomes through a modernized and interoperable electronic health record.  VA’s Electronic Health Record Modernization (EHRM) program, intended to fix health record interoperability between the Department of Veterans Affairs (VA) and Department of Defense (DoD), is failing.

How did we get here?

In 2017, after years of effort and millions of dollars, VA Secretary Shulkin cut through the Gordian Knot of VA-DoD turf battles and decided that VA should use the same COTS health record product as DoD to achieve health record interoperability. At the time, I worked at VA and supported that decision.
This program was originally estimated to cost $6 billion. However, five years later, the EHRM program has effectively become a massive $50 billion sole source contract to customize Oracle/Cerner’s “Millennium” COTS product to recreate functionality already found in VA’s VistA system.

What went wrong?

Two fundamental assumptions underlie VA’s decision to adopt the Cerner Millennium product.
Assumption 1: By using the same COTS product, VA-DoD health record interoperability could more easily be achieved (true).
Assumption 2: The functionality in the Cerner Millennium COTS product was nearly sufficient to support Veterans’ health care needs and VA clinical workflows (false). The title of the July 14, 2022 VA Office of Inspector General’s report said it all: “The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.“ VA’s hopes that functionality gaps in the Cerner Millennium product could be patched through change management were dashed on the rocks of patient harm.

What can be done?

VA and Congress should recognize the signs of a failed program: cost growth, missed schedules, scope creep, lack of stakeholder buy-in, and misaligned accountability.
Stop the current VA/EHRM program.
Start a new program that leverages the benefits of VistA and DoD’s Cerner Millennium rollout. The new program should:

1. Be measured primarily by Veteran health outcomes.
2. Be modular and incremental.
3. Focus on function.
4. Separate healthcare data from healthcare software applications. Applications should revolve and evolve around data.
5. Shift the software language MUMPS workforce problem to the private sector. As stated in the Determination and Findings statement that launched the EHRM program: “Software development is not a core competency of VA.”
6. Instill competition to incentivize innovation. Break up the monopolies of VA VistA code maintenance and proprietary Oracle Cerner Millennium code.
7. Let VHA (Veterans Health Administration) subscribe to software-as-a-service modules that meet its clinical needs. Subscribing to VistA-Modules-as-a Service (VMaaS), could reduce VistA complexity, increase modularity, create competition and innovation, and reduce risk. VHA could use its own funds to subscribe to VMaaS modules, thereby freeing up appropriated Office of Information and Technology (OIT) dollars to be used for IT technical debt.
8. Reassign programmatic responsibility from the VA Deputy Secretary to the VA UnderSecretary for Health.

Conclusion.

The VA EHRM program is not achieving its goals and requires a comprehensive overhaul. VA should start fresh with a new program that puts Veterans’ care first. VA should incorporate functional modularity, stakeholders’ input, private sector competition, legacy capabilities, disciplined scope management, and improved accountability into the new EHRM program.