VA’s decision to embrace the Cerner EHR solution as its choice for a next generation EHR foundation would seem to be a wise move that recognizes risks while also moving forward. The VA award of a $10B contract to Cerner is an enormous commitment by VA, but appears to be significantly smaller in its initial commitment than the DoD implementation ($782M vs $4.3B). DoD’s Cerner implementation has encountered many significant obstacles – as should have been expected – but the VA plan would seem to keep it on course to learn from the DoD experience, lessen its commitment and risk should the Cerner solution have insurmountable problems, and continue to offer the prospect of increased interoperability between VA and DoD.
As I wrote earlier, VA has a long history of success with internal innovation from the work of the MUMPS Underground to develop DHCP and VistA. While that success has been hailed by many (including Congress), it has also been criticized by many (including Congress) for being too expensive to maintain. The potential of using a commercial product like Cerner as a foundation for the next generation EHR remains to be realized and, in these early stages of implementation, it’s obvious that technology, workplace, workflow, and culture challenges will be significant. VA’s historic collaboration between clinicians and technologists will be challenged again to work with a private sector partner to identify solutions that appropriately balance costs and benefits. Having worked extensively at both VA and DoD, I have often marveled at the different cultures that exist in each behemoth agency. Adding another behemoth private sector company to the mix won’t be easy.
VA’s health system has a significantly different patient population than DoD’s or even any typical private sector health system or hospital. VA also has a mission that includes a significant research support goal that is different from DoD or the private sector. DoD’s management approach is derived from a military foundation whereas VA’s approach is more often collegial and cooperative. Neither operates in a private sector, profit motivated environment. Related to this, one challenge of the DoD Cerner implementation that is becoming apparent is the importance of extensive change management processes to ensure successful implementation. The training needs have been significantly higher than expected. Changes to workflows were always recognized to be needed, but the difficulty in defining and implementing these has caused additional organizational stress.
The recently released Initial Operational Test and Evaluation (IOT&E) report regarding DoD’s Cerner implementation at its first four sites cited significant problems, including a large number of help desk tickets, potential capacity and latency problems, and a general finding that the system is “neither operationally effective nor operationally suitable”. Obviously, these findings indicate significant problems. However, DoD is committed to using Cerner, and they are working to address all of these problems. To me, the latency/performance issues are the most worrisome. The DoD (and VA) technology staffs (and their contractors) have worked long and hard on the legacy systems to ensure that users (clinicians) have as little delay as possible in their workflows to facilitate an effective and efficient interaction with patients and their families.
Perhaps, a slower implementation within DoD is appropriate. That consideration seems to be first and foremost in the minds of VA as it chooses to stick with the planned implementation of Cerner for its use while keeping its financial commitments low until more DoD success can be seen. The Cerner EHR solution must be able to demonstrate it can effectively operate in the DoD and VA environments before it replaces the existing legacy agency EHR systems. VA, DoD, and Cerner must implement a more satisfactory operational environment before making further commitments that could compromise the clinicians at these hospitals and, most importantly, the health and well-being of our veterans, service members, and their families.