We took a broken system and just broke it completely

Project touted to make veterans’ health care seamless, but some doctors say it’s a disaster.

The military’s ponderous cybersecurity system was largely to blame, but doctors were frustrated contractors hadn’t figured out a way to work around the problems. AP Photo

By Arthur Allen, POLITICO March 08, 2018

President Donald Trump last year hailed a multibillion-dollar initiative to create a seamless digital health system for active duty military and the VA that he said would deliver “faster, better, and far better quality care.”

But the military’s $4.3 billion Cerner medical record system has utterly failed to achieve those goals at the first hospitals that went online. Instead, technical glitches and poor training have caused dangerous errors and reduced the number of patients who can be treated, according to interviews with more than 25 military and Veterans Affairs health IT specialists and doctors, including six who work at the four Pacific Northwest military medical facilities that rolled out the software over the past year.

Four physicians at Naval Station Bremerton, in the Puget Sound, one of the first hospitals to go online, described an atmosphere so stressful that some clinicians quit because they were terrified they would hurt patients, or even kill them. Prescription requests came out wrong at the pharmacy. Physician referrals failed to go through to specialists. Physicians were unsure how to do basic things such as request lab reports.

Doctors complained it could take 10 minutes to get into the system, which then frequently kicked them out. The military’s ponderous cybersecurity system was largely to blame, but doctors were frustrated contractors hadn’t figured out a way to work around the problems, as they had with the previous electronic record system.

“We took a broken system and just broke it completely,” said one doctor, who like most of those interviewed requested anonymity because they lacked military authorization to speak about the project.

Patient Safety Reports — required whenever a life- or limb-threatening medical error is discovered — were “being filed almost every day” in the first few months, said another physician at Bremerton. One report dealt with a patient admitted with a critical heart ailment who later died after getting the wrong treatment, partly because of tests that were sent to another military hospital and lost. The role of Cerner’s software in the death is unclear since it is often difficult to pinpoint the specific cause of errors in complex medical systems.

These and other problems, particularly concerns about the VA’s ability to share records with civilian health systems, contributed to VA Secretary David Shulkin’s decision in December to delay signing a $10 billion contract to install Cerner at the VA, which would be the largest electronic health record job in history. When done, the project would cover 19 million people in the military and VA systems.

Despite the startup issues, which have been glossed over in public discussion of the project, the White House continues to make the overhaul of the military and VA medical records a centerpiece of its government reform efforts.

“This was a huge win for our service,” Jared Kushner told a health IT conference in Las Vegas on Tuesday, referring to Shulkin’s decision last spring to use Cerner following consultations with Kushner’s office. “The president wants to make interoperable health records available for all Americans.”

But Kushner’s comments gave the impression the military had already created an electronic record system, and was just waiting for the VA to connect to it. In fact, the military’s MHS Genesis project, which started rolling out in February 2017, is still in the early stages, with completion scheduled for 2022.

And the tough experiences described by doctors and others suggest a thorny path ahead.

Bob Marshall, a health IT specialist at Madigan Army Medical Center, another early rollout site, blamed the poor start partly on the Pentagon acquisition office’s inexperience with civilian record systems and the lack of a “sandbox” where clinicians could perfect the system before it was turned on.

A digital health system must be configured properly before it goes live, said Marshall, who has broad experience in civilian and military IT work. That did not happen in this rollout, he said.

“The bottom line is… the Cerner user build is immature and needs to be brought up to a functional level,” he said. “There were some expectations at higher levels that this… was an out-of-the-box solution that would work perfectly, but it didn’t.”

Officials from Cerner and Leidos, the lead contractor on the project, acknowledge startup difficulties but said they’re temporary. They said they are making fixes and physicians will get used to other changes. They note that Fairchild Air Force Base near Spokane, Washington, which has a small clinic that went live with the system in February 2017, recently received an industry rating indicating it is making good use of it.

While neither company would comment on safety incidents, Cerner General Manager Travis Dalton said the system overall was making medicine safer.

