Modernizing The Veterans Health Administration’s Electronic Health Record System

The Veterans Health Administration and the Electronic Health Record

The Veterans Health Administration (VHA) is the nation’s largest health system and is managed by the Department of Veteran Affairs (VA) (US Department of Veterans Affairs, 2009). The VHA provides care at nearly 1300 locations including 171 medical centers and 1,112 outpatient sites, which serves roughly 9 million Veterans each year (US Department of Veterans Affairs, 2009). 

The VA was one of the earliest pioneers for the Electronic Health Record (EHR). The EHR is a digital version of the patient’s chart. The EHR captures patient information in real time and makes it instantly accessible to authorized providers (HealthIT, 2022). The EHR is crucial in a patient’s care because the information put into the record can be shared amongst providers across healthcare entities and other organizations (HealthIT, 2022). 

Starting in the 1980s, the VA has worked on improving the EHR experience. They first transitioned from the paper health record to an electronic record through the use of the Decentralized Hospital Computer Program (DHCP) (Tong, 2015). The program served as a central location for patient data. The VA continued to work through several iterations of the DHCP until they landed on a tool that was much more comprehensive (Tong, 2015). The new tool was titled the Veterans Health Information Systems and Technology Architecture or commonly known as VistA (Tong, 2015). 

The VistA system was implemented across all veteran healthcare sites and provides clinical, financial, and administrative functions. VistA was highly rated amongst physicians and providers in Medscape surveys done in 2014 and 2016 (Baker, 2022). VistA has also been the EHR system for the VA for over 30 years (Baker, 2022). Despite VistA’s notable achievements, the EHR system is outdated, expensive to run, and has quite challenging to maintain (Senate RPC, 2020). VistA also lacks interoperability with the Department of Defense (DOD) and other private health provider systems (SenateRPC, 2020).   

The VA has tried repeatedly over the past 20 years to modernize VistA and make it interoperable with DOD. In 2008 Congress mandated it, requiring DOD and VA establish fully interoperable EHR systems that would allow for sharing health care data across departments. In 2013, the VA launched yet another plan to modernize the system, dubbed “VistA Evolution.” The program expanded the use of the “Joint Legacy Viewer,” a tool that allowed VA medical personnel to view a read-only display of patient data from DOD and other health care providers. While an improvement, the JLV was a far cry from true interoperability. (https://www.rpc.senate.gov/policy-papers/modernizing-vas-electronic-health-record-system). 

In 2011, the VA enlisted an open-source community called OSEHRA (the Open Source Electronic Health Record Agent) to develop enhancements to VistA. This decision was part of a joint effort with the U.S. Department of Defense (DoD) to store all veterans’ and service members’ health records electronically using a single source. (https://ehrintelligence.com/news/ehr-and-the-va-part-i-history). 

After years of failing to adequately modernize VistA or build a suitable EHR system, the VA decided to purchase Cerner as its EHR system in 2017 (SenateRPC, 2020). The VA selected this vendor because it is the same one that the DOD purchased back in 2015, hoping that using the same vendor would solve for some of the interoperability challenges (SenateRPC, 2020). The VA Electronic Health Record Modernization (EHRM) program was created to generate unification between the VA and the DOD by having both entities use a singular EHR system (Department of Veterans Affairs, 2021). Through the VA EHRM, VistA will be replaced with a commercial solution, Cerner Millennium (Department of Veterans Affairs, 2021). 

Evolution of the Veterans Health Information Systems and Technology Architecture (VistA)

For the VA to continue delivering a high-quality experience for veterans, their clinicians and staff needed a modern platform that provided improved access to each veteran’s health record (Department of Veterans Affairs, 2021). The VA is now undertaking one of the largest government transformation efforts ever; implementing a commercial EHR that will provide full interoperability with the DOD, the U.S. Coast Guard and Community Care providers, enabling a smooth experience for veterans (Department of Veterans Affairs, 2021). 

The EHRM will finally give VA providers uninterrupted access to a patient’s entire health record (Department of Veterans Affairs, 2021). The EHRM will also bring in improved health data analysis provided by advanced analytics. Equipped with tools to support decision making and improve patient outcomes, the new EHR system will give clinicians, providers, and staff members instantaneous access to the patient’s information they need (Department of Veterans Affairs, 2021). 

