In abandoning VistA, VA faces culture change that’s ‘orders of magnitude bigger’ than expected

The recent announcement from the Veterans Affairs Department about its plans to abandon the Veterans Information Systems and Technology Architecture (VistA) and adopt a commercial, off-the-shelf electronic health record is earning some praise, some criticism and many more words of caution from federal IT experts.

In making the announcement, VA Secretary David Shulkin said he recognized the move is one that comes with an immense amount of risk. But as the department begins initial conversations with Cerner Corporation over the next three to six months, VA believes it can borrow some lessons learned from the Defense Department. The department purchased the same overall product that DoD uses but will make several changes to adjust to VA’s needs.

“Right now my issue is getting there quickly,” Shulkin told reporters June 20. “I’ve determined the best way to do this is directly with Cerner. We will be looking for help from what I would call an integrator through separate procurement strategies. I want to take advantage of what DoD already has learned, already has essentially carved the years off of our process for change management and … procurement and laying the foundation.”

There are many unknowns — namely with the project’s timeline and costs — but some federal IT experts say one thing is clear: the culture change associated with a such a massive undertaking will be the biggest challenge the department will face in adopting a new electronic record.

“No matter how much you accept that the culture change is going to be big and you talk about change management, the culture change is going to be orders of magnitude bigger than anybody thinks it’s going to be right now,” said Roger Baker, an independent consultant and former chief information officer for VA.

VA currently has more than 100 versions of VistA. Those versions exist because VA hospitals largely had the freedom over the past 40 years to change the software to conform to the standards their leaders and doctors wanted to see, Baker said.

“It’s an absolutely fundamental part of the [Veterans Health Administration] culture that the local facility is in charge of deciding how they will do medical care for the local veteran,” he said. “You’ve heard the old saying, ‘If you’ve seen one VA, you’ve seen one VA.’ That’s exactly what that means. They do not implement universally-standard processes across VA medical facilities. That’s what made VistA hard to move forward.”

But Baker said this precedent can’t continue as VA leaders begin to implement the new EHR. The department must push standardization without completely rejecting all ideas or suggested changes to Cerner’s off-the-shelf product.

“You’re going to have balance between the two, and you’re going to have to take the route of ‘we will not allow changes … willy-nilly or just because somebody thinks they’re a good idea,'” Baker said. “We’re going to have a change patrol board, and it’s going to be ruthless in its demand for why a change is needed.”

At the same time, VA leaders must find a way to  get buy-in from the department’s programmers, developers and IT specialists who stay on to begin the Cerner implementation.

The best way is to give them a new way to do their current jobs, said Robert Klopp, former CIO at the Social Security Administration. He led SSA’s IT modernization efforts over the past two years.

“Really what we need to change their behavior is to change the tools and environment that they have to work in,” he said. “If we give them modern tools and allow them to think about the problem in a modern way, like a Silicon Valley developer might think about it, instead of giving them ancient tools and highly prescriptive standards that are legacy standards, we can fairly quickly change their behavior and open their minds and things will start going in the right direction naturally. In other words, we’ll change the culture.”

Klopp said that approach worked well for SSA developers and IT specialists, who like many of their counterparts at VA, had worked on legacy IT systems for decades.

As VA fleshes out its procurement strategy, timeline and budget for the new EHR, it will continue to make upgrades and continue maintenance on VistA.

That news drew frustration from some lawmakers, but the department told a House Veterans Affairs subcommittee last week that it doesn’t expect to ask for additional appropriations to begin to pay for the new EHR. The president’s budget request in fact includes a $215 million cut to IT spending at VA in fiscal 2018.

Until it begins true implementation, VA will operate in a kind of “dual mode.”

“Dual mode doesn’t mean you leave the old guys behind,” Klopp said. “It just means that you accelerate movement toward modernity by creating a group that is completely modern and that creates some gravity that pulls the rest of the people along at a faster pace.”

He saw SSA employees take to these concepts more quickly and broadly than he first expected.

“That was far more effective than trying to slowly and incrementally move everybody toward modernity,” Klopp said.

Leadership

VA has not yet named a new chief information officer. Shulkin said during a June 14 budget hearing that a candidate for the CIO position withdrew his name but did not offer a more detailed explanation.

Regardless, the new CIO will need to strike a delicate balance, one that carefully creates a modern development environment where VA employees can be involved and innovative in the implementation process but one that also takes a firm stance on standardization.

This isn’t the time for “soft management,” Baker said, but one that embraces a “my way or the highway” mentality.

“If you’re too squishy, you’ll never get where you want to go, and so you have to take the hard road. To the extent you can be soft, you [can], but you have to recognize the decisions where you can’t be soft, and standardization is one of those areas where they just cannot be soft. The moment they start creating multiple versions of that software, they’re done.”

Though Klopp said he saw success in letting SSA employees innovate in non-traditional ways, he recognizes that having too many ideas can unnecessarily slow down and complicate development sprints.

“The CIO has to recognize when evaluating options is an opportunity to allow people to be creative to the benefit of the organization and when evaluating options is just analysis paralysis,” he said.

Both Klopp and Baker said the next VA CIO needs to be fearless: he or she will likely receive push-back from VA employees, Congress, veterans service organizations and the press.

“The culture change from implementing a commercial package for VHA, for the doctors, is going to be massive,” Baker said. “It will be the biggest possible culture change in the second biggest organization in government. That’s the real risk. Will they get VA doctors to accept? You can’t change the process. You must implement the national process … otherwise, they’ll end up with 126 versions of the commercial software. That is a pure failure path.”

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Yet Ed Meagher, a former deputy assistant secretary and deputy CIO for VA, believes the coming move to a commercial EHR will, in fact, prompt VA clinicians to change the way they care for and treat veterans, but not for the better.

VistA was built for caregivers in mind, he said. But commercial EHRs are designed with insurance providers in mind, and Meagher said the move will force VA doctors to think more about documenting costs and less about caring for veterans.

“Any time you try to change someone’s business process — how they do their business the way they’ve been trained — you have a long, hard road ahead of you, a real bumpy road,” Meagher said.

But VA leaders must acknowledge that the department may risk losing talented health care professionals in order to win the data standardization debate.

“The CIO is going to have to make a lot of decisions that really are above his or her pay grade, but they’re in the IT expertise lane,” he said. “Where he or she needs to be is for Secretary Shulkin to have said, ‘You make the decision, I’ll make the mistake.'”