In the first year, he said, the new computer system issued thousands of meaningful alerts that helped clinicians avoid bad decisions, including a suicide risk alert that has been added to about 100 patient charts.

‘I can’t log vital signs or charts’

Efficiency promises notwithstanding, the new system has resulted in significant slowdowns so far, said physicians at the two hospitals that went live with MHS Genesis in September and October, respectively.

At Bremerton, the system is so cumbersome and confusing that doctors who saw 18 to 20 patients a day now see 12 or 14, they said. When Navy Secretary Richard Spencer came to visit in November, it took staff five minutes to get into the Cerner program. Cerner and military officials declined to comment on the reported incident.

“I’m sitting in front of someone, and the [patient is] launching into their problems, and I can’t even open a screen to write them down,” said one physician. “I can’t log vital signs or charts. I can’t write orders in. I have patients I’ve seen for 12 years, but their data has not migrated over. So I have to log into the old system. Each time, it takes five or 10 minutes to log on. I’m data mining, trying to build a record, address the current problem, find the pitfalls.”

At times clinicians could not obtain a patient’s latest laboratory results in the system. “You’re adjusting medications based on what you think is there,” the physician said.

Some staff members have started taking anti-depressants to deal with stress and grief, another doctor said. “The people I work with come to work every day wanting to do a good job, and it doesn’t feel good not to.”

Defenders of the project said glitches are to be expected.

They note that the military’s implementation was complicated by the fact that it was simultaneously upgrading telecommunications hardware at the bases and also moving the medical services of the Navy, Air Force and Army under a single Defense Health Agency command.

After clinician complaints reached a critical mass in December, the military and its partners began an eight- to 10-week “stabilization” period, with experts flown in from Washington and Kansas City, Cerner’s home base, to iron out problems. In the process, they are laying down a blueprint to roll out the system at bases in the rest of the country, said Stacy Cummings, who oversees the modernization for the Defense Department.

Cummings said some changes had been made in response to safety red flags. For example, doctors noticed that time-zone differences in the software might be affecting the timing of newborn liver function tests, which are supposed to be performed within a narrow window. That problem was quickly fixed, she said.

Nobody is saying, “You got to turn this off”

The expert repair team sent out to Madigan in mid-January will remain through March, making some immediate patches while major software redesigns are performed at Cerner headquarters through May, Cummings said. Senior officials could sign off on the Pacific Northwest rollout — known as the initial operating capability, or IOC — in the summer. If that happens, the military will start implementing the next wave, with medical facilities from San Diego to Alaska going live in 2019.

In an interview, leaders of the project from Leidos, the lead contractor, Cerner and Accenture, another big subcontractor, said medical staff everywhere often react with frustration and anger to new digital record systems. But the executives acknowledged problems and said they were working together to fix them.

Cerner software templates that matched particular types of clinicians with access to certain information and capacities were mismatched with the military’s system, said Jerry Hogge, deputy group president of Leidos Health Solutions.

“We found we had to refine how roles and training were aligned, and the workflows we designed needed to be redesigned,” he said. “But that’s why we wanted to have the IOC, to shake all those things out.”

“The most challenging part of any of these deployments is the change process,” Hogge added. “The human nature part of learning something new.”

“They [physicians] say they want things better, but nobody is saying, ‘You got to turn this off,’” said David Norley, Cummings’ senior aide.

Cummings acknowledged that clinicians should have been taught more about the new processes required of them before the system went live. Officials are also working to make it easier for physicians to get into the system, but the military’s cybersecurity precautions mean it will never be as painless as in civilian medicine, she said.

In the six weeks since the review started, there have been changes for the better, at least at Madigan, the largest of the four facilities, said Marshall, who was chief medical information officer there before retiring three years ago. He returned in part to help with the implementation.

At Madigan, the system now shows physicians a single menu where they can view patients in outpatient, inpatient or maternity care, he said. Broken scroll bars that made it hard to order drugs or lab tests have been fixed.

“That doesn’t sound like much, but it’s extra seconds per patient,” Marshall said.