The transition to the new EHR system will happen over the course of a 10-year period and is anticipated to end in 2028 (SenateRPC, 2020). The VA EHRM Integration Office will manage deployment of the new EHR system. The $16 billion contract to replace VistA and all of its instances was awarded to Cerner in May 2018 (SenateRPC, 2020). In 2020, the EHR program was allocated about $1.5 billion (SenateRPC, 2020). In 2021, the EHR program exceeded $2.6 billion (SenateRPC, 2020). The progress and allocation of funds will be monitored by the Office of Management and Budget’s Federal IT Dashboard as an IT investment (SenateRPC, 2020). 

The VA EHRM has identified 8 project objectives to ensure a successful EHR implementation (Department of Veterans Affairs, 2021). 

Moving forward to create a seamless and harmonized VA digital experience using a Human-Centered Design approach. 

Ensuring clinical and practice management systems are functional and providing staff with tools  to deliver the safest, most effective, and timely, evidence-based care to Veterans. 

Ensuring frontline employees have the right tools and training to make full use of the EHR features to provide world-class care to Veterans. 

Ensuring site and technical infrastructure is configured to meet system and user requirements is well-tested, and is fully operational to support the provision of care. 

Establishing effective management and project oversight to optimize cost, schedule, programmatic performance, and governance. 

Ensuring productivity and clinical workflows are optimized and the system is configured to maximize operational efficiency.

Channeling data-driven decisions through a single governance body, incorporating stakeholder inputs and ensuring that good management discipline is applied, and risk management is rigorous. 

Ensuring clinical and practice management systems are functional with a secure unified Veteran-centered data model. 

Successful implementation of the VA EHRM depends on key stakeholders from cross-functional areas. The VA EHRM project stakeholders are as follows:

• Government Accountability Office (GAO)
• Office of the Inspector General (OIG)
• Office of Electronic Health Record Modernization (OEHRM)
• The Office of Acquisition, Logistics, and Construction (OALC)
• The Veterans Experience Office (VEO)
• The Office of Information & Technology (OIT)
• The Office of Enterprise Integration (OEI)
• The Veterans Benefits Administration (VBA)
• The Veterans Health Administration (VHA) 

Cerner was awarded the contract to develop the new EHR system for the VA. Cerner is partnering with over 20 partners to ensure the EHR system is deployed successfully (Fischer, 2021). Cerner’s core partners include AbleVets LLC, Accenture, Forward Thinking Innovations LLC, Guidehouse, HCTec, Henry Schein Inc., Leidos, MicroHealth, and ProSource 360 (Fischer, 2021). Cerner has also partnered with other businesses, a few of them veteran-owned to assist in the implementation. These businesses are Cerner’s premier partners and include Sharpe Medical Consulting, Signature Performance, Thomas Riley Strategies, ACI Federal, B3 Group Inc., Blue Sky Innovation Solutions, Clarus Group, Forward-Thinking Solutions, Healthcare Resource Group, KRM Associates Inc., Liberty IT Solutions, MedicaSoft, MedSys Group, Holland Square Group, Program Management Solutions, and Point Solutions Group.  

Challenges with VistA

In 2018, the VA awarded a $10 billion contract to Cerner for the VA EHR Modernization Project (Sweeney, 2018). The $10 billion dollar deal, spread out over 10 years, is the largest health IT projects in the government’s history (Sweeney, 2018). The no-bid contract took approximately 6 months to negotiate and finalize details (Sweeney, 2018).

The estimates for the project were severely underestimated. The OIG performed an investigation in 2019 in which it found that there were two factors attributing to the project costs (Fischer, 2021). The first factor was the actual IT work (Fischer, 2021). The second factor was infrastructure upgrades that needed to occur at the VA’s medical facilities (Mitchell, 2021). Many of the facilities are over 50 years old and need significant work including heating, cooling, ventilation, and cabling to support the new EHR program (Mitchell, 2021). After the OIG concluded its investigation, it found that the project was $3.6 billion short of adequately launching the new EHR program (Fischer, 2021). In 2020, the VA asked for an additional $1.2 billion in its fiscal year to continue the EHR work (Landi, 2020). In 2021, the ask has increased to $2.6. billion for the fiscal year (Landi, 2020). Of that $2.6 billion, over $1 billion is for infrastructure upgrades, another $1 billion is for the Cerner EHR contract, and nearly $260 million is to add additional staff to the project management office (PMO) (Landi, 2020). Currently, the VA has estimated the increased initial project cost from $10 billion to $16 billion over the 10-year period (Landi, 2020).

