Electronic Health Records: VA Needs to Address Management Challenges with New System
Fast Facts
Veterans Affairs is in the process of replacing its IT system used to maintain veterans' health records—and has deployed its new system to a few locations.
But the new system has presented issues for some users. For example, many users said that they weren't adequately trained to use it. They also said that having to use the new system had decreased morale and job satisfaction and increased burnout among VA staff.
The VA hasn't established goals to assess user satisfaction with its new IT system. We recommended it do so.
Highlights
What GAO Found
The Department of Veterans Affairs (VA) organizational change management activities for the Electronic Health Record Modernization (EHRM) program were partially consistent with seven leading practices and not consistent with one leading practice (see table).
Extent to Which the Electronic Health Record Modernization (EHRM) Program's Activities Were Consistent with Organizational Change Management Leading Practices
|
Leading practice |
GAO assessment |
|---|---|
|
Developing a vision for change |
Partially consistent |
|
Identifying and managing stakeholders |
Partially consistent |
|
Communicating effectively |
Partially consistent |
|
Assessing the readiness for change |
Partially consistent |
|
Increasing workforce skills and competencies |
Not consistent |
|
Identifying and addressing potential barriers to change |
Partially consistent |
|
Establishing targets and metrics for change |
Partially consistent |
|
Assessing the results of change |
Partially consistent |
Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-23-106731
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 (EHR) system.
Most users have expressed dissatisfaction with the new system. VA's 2021 and 2022 surveys showed that users were not satisfied with the system's performance or training. About 79 percent (1,640 of 2,066) of users disagreed or strongly disagreed that the system enabled quality care. 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. Further, VA has not established targets (i.e., goals) to assess user satisfaction. Until it does so, VA lacks a basis for determining when satisfaction has sufficiently improved for the system to be deployed at additional sites. Such a basis helps ensure that the system is not deployed prematurely, which could risk patients' safety.
VA did not adequately identify and address system issues. Specifically, VA did not ensure that trouble tickets for the new EHR system were resolved within timeliness goals. It subsequently worked with the contractor to reduce the number of tickets that were over 45 days old. Nevertheless, the overall number of open tickets has steadily increased since 2020. Accordingly, it is critical that system issues be resolved in a timely manner. Additionally, although VA has assessed the system's performance at two sites, 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.
In April 2023, VA announced that it planned to halt future deployments of the new EHR system to focus on making improvements at the five sites currently using the system.
Why GAO Did This Study
VA uses the Veterans Health Information Systems and Technology Architecture (VistA), which includes the department's legacy EHR system, to manage health care for its patients. VistA is technically complex, costly to maintain, and does not fully support the need to exchange health data with other organizations. In June 2017, VA initiated the EHRM program to replace VistA.
Congressional report language associated with the VA appropriations for fiscal years 2020 through 2022 contained provisions for GAO to review VA's EHR deployment. GAO's objectives were to determine the extent to which VA has (1) followed leading organizational change management practices for the EHRM program, (2) assessed satisfaction with the new system, and (3) identified and addressed EHR system issues. GAO identified leading change management practices and evaluated VA's activities against these practices. It also reviewed the results of surveys that VA conducted to determine users' satisfaction with the new EHR, conducted interviews with selected users, and interviewed officials on user satisfaction goals. Further, GAO analyzed VA's data on the contractor's performance meeting time frames for addressing system trouble tickets.
Recommendations
GAO is making 10 recommendations to VA to address change management, user satisfaction, system trouble ticket, and independent operational assessment deficiencies. VA concurred with the recommendations and described actions the department plans to take to address them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs |
Priority Rec.
1.
The Secretary of VA should ensure that VA documents a VA-specific change management strategy to formalize its approach to drive user adoption. (Recommendation 1) |
VA concurred with this recommendation. As of March 2024, VA had worked with its contractor to update the contractor's change management plan to be more VA specific and stated that the Electronic Health Record Modernization program office and Veterans Health Administration Office of Health Informatics are collaborating to develop an enterprise change management strategy that is targeted for completion in September 2024. We will continue to monitor the department's progress towards implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
2.
