Electronic Health Records: VA Needs to Identify and Report System Costs

GAO-19-125 Published: Jul 25, 2019. Publicly Released: Jul 25, 2019.
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Fast Facts

The VA’s health information system is more than 30 years old and is costly to maintain. Over nearly 2 decades, VA’s multiple modernization efforts have continually fallen short.

In June 2017, VA announced it would buy the same system DOD is implementing. VA plans to continue using its current system during a decade-long transition.

We reviewed the early stages of this transition. Among other things, we found VA lacked insight into the total costs for the current system. This could make it more difficult to make decisions during the transition to the new system.

We recommended VA more reliably identify and report system costs.

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What GAO Found

The Department of Veterans Affairs (VA) has various documents and a database that describe parts of the Veterans Health Information Systems and Technology Architecture (VistA); however, the department does not have a comprehensive definition for the system. For example, VA has identified components that comprise VistA, identified interfaces related to the system, and collected system user guides and installation manuals. VA has also conducted analyses to better understand customization of VistA components at various medical facilities. Nevertheless, the existing information and analyses do not provide a thorough understanding of the local customizations reflected in about 130 versions of VistA that support health care delivery at more than 1,500 sites. Program officials stated that they have not been able to fully define VistA due to the decentralization of the development of the system for more than 30 years. Cerner's contract to provide a new electronic health record system to VA calls for the company to conduct comprehensive assessments to identify site-specific requirements where its system is planned to be deployed. Three site assessments have been completed and additional assessments are planned. If these assessments provide a thorough understanding of the 130 VistA versions, the department should be able to define VistA and be better positioned to transition to the new system.

VA identified costs for VistA and its related activities adding up to approximately $913.7 million, $664.3 million, and $711.1 million in fiscal years 2015, 2016, and 2017, respectively—for a total of about $2.3 billion over the 3 years. However, of the $2.3 billion, the department was only able to demonstrate that approximately $1 billion of these costs were sufficiently reliable. In addition, the department omitted VistA-related costs from the total. The lack of a sufficiently reliable and comprehensive total cost for VistA is due in part to not following a well-documented methodology that describes how the department determined the costs for the system. As a result of incomplete cost data and data that could not be determined to be sufficiently reliable, the department, legislators, and