VA's homegrown electronic health record system is at an inflection point -- one that encapsulates the state of the agency's entire technology operation.
The Department of Veterans Affairs is rushing to make changes to its IT infrastructure and systems before the next administration enters the White House. And skeptical lawmakers, oversight bodies and outside experts are cautiously optimistic about the eventual outcomes.
The key words, though, are "cautiously" and "eventual."
The agency continues to face accountability issues, and its sudden shifts on systems and oversight reveal a different story from what is usually told in the hearing rooms on Capitol Hill. In addition, about $4.2 billion appropriated for the VA's Office of Information and Technology (OI&T) is at stake. To judge by the tone on Capitol Hill, lawmakers' patience is wearing thin.
"Whether it's funding or staffing, Congress has given VA nearly everything it has asked for to improve its information technology systems and infrastructure," Rep. Jeff Miller (R-Fla.), chairman of the House Veterans' Affairs Committee, told FCW. "For its part, VA and the Obama administration have time and again failed to deliver meaningful results."
Pressure for change is coming from inside the agency as well. The VA Commission on Care recently recommended a major restructuring of IT at the agency, including adding a CIO at the Veterans Health Administration with a direct line to the VA CIO. The commission's June 30 report also calls for VA to acquire a "comprehensive, commercial off‐the‐shelf information technology solution to include clinical, operational and financial systems."
But pivoting away from VistA, the agency's homegrown electronic health record system, would be a major shift for the VA.
Former VA CIO Roger Baker said VistA is the only EHR designed by doctors, not technologists.
"That is the real power of VistA, and it remains the real power of VistA," he added.
The system, rooted in 1970s code, is designed to assist doctors in their daily work. Providers at the various VA medical facilities nationwide customize it for their specific needs.
"Most people don't realize how all-encompassing VistA is as a hospital automation system," said Baker, who left the agency in 2013. "It supports [and] enforces so many of the medical processes in every VHA hospital and goes far beyond what a commercial EHR product does."
One downside, however, is that modern "third-party software is difficult to integrate into VistA, and there are many parts of VistA that third-party products just can't replace," he added.
VistA also has a broad user base outside VA. And although that fact is unlikely to influence the department's decisions to any large degree, it does speak to the platform's value.
The Open Source Electronic Health Record Alliance gives outside hospitals and health care systems commercial access to the VistA software. At an OSEHRA conference in late June, attendees praised VistA and expressed concern that the VA's commitment to the platform might be waning.
Nancy Anthracite, an OSEHRA group leader, said "lots of lobbyists" are trying to move VA to a commercial product. But the real problem, in her opinion, lies in the agency.
"The people who have just arrived into the VA don't know about VistA,...what they've got and why it would be hard to shift from it," she said, adding that it would be "very, very expensive" to tailor a commercial product to accommodate all the functionality that VA medical facilities need.
Feras Kamal, CEO and co-founder of Electronic Health Solutions, started implementing VistA at medical facilities in Jordan in 2007. Almost 100 sites are using it now, he added, and it has proven to be a cost-effective and attractive solution for the country.
"VistA is solid," Kamal told FCW. "It has all the safety measures and other features [and] it easily can be enhanced and taken to a different level. But taking it out and going commercial is going to be really difficult, even within the VA."
Baker said that as integral as it has been to the department, the 40-year-old system might be coming to the end of its life as more and more doctors prefer newer commercial products.
"It puts OI&T in a very difficult position," he said, adding that both commercial and in-house options have their drawbacks. "And a lot depends on" the Defense Department.
DOD is in the midst of implementing a new EHR system under its Defense Healthcare Management System Modernization (DHMSM) program. The Pentagon is making a $4.3 billion bet that a commercial system from Cerner and Leidos can support the needs of the sprawling Military Health System.
"If DOD can successfully implement DHMSM, then VA should be looking at implementing that same product," Baker said. "If DOD fails, it may be essential that VA have a still vital VistA as a fallback. As far as the dollars go, the investment in VistA remains relatively small compared to the cost of replacing [it]."
Baker estimated that the cost could be as high as $16 billion.
With those considerations in mind, VA is working on making VistA integrate better with modern technology. There are 130 instances of VistA running at VA sites, and the department can't update them all at once, which makes it difficult to coordinate patches and upgrades.
Fred Mingo, deputy program executive for VistA Evolution -- the agency's plan to modernize the system -- told FCW, "VistA was created during a time of great innovation, and the VA's leadership with electronic health records helped change the trajectory of health care for the country -- something the department is proud of. The VA aims to maintain and/or regain this leadership role again in the future."
A high-stakes wager
Harold Gracey, another former VA CIO who also served as the department's chief of staff, said the VA is facing a tough challenge. "You can't just pull out an old system and put in a new one," he said. "It's too risky."
Lawmakers have praised current CIO LaVerne Council for what she's done in the year she's been on the job. "We are putting the right governance in place," Council told FCW. "We are putting the right processes in place."