The project plan has a timeline for deployments of the Cerner EHR system over the next couple of years. The tables below provide dates of deployment for the next two years. After deployment is completed, clinicians at the VA medical centers will have a complete and holistic record of a patient’s medical history. 

Abbreviations

Decentralized Hospital Computer Program (DHCP)

Department of Defense (DOD)

Department of Veteran Affairs (VA)

Electronic Health Record (EHR)

Electronic Health Record Modernization (EHRM)

Government Accountability Office (GAO)

Office of Electronic Health Record Modernization (OEHRM)

Office of the Inspector General (OIG)

Office of Acquisition, Logistics, and Construction (OALC)

Office of Enterprise Integration (OEI)

Office of Information & Technology (OIT)

Project Management Office (PMO)

Veterans Benefits Administration (VBA)

Veterans’ Health Administration (VHA)

Veterans’ Health Information Systems and Technology Architecture (VistA) 

References

Administration, V. H. (2009, June 10). About VHA. Veterans Health Administration. Retrieved February 12, 2022, from https://www.va.gov/health/aboutvha.asp

Baker, R. (2022, January 26). Why VA’s Electronic Health Record Mega-Project is Failing. FCW. Retrieved February 12, 2022, from https://fcw.com/it-modernization/2021/07/why-vas-electronic-health-record-mega-project-is-failing/259229/

Electronic Health Record: Comprehensive Lessons Learned. US Department of Veterans Affairs. (2021, July). Retrieved February 12, 2022, from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=https%3A%2F%2Ffederalnewsnetwork.com%2Fwp-content%2Fuploads%2F2021%2F07%2F071421_va_ehr_lessonslearned_FNN.pdf&clen=2198486&chunk=true

Fact Sheet. Department of Veterans Affairs Electronic Health Record Modernization. (2021, November 4). Retrieved February 19, 2022, from https://www.ehrm.va.gov/resources/factsheet

Fischer, J. R. (2021, June 3). VA Underestimates EHR Modernization Budget. Healthcare Business News. Retrieved February 19, 2022, from https://www.dotmed.com/news/story/54990

Frequently asked questions. Department of Veterans Affairs Electronic Health Record Modernization. (2021, April 8). Retrieved February 12, 2022, from https://www.ehrm.va.gov/resources/faqs

The VA’s Solution: Cerner

Landi, H. (2020, February 27). VA asking for $1.2B more to continue Cerner Ehr Project. Fierce Healthcare. Retrieved February 19, 2022, from https://www.fiercehealthcare.com/tech/as-va-pushes-cerner-ehr-go-live-to-july-key-lawmakers-vow-to-take-tighter-control-project

Mitchell, H. (2021, June 9). Biden proposes $56m budget increase for VA’s Cerner Ehr Modernization in 2022. Becker’s Hospital Review. Retrieved February 19, 2022, from https://www.beckershospitalreview.com/ehrs/biden-proposes-56m-budget-increase-for-cerner-ehr-modernization-in-2022.html

Modernizing VA’s Electronic Health Record System. Senate RPC. (2020, November 10). Retrieved February 12, 2022, from https://www.rpc.senate.gov/policy-papers/modernizing-vas-electronic-health-record-system

Sweeney, E. (2018, May 21). VA signs $10B deal with cerner, but implementation challenges still loom large. Fierce Healthcare. Retrieved February 19, 2022, from https://www.fiercehealthcare.com/tech/va-cerner-ehr-contract-10b-dod-shulkin-wilkie-mhs-genesis

Tong, K. (2015, November 16). EHR and the VA: Part I – History. EHRIntelligence. Retrieved February 12, 2022, from https://ehrintelligence.com/news/ehr-and-the-va-part-i-history

What is an electronic health record (EHR)? HealthIT.gov. (2019, September 10). Retrieved February 12, 2022, from https://www.healthit.gov/faq/what-electronic-health-record-ehr 

In this case study our team will discuss the Department of Veteran Affairs, Electronic Health Record Modernization (EHRM).  The purpose of the EHRM is to provide a single health care  system that stores health information and tracks all aspects of patient care. The three major components to the EHR program are:  

• To implement a new EHR platform that is able to exchange and make use of information with the VA and community care providers, creating a simplified records system for active duty and retired veterans.
• To provide Veterans and medical professionals with an overall picture of a patient’s medical history, bridging the gap by connecting military service and health outcomes through data system analytics.
• To offer a consistent patient scheduling experience at VA medical facilities and healthcare partners nationwide. 

Since its inception in 2018, the EHRM was thought to be a well-organized,  innovative and structured program. But, over the years the system has proved to be an issue with a broken data collection system,  missed deadlines, and misuse of funds of over $16 billion dollars and counting.  Our team will evaluate these issues and come up with recommendations for getting the program back on track.

• In June 2017, it was determined based on its findings to have the VA EHR system.
•   The VA awarded a contract in May 2018 to Kansas City, Missouri-based Cerner Corporation.  The company was asked to replace the current VA HER system with Cerner Millennium. This platform was already in use by the Department of Defense (DOD).
•  June 2018, The Office of Electronic Record Modernization (OEHRM) was established.  The OEM manages the deployment of the VA’s EHR system.
•   September 2018, Model Validation Event. The purpose of this event is to test the model of the system for data errors or any other issues that the system may have prior to the official launch. 
• November 2018,  National Workshop 1, the first of 8 hearings before Veteran Health Administration (VHA) on the review of the Electronic Health Record Modernization Program (EHRMP)
•  January 2019, National Workshop 2, (EHRMP) review hearings
• February 2019, National Workshop 3, (EHRMP) review hearings
• April 2019, National Workshop 4, (EHRMP) review hearings
• May 2019, National Workshop 5, (EHRMP) review hearings
• June 2019, Vital Session 1, VA Innovative Technology Advancement Lab (VITAL)·    The VA Innovative Technology Advancement Lab (VITAL) teaches users how to optimize EHRM by collaboratively solving real-world problems identified by VA participants. The VITAL program consists of four, three-day, in-person sessions across 12-18 months, monthly virtual checkpoints and a core capstone project chosen by participants. VITAL introduces its participants to a professional network that crosses VA facilities and professional disciplines and encourages solution-sharing across VA.
•  July 2019,  National Workshop 6, (EHRMP) review hearings
•  August 2019,  National Workshop 7, (EHRMP) review hearings
•  September 2019, National Workshop 8, (EHRMP) review hearings
• October 2019, Vital Session 2, VA Innovative Technology Advancement Lab (VITAL), repeated session.
• October 2020,  Go-Live at Mann-Grandstaff, according to the article by HIT Consultant “Cerner Corporation today announced the historic and successful first deployment of a modern electronic health record (EHR) at Mann-Grandstaff VA Medical Center in Spokane, WA. The go-live marks the first time in history three federal departments are using the same EHR — a historic milestone toward improving the secure and seamless exchange of health information across the federal government.”

Why did the VA EHR system break down?  (clean up this section)

The VA has finished its 12-week strategic review of the massive Cerner Millennium electronic health record modernization (EHRM) project, VA Secretary Denis McDonough announced June 30. Review completion came just in time for McDonough to answer concerned members of the Senate and House Committees on Veterans’ Affairs about VA Office of Inspector General (OIG) and Government Accountability Office (GAO) reports discussing problems surrounding the initial deployment of the Cerner system in the Pacific Northwest nine months ago. 

The secretary announced the strategic review of the EHRM within days of taking office Feb. 9 because of major issues swirling after the new system went live at Mann-Grandstaff VA Medical Center (VAMC) in Spokane, Wash. There have been mounting concerns over the $16 billion project because of its cost and massive scope.

