Electronic Health Record Modernization: VA Needs to Address Change Management Challenges, User Satisfaction, and System Issues

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

Source: GAO analysis of Department of Veterans Affairs (VA) data. | GAO-23-106685

Legend: Consistent – VA provided evidence that it conducted organizational change management activities mostly consistent with leading practices. Partially consistent – VA provided evidence that it conducted organizational change management activities consistent with some of the leading practice criteria, but some key parts were not followed. Not consistent – VA did not provide sufficient evidence that it followed leading practices.

Until the program fully implements the eight leading practices for change management, future deployments are at risk of continuing change management challenges. These challenges hinder effective use of the new electronic health record (EHR) system, impede users' knowledge of new workflows, and limit the utility of system improvements.

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 6 percent (120 of 2,066) of users agreed that the system enabled quality care. In addition, about 4 percent (92 of 2,074) of users agreed 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. 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.

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 provide health care to its patients. In June 2017, VA initiated the EHRM program to replace VistA because it is technically complex, costly to maintain, and does not fully support the need to exchange health data with other organizations. Specifically, VA began to acquire the same EHR system DOD was acquiring. VA has reported obligating about $9.42 billion on EHRM from fiscal year 2018 through the first quarter of fiscal year 2023.

GAO was asked to testify on its recently completed review to determine the extent to which VA has (1) used organizational change management strategies for the EHRM program consistent with leading practices, (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 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 system trouble ticket data and compared them to VA's service level agreement with its contractor.