Physicians at Madigan and Bremerton said the software works well in their emergency rooms.

Madigan is the only of the four bases to have a team of medical IT experts who can speak the same language as both computer engineers and doctors.

Bigger challenges ahead for VA

The military’s troubles have offered the VA an opportunity to examine potential bugs before launching its Cerner project, which is expected to take 10 years.

“We’ve learned from where the Department of Defense would have chosen to go if they had the information we have now, and we think we’re working on a much better, stronger contract that will avoid some of the problems we’ve seen in [the MHS Genesis] implementation,” Shulkin told reporters last week.

Shulkin continues to say that when the problems are resolved and the system built, it will transform how information is shared among doctors and hospitals across the U.S. health care system. The VA eventually will get 30 percent more capability than the military has, he said.

However, MHS Genesis’ troubles alarm some VA officials, who note their health care system is vastly larger and more complex than the one run by the military. It also takes care of a generally sicker population, often dependent on records that stretch back decades.

Shulkin’s decision to delay the contract won widespread praise, but critics bemoan his decision last year to shutter an internal program to modernize the VA’s existing digital record system, known as VistA. Many health IT experts left the agency after cancellation of the program, which involved hundreds of staff and contractors.

Partly due to political strains at the agency, where Shulkin’s job appeared at risk, the VA is without senior officials who would make key decisions in the Cerner implementation. There is no chief information officer, for example, and the Veterans Health Administration lacks both a director and a senior IT officer.

“The VA is in kind of a holding pattern,” said a mid-level IT director there. “We don’t have advocates for some of the things that really need advocacy.”

VA spokesman Curt Cashour declined to allow the VA officials leading the Cerner deal to speak with POLITICO, citing the pending contract talks.

But four senior health IT experts who were involved in the internal project told POLITICO that while they understood Shulkin’s desire to jettison expensive programs, he might regret the loss of expertise and technology, which they believe could make the Cerner implementation truly transformative.

“We’re doing a once-in-a-lifetime replacement of an… [existing electronic health record system] that’s pretty functional — some of our physicians like it better than Epic or Cerner,” said a recently retired VA official. “Why replace it with something that’s basically the same?”

Two of the VA officials who left the agency expressed concern about whether clinicians will be able to access needed data from patients who are seen in both the Cerner and VA digital systems during the long conversion to Cerner. To achieve this goal will require significant investment, they said.

Shulkin has met with other software vendors and health care systems to discuss solutions that might tie together veteran and active duty records during the long transition to a single platform, according to a close associate.

House Veterans Affairs Chairman Phil Roe (R-Tenn.) recently visited Fairchild Air Force Base — home of the first military clinic rollout — and returned shaking his head. Roe, a retired obstetrician-gynecologist, noted that doctors at the base couldn’t easily call up patients’ records. The VA may face the same problems, he said.

The $10 billion Cerner contract, Roe noted, “doesn’t even include the costs of updating infrastructure to accommodate the new [record system], implementation support or sustaining VistA up until the day it can be turned off.”


Also see
Making Electronic Medical Records More Personal Wisconsin Public Radio
New VA CIO urged to avoid past EHR modernization mistakes Healthcare Informatics Institute
Lamwmaker: Don’t Let “Rudderless Leadership” Cripple VA Health Record Overhaul Nextgov
The U.S. Defense Department’s Deeply Flawed Electronic Health Records Program IEEE Spectrum
DoD-Cerner EHR project finding improvements, despite some challenges Healthcare IT News
DoD MHS Genesis EHR Implementation Proceeding on Schedule EHR Intelligence
VA to Complete Cerner EHR Implementation in 7 to 8 Years EHR Intelligence
Canadian Cerner EHR investigation finds install was mismanaged, underfunded Healthcare IT News
Canadian Cerner install under investigation again, but mishaps go deeper than the tech Healthcare IT News
Cerner Wins Bid to Redo Health Data The New York Times
Epic notches a first with Canadian EHR install Healthcare IT News
Nanaimo doctors say electronic health record system unsafe, should be shut down The Times Colonist

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