While the discrepancies and under-reporting of project cost estimates of more than $5 billion highlighted in one of the VA OIG reports were frustrating, “the issue was more about caring for veterans and them seeing the benefits of the system at some point in their lifetime,” said Moran. 

Findings: (GAO, VA OIG, and VA Strategic Review Findings) still need to complete this section  

1) What are the major causes behind the failure of the VA’s electronic health record mega-project?

One of the main reasons why the VA’s electronic health record mega-project failed is the lack of analysis of the project. The project team involved in the project development process failed to identify the areas which need development or replacement. The project manager involved in the process of development of the project failed to estimate the cost of the project (Flyvbjerg et al. 2018). They failed to identify the cost of the development of the infrastructure of the project. This barred the organization to understand and estimate the project’s requirement, which is thus one of the major reasons for the failure of the project. Another reason which the project failed is due to the continuous missing of deadlines of the project. In the initial phase of the development of the project, the project barely followed the timeline, leading to a huge lag in the completion of the project. This summed up the increase in the cost of the project as well (Raykar & Ghadge, 2016).

Benefits of the New EHR System

2) What are the documented reasons by the Government Accountability Office for the failure of most of the government programs of the scale of EHRM?

According to VA, the most documented reason due to which the government programs fail is due to the underestimation of the cost of the project. Estimation of the cost required for the completion of the project is the duty of the project manager to implement. However, the lack of time or reluctance of the project manager to conduct a thorough analysis of the project leads to the failure of the projects held by the government.

3) What is the track record of VA with the large-scale system development and deployment?

VA has always focused on the development and implementation of new technologies to ease up the processes in use. Although it has tried to bring about major changes in dealing with the electronic health records and other aspects related to the veteran’s data, they have failed to succeed with their scope and project development process. The initial EHR system which they have implemented was developed was outdated and expensive and did not even serve the purpose of the organization. The next one which was put into operations did not meet the expectations as well. However, the department has put up efforts to make the aspects right but those did not end up well.

4) What is the role of accountability for the success of the program?

The term accountability in a project is meant for depicting the obligations of an individual for their activities in the project. Here accountability of VA towards proper judgement and decision making in the project along with proper analysis and estimation of the cost is highly responsible for measuring the performance of the project (McGrath & Whitty, 2018).

5) How does lack of change management negatively impact the project’s progress?

Change is inevitable in a project; however, the change shall be handled gracefully else it can give rise to conflicts in the project which shall delay the project even further. Change management helps in the identification and management of organizational changes. The absence of the same leads to chaos and pandemonium while implementing the changes.

6) Does resistance from the employees create difficulties in implementing the system?

Employees are considered to be the building block of the organization. Any resistance from the employees of the organization will slow down the progress. If the employees feel insecure with the implementation of the project or they are not willing to adapt to the new technology they can resist the change which will again slow down the entire implementation process, leading to cost and time overrun.

7) Is hiding the truth from the last three years regarding the issues that occur one of the major reasons behind the project’s failure?

The VA EHRM program failure may be attributed to many factors. Although the program has witnessed several shortcomings, we believe that hiding the truth about the program for the last three years is a major contributor to the failures being witnessed now. When the project to replace VistA was rolled out a few years ago, it immediately showed signs of failure which was not communicated. The truth about the success of the early stages of the implementation of the project was hidden from the stakeholders, (ALLEN et al., 2022). A lack of openness during project implementation is a major concern that may lead to disastrous failures. Hiding the truth may have been convenient for the project’s managers in the short run, but impacts are now emerging.

Timeline for Implementation

Hiding the truth may be the major cause of the current failures of the VA EHRM project. The handlers of the project concealed several important truths from the stakeholders, which may have contributed to the failure. First, the project lied about the success of the training process. Replacing VistA with Cerner’s EHRM implied that healthcare workers, who are the primary users of the program needed to undergo training to learn how to use the new system. During the first deployment at the Mann-Grandstaff V.A. Medical Center in Spokane, the employees complained about the training program. Although the project reported that the user’s training was successful, reports emerge that almost two-thirds of the participants failed the accompanying test, (“Hidden Costs and Flawed Training Plague the V.A.’s Huge Software Upgrade”, 2022). Office of the inspector general found out in an investigation that the proportion of employees who passed the training was 44% contrary to the 89% figure reported by the project.