The Secretary of VA should ensure that the department's planned improvements to communication of system changes meet users' needs for the frequency of the updates provided. (Recommendation 2) |
VA stated that it concurred with this recommendation. As of March 2024, the department had taken steps to improve communications of system changes to end users and established a rapid process improvement workstream to gather feedback and update processes to ensure that communications of system changes are distributed consistent with users' needs. Because VA has temporarily paused further system deployments, we will continue to monitor the department's progress towards implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
3.
The Secretary of VA should take steps to improve change readiness scores prior to future system deployments. (Recommendation 3) |
VA stated that it concurred with this recommendation. As of March 2024, the department established a target for improving change readiness questionnaire scores. However, because VA has temporarily paused further system deployments, VA has yet to collect new change readiness scores. After system deployments resume, we will revisit the department's actions in response to this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
4.
The Secretary of VA should ensure steps taken by the EHRM program and Oracle Cerner to increase workforce skills and competencies through improved training and related change management activities have been effective. (Recommendation 4) |
VA stated that it concurred with this recommendation. As of March 2024, the department had taken steps to increase workforce skills and competencies through learning labs, updates to system training, and building informatics staff expertise. When VA continues its deployments of the new EHR system, we will revisit the department's progress toward implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
5.
The Secretary of VA should address users' barriers to change, by ensuring planned completion of all actions identified in the Secretary's Strategic Review. (Recommendation 5) |
VA stated that it concurred with this recommendation. As of March 2024, the department was continuing to address 10 of 69 strategic review recommendations. We will continue to monitor the department's progress toward implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
6.
The Secretary of VA should develop a plan, including a timeline, for establishing (1) targets for measuring the adoption of changes and (2) metrics and targets to measure the resulting outcomes of the change. (Recommendation 6) |
VA stated that it concurred with this recommendation. As of March 2024, the department had identified metrics and targets for change management activities but was continuing to refine the functional and technical quality standards to monitor program performance during system implementation and post go-live. VA plans to complete these activities in May 2025. We will continue to monitor the department's progress toward implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
7.
The Secretary of VA should measure and report on outcomes of the change and take actions to support users' ability to use the system to reinforce and sustain the change. (Recommendation 7) |
VA stated that it concurred with this recommendation. As of March 2024, the department had identified metrics and targets for change management activities but had not yet reported on outcomes relative to the targets. VA plans to complete these activities in May 2025. We will continue to monitor the department's progress toward implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
8.
The Secretary of VA should establish user satisfaction targets (i.e., goals) and ensure that the program demonstrates improvement toward meeting those targets prior to future system deployments. (Recommendation 8) |
VA stated that it concurred with this recommendation. As of March 2024, the department had taken steps intended to improve user satisfaction with the system but had not yet established targets satisfaction targets. We will continue to monitor the department's progress toward implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
9.
The Secretary of VA should make certain that future system trouble tickets are resolved within established timeliness goals. (Recommendation 9) |
VA stated that it concurred with this recommendation. As of March 2024, the department had taken steps to resolve trouble tickets within established timeliness goals. These steps included ongoing activities such as establishing a workstream to reduce the number of old tickets, improving strategies to better categorize tickets for efficient resolution, and reducing the misdirection of incoming trouble tickets between the VA enterprise service desk and the system contractor's help desk. We will continue to monitor the department's progress toward implementing this recommendation.
|
| Department of Veterans Affairs |
Priority Rec.
10.
The Secretary of VA should reinstitute plans to conduct an independent operational assessment to evaluate the suitability and effectiveness of the new EHR system for users in the operational environment. (Recommendation 10) |
VA concurred with this recommendation and stated that it would reinstate plans to conduct an independent operational assessment. However, the department had not established a target date for completing the assessment. We will continue to monitor the department's progress toward implementing this recommendation.
|