VA lacks goals to assess satisfaction with new EHR, watchdog finds

The Department of Veterans Affairs has not established goals to assess user satisfaction with its new Oracle Cerner electronic health record system—compounding broader concerns about the department’s lack of adherence to leading change management practices—according to a report the Government Accountability Office released on Thursday. 

The review—which the watchdog noted was mandated by congressional report language “associated with the VA appropriations for fiscal years 2020 through 2022”—assessed clinician and staff satisfaction with the Oracle Cerner software, examined the department’s change management strategies for the system’s rollout and “identified and addressed EHR system issues.”

VA’s deployment of its new multi-billion dollar EHR system has been beset by performance and technical glitches, patient safety concerns and cost overruns since its inaugural rollout at the Mann-Grandstaff VA Medical Center in Spokane, Washington in 2020.

This has included reports of veteran deaths associated with the software’s use, as well as a highly critical report issued last July by the VA Inspector General’s office that found that more than 11,000 veterans’ clinical orders at the Spokane medical center were routed to an “unknown queue” without notifying clinicians.

VA announced last month that it was delaying future deployments of the Oracle Cerner software until it “is confident that the new EHR is highly functioning at current sites and ready to deliver for veterans and VA clinicians at future sites.” The new system has been deployed at only five of VA’s 171 medical centers.

GAO’s report found that VA “has taken steps to obtain feedback on the performance and implementation” of the Oracle Cerner EHR system, including by contracting with an outside vendor in September 2022 to conduct surveys of users’ satisfaction with the software, but that the results showed that the vast majority of respondents “were not satisfied with the performance of the new system or the training for the new system.” 

“For example, about 79 percent (1,640 of 2,066) of users disagreed or strongly disagreed that the system enabled quality care,” the report noted. “In addition, about 89 percent (1,852 of 2,074) of users disagreed or strongly disagreed that the system made them as efficient as possible.”

Despite conducting the survey, GAO found that VA “has not established targets (i.e., goals) to assess user satisfaction,” which has left the department “limited in its ability to objectively measure progress toward improving EHRM users’ satisfaction with the system.” 

The lack of targeted metrics for user satisfaction, the report noted, means that VA “will also lack a basis for determining when satisfaction has improved,” which “would help ensure that the system is not prematurely deployed to additional sites, which could risk patients’ safety.”

Concerns about VA’s oversight and accountability of the software modernization program also extended to the functionality of the new EHR system. While GAO noted that VA assessed the performance of the Oracle Cerner software at two deployment sites, it found that “as of January 2023, it had not conducted an independent operational assessment, as originally planned and consistent with leading practices for software verification and validation.”

“Without such an independent assessment, VA will be limited in its ability to (1) validate that the system is operationally suitable and effective, and (2) identify, track and resolve key operational issues,” the report added.

Additionally, GAO said that VA “did not adequately identify and address system issues,” including ensuring “that trouble tickets for the new EHR system were resolved within timeliness goals.” While the department has worked with an outside contractor “to reduce the number of tickets that were over 45 days old,” the review said that “the overall number of open tickets has steadily increased since 2020.”

“Until the program fully implements the leading practices for change management, future deployments risk continuing change management challenges that can hinder effective use of the new electronic health record system,” the report said. 

GAO offered ten recommendations to VA, including calling for the department “to address change management, user satisfaction, system trouble ticket and independent operational assessment deficiencies.” VA concurred with the watchdog’s recommendations.