The lack of honesty contributed to the current setbacks because if the training results were honestly reported, proper mitigation measures could have averted the current situation. The training’s honest results could have helped the project improve the training program and the system at large. The project management could have identified flaws at a very early stage and improved as necessary.

8) How does the training program for hospital staff impact the project’s progress?

Training should be kept as a part of the entire change management process. Implementation of new techniques requires proper training and development of the employees for getting adapted to the changes that have been identified. Thus, training should not impact the progress of the project.

9) Is improper budget estimation during the project the main reason behind the shortfall of the project budget?

Apart from the issue of hiding the truth, another potential major cause of the failure is the improper estimation of the budget. The report by OIG in 2019, revealed that the project budget was severely underestimated. The report identified two factors as the major contributors to the budget cost. The OIG notes that apart from the actual IT work which the contractor is assigned to undertake, the VA’s medical facilities need serious infrastructure upgrades. It seems the upgrading process was not factored in during the budget estimation. The project is requiring more budget than planned when it’s only about three years old. The estimated total budget for the VA EHRM project is $16 billion for the whole work.  

The funding of the project was planned to be distributed throughout the project’s lifespan. But from the early years of the project, it is revealed that the actual cost is way beyond the estimated annual budget. For example, Cerner asked for an additional $1.2 billion in 2020 to complete the year,s IT work. The additional funding in part was supposed to facilitate the infrastructure upgrades, which seem to have been neglected for over 40 years, (ALLEN et al., 2022). Although the project was estimated to cost $16 billion, reports reveal that it could cost over $21 billion. 

Investment in the EHR Program

The budget underestimation may be the reason for the failure. When the cost of a specific activity becomes excess than expected, it may lead to delays. Underestimation of the cost may tempt the management to utilize less experienced and skilled staff to try to cut costs. Again, the number of staff may be little than the appropriate number needed to complete certain tasks at the right time. The report by the OIG shows that there was understaffing because $260 million of the additional funds was used to employ additional staff. Thus, the understaffing caused by the budget restrain could be the cause of the failure.  

10) Why has the project missed almost each of the set deadlines?

The project failed to estimate and analyze the existing issues thoroughly. It has discovered each one of them while proceeding with the new system. This has led to the increase in the cost of the project, and also prevented the project to meet the scheduled deadlines.

11) What can be done in order to mitigate potential causes of failure?

There are several potential causes of failures for the VA’s EHRM project. The project is just about three years into its lifespan. It is estimated that the project will run until 2028 when the existing contract with Cerner will expire. Although several signs of failure are being witnessed, including missing almost every major timeline, there is still room to rectify the flaws and have a smoothly running project as planned. One of the actions that need to be implemented to mitigate some of the causes of failure is to undertake a new budgeting and scheduling process. Based on the report by the OIG, it is revealed that the project sought an additional budget in 2020 because the allocated funds were insufficient, (ALLEN et al., 2022). Thus, a new budget that includes all items needs to be developed. The current budget did not factor in the issue of the infrastructure upgrade. The new budget should include all factors that will affect the cost of the project.

Secondly, the project needs to observe integrity by upholding honesty in its operations. Hiding the truth has been a cause of failure. Challenges during the implementation of the project were hidden from all the stakeholders. The project management should thus improve the communication culture within the project. Honest progress results should be communicated to the entire stakeholder so that appropriate actions will be taken on time. The project should acknowledge any shortcomings and work on improving poorly performing operations.  Communication is crucial for the success of any project.

12) What is the likelihood of project failure?

If the project continues to miss out on timelines, and if the project budget keeps increasing by such a huge amount from the initial estimate, it is most likely to fail. Already, there is a huge increase in the amount of cost estimated for the project it increases further with the course of time, the project is most likely to fail.

According to the Government Accountability Office, the VA HER modernization project faced challenges in every phase of the project. In its first three years, the EHRM program is clearly on the path to failure. It has missed nearly every deadline it has set, and its budget estimate has expanded from $16 billion to $21 billion. We have reviewed many publicly available documents and  there is no indication that VA has followed the instructions to implement the various GAO-recommended governance, organization, accountability, or execution measures intended to help agencies avoid large-scale failures. Moreover, the governance, execution, and testing advice by the third-party healthcare providers, who had success in this sector for similar projects, were also ignored.

VA HER modernization is scheduled to implement the software infrastructure at 10 locations in 2022 and 25 locations in 2023.

Project Phase	Current Status
Schedule	–          The deployments which were scheduled last year they are will be deployed in the second and third quarter of 2022 (behind schedule) –          The schedule of deployment is delayed for many sites because of Omicron Corona Virus surge
Budget	–          Project is 6 billion behind schedule and it is expected to have further financial setbacks as it progresses in 2022 and 2023 –          The VA HER health record’s crucial interdependencies with other VA IT systems that are being deployed and upgraded in parallel has increased its testing quality cost
Quality	–          The testing and quality improvement recommendations has been shortened because of short of staff (Omicron surge) –          The original project successful deployment criteria has been softening to get it deployed as “phase 1 deployment” which means any shortcoming in quality will be tackled during the operational phase. (Federal News Network – 2021)
Scope	–          The scope of the VA’s EHR modernization project has drawn scrutiny from watchdogs and regulators. (Health Care News, July 2021) –          The scope of the project has been updated many times since its inception

After much research we are able to put together our own analysis on “how VA HER has been managing the major project management areas”. Our research is based on public data, Congressional and Senate hearing transcripts, and government officials’ statements. We have analyzed the third-party contractors, risks that were discovered during the implementation phase and caused serious budget and scope crises, and software infrastructure. For any project, VA’s Office of Information and Technology (OIT), which is responsible for most of the large systems development programs, adopted disciplined incremental and agile program management approaches about a decade ago, resulting in substantially improved results. Unfortunately, the EHRM program is not managed by OIT. Instead, it is being executed by a separate program management organization in the traditional “waterfall” approach that contributed to so many VA failures.

This project is lacking the central leadership concept of governance which means that VA’s EHRM program management organization exists outside both the business owner (the Veterans Health Administration) and the department’s technology (OIT) organizations. The result is a lack of accountability for the success of the program by the two organizations most impacted by its success or failure.

Area	Flag	Comments
Scope	Red	The scope of the project has changed many times and there are still outstanding questions about the scope of the project.
Schedule	Red	The changing scope is hammering the project schedule. Missing almost every milestone, removal of necessary slack to save time, and mismanagement of critical path is further hurting the project schedule.
Budget	Red	The project cost overrun is having a huge impact on project success as the project is already $6 billion behind schedule. The scope and schedule change will further push pressure on the project schedule. For a successful deployment, it is necessary to get additional funding.
Risk	Red	Because of the size of the project, a detailed project risk analysis, and related risk mitigation strategies were not discovered timely. As the project is progressing, we are seeing more operational, budget, schedule, and technical environment risks.
Contracts	Yellow	Short of full-time employees (FTE’s) and budget have caused many contractual disputes and many of them are still outstanding. The contract management team is working on resolving these disputes.
Quality	Yellow	The project quality plan has been cut down many times to save time and cost which is causing new risks in the project.
Project Team	Yellow	The project team was originally co-located and working in a good project environment but when Coronavirus hit the nations, everyone started working from home, distant locations which caused many team-building related issues. Because of a surge in the Omicron virus, the team is still struggling with similar issues.
Communication	Red	Since most of the project communication planning was done for the co-located team and later everyone started working from home or distant locations, the state-holder engagement and the communication plan were not altered swiftly.
PMO	Yellow	The project was started with a strong independent PMO but later there were many political appointments that caused its work to get slow but PMO practices are still intact.
Others	Yellow	The project adopted a temporary work-from-home structure, thinking Coronavirus crisis are temporary, therefore they never implemented a good infrastructure for it.

Green: Good standing – No negative impact on project

Yellow: Marginal standing – Some negative impact on the project but doesn’t contribute to the failure of it

Red: Unsatisfactory – Contribute to the failure of the project

The primary recipient of the EHRM program is the VHA, one of the nation’s largest health care systems. The EHRM program will replace VA’s current EHR (CPRS/VistA) with a newer system from Cerner Corporation; the same system being installed by the Department of Defense. The rationale for the investment in the new EHR has been that the current system is old and costly to maintain and that there is a need for a better exchange of data with the Department of Defense. Missing from that rationale has been designing elements that would benefit VHA and its staff, such as increased quality of care, more efficient work processes, increases in patient safety or reductions in the cost of care. Combined with the lack of accountability caused by the separate program office, this has made VHA a skeptical party to the EHRM implementation. This is a clear indication that this project lacks the buy-in from the primary customer.

The officials of the VA issued a risk report after the first/initial deployment of the new system. The risk related to data migration, performance measurement, goals, and quality of data is discussed in detail. The conclusion of the report suggests the immediate need to address strategic and clinical risk so that the project will get back on track. The project lacks the detailed system requirements, performance and quality requirements, post-pandemic stakeholder engagement plan, and VA has ignored change management realities. Both the 2014 and 2016 Medscape surveys reported that VA’s current EHR, CPRS/VistA, was the most highly rated EHR system by clinicians nationwide. In those same surveys, Cerner, the basis for the new EHRM, was rated in the middle of the pack. From a change management perspective, this indicates a huge challenge facing the EHRM program. We have also identified the culture of the VA organization as a major threat/risk to the project. The hiding from the truth has been a cultural problem at VA for many years and has been a cause or a contributor to many of VA’s very public failings. In perhaps its most difficult task, VA must correct this problem, so that it can deal with the true state of the EHRM program if it is to have any chance at success.

Risk Type	Risk Details
Strategic Risk	–          Political appointees have created extra communication channels which affect the team confidence, morale, and commitment to the project –          Project team sees this project as a politically motivated effort which is hurting the core objective of the project
Scope Risk	Since project’s inception, there are many changes to the scope which has created many unknown unknowns.
Cost Risk	In the year 2023, there will be 25 deployments across America. The project is already over budget, with the budget and scope changes, it is highly likely that the project will require more money when it gets into the year 2023.
Schedule Risk	The deployment of 2021 is postponed to 2022, and with a cost overrun, it is expected that the project will miss key milestones in 2022 and 2023. The project lacks the schedule contingencies to mitigate changes.

We are confident to conclude that we have history convincing evidence that VA EHR project is failing because it didn’t follow the standards of complex software project management practices. During the initiation, planning, execution, and testing, management ignored the warnings by US Government Accountability Office. The Reports saying “If VA does not close or appropriately address all critical and high severity test findings prior to deploying at future locations, the system may not perform as intended.”

 In the picture above, VA deployed its new EHR system in Spokane, Washington, on October 24, 2020, with no open critical severity test findings and with 306 of the 361 high severity test findings closed. Of the 55 remainings, 47 had workarounds that were accepted by the user community, seven were associated with future deployments, and one had a solution identified at the time of initial deployment.

After looking into many aspects of failure, we think that the project failure primarily falls into the following:

Lack of resource planning

Unclear goals and objectives

Lack of project visibility

Communication gaps

Scope creep

Unrealistic expectations

Lack of risk management

Conclusion:

After performing research and analysis on the case study there are certain things which can be concluded. Firstly, the project is lacking basic aspects of project management practice, that is abiding by the time and cost requirement of the project. The project fails to analyze the risks, calculate issues which can affect the project and even fails to estimate the cost of the project. All these can be fatal cause of failure of the project if not addressed.

It is highly recommended that the project makes use of project management knowledge areas and project management methodologies for conducting the project. This can help in ensuring successful completion of the project that too within the projected cost and time of the project.

References:

Flyvbjerg, B., Ansar, A., Budzier, A., Buhl, S., Cantarelli, C., Garbuio, M., … & van Wee, B. (2018). Five things you should know about cost overrun. Transportation Research Part A: Policy and Practice, 118, 174-190.

McGrath, S. K., & Whitty, S. J. (2018). Accountability and responsibility defined. International Journal of Managing Projects in Business.

Raykar, P., & Ghadge, A. N. (2016). Analyzing the critical factors influencing the time overrun and cost overrun in construction project. International Journal of Engineering Research, 5(1), 21-25.