But as the VA acknowledged in a recent report, the "aggressive timeline for upgrading VistA cannot match the accelerating trends of both technology and veterans' needs."
That's why the VA is simultaneously pushing what officials are calling a digital health platform -- a modern, cloud-based architecture that can unify the 130 instances of VistA, support the new generation of mobile health apps and provide interoperability with caregivers outside the VA system, whether in DOD or the private sector.
VA spokesman Henry Huntley described the platform as "a new partnership between VA and cutting-edge health industry experts, and...an opportunity for VA to continue to lead in federal government innovation, public/private partnership and [Federal IT Acquisition Reform Act] implementation."
The digital health platform is also meant to address the concerns of watchdog organizations, including the Government Accountability Office. It calls for "greater IT innovation by fostering an interoperable ecosystem of solutions and services through its open interface framework," Huntley said.
VA Undersecretary for Health David Shulkin told lawmakers in June that the agency is "looking at a transition plan that brings VA into a future state where all of health care is going to need to be, and that's this issue of interoperability with community providers, the VA and DOD."
He said the money appropriated for VistA Evolution would never go to waste, "regardless of whether our path forward is to continue with VistA, shift to a commercial EHR platform as DOD is doing or some combination of both."
Skeptics on the Hill
Rep. Will Hurd (R-Texas), who leads the House Oversight and Government Reform Committee's IT Subcommittee, told FCW that "the issues we are dealing with within federal IT are not technology issues, they are leadership issues." He added that "while the GAO and [inspector general] may be skeptical…skepticism has been based on a long history of poor performance by the VA rather than the specific new things LaVerne Council has been working on."
Hurd said moving to a new system will likely generate pushback from doctors who resist learning a new way of doing their jobs, but he added that the main focus should be on veterans.
"If you have a doctor saying they like the VistA for data entry, that's great, but are they being able to see all the records, is that piece in?" Hurd asked.
He said he believes there is a disconnect between OI&T's Washington, D.C., headquarters and VA hospitals and health centers around the country. "As the VA starts implementing new software, it should focus on how…they ensure that the experience for the veteran is better," Hurd said. "Veterans shouldn't have to wait 30 days to schedule an appointment."
Some of the skepticism Hurd describes stems from the long wait in Congress for the VA and DOD systems to work together. Under the National Defense Authorization Act of 2014, both agencies had to certify that their EHR systems are fully interoperable and able to share records. DOD certified in November 2015 that it had done its side of the work, and the VA followed suit in April.
Regarding interoperability, Rep. Blake Farenthold (R-Texas) told FCW that the VA "will get there. It's just frustrating to see the government over and over again [fail] to move into the 20th century, much less the 21st century."
The problems go beyond decades-old IT systems and lie in cultural issues at the top and how the agency communicates internally.
Veterans Affairs Secretary Robert McDonald came under heavy fire this year, with some lawmakers asking for his resignation, after he made comments comparing veterans' wait times at VA hospitals to the wait times for rides at Disney theme parks.
"It's quite obvious that VA's leaders aren't at all serious about holding problem employees accountable," Miller said. "Until VA starts putting veterans' customer service before the job security of misbehaving employees, the department will continue to lurch from one scandal to another, and veterans will continue to pay the price."
Baker, who dealt with his share of congressional oversight while serving as CIO, said there will always be resistance to change at an agency as large as the VA. But within OI&T, he added, "maintaining the [positive] connection between the real users and IT people who have to implement the systems has been the big challenge. That's where the issues come from."
The agency is "undergoing a massive transformation," Huntley said. "VA is modernizing its culture, processes and capabilities to put veterans first, and at OI&T, we have shifted the very foundation of how we do business."
The election's impact
Most agree that VA's IT leadership has made significant changes, though perhaps more slowly than many would like. Now a big concern is how the next administration will affect all that progress.
"If Trump gets elected as president, he is going to privatize the VA, so the VA will go away," Sen. Jon Tester (D-Mont.) said. "That means the veterans won't have the health care, and look, it's tough getting in the door, but once you are in there, it's pretty damn good health care."
Even if that does not happen -- and full privatization seems unlikely -- people are concerned about whether current leaders will be able to continue making progress when a new political appointee takes over the department. That is something Council herself hopes will go smoothly.
"The biggest concern is that when one leader leaves and another one comes in, they immediately want to change everything," she said. "My hope is that I will leave very good notes for my successor, and what they will do is do the things that I ran out of time to do and continue the team down that path versus distract the team and turn left."
Gracey said the timeline given to Council to achieve certain objectives was a "pretty aggressive agenda," but at the end of the day, "she's got to pull all those tens of thousands of people with her to make it work, and that's a big challenge."
Hurd, meanwhile, said he sees "a glimmer of hope." Still, he added, "we have to get that done quicker and faster so that the veterans can see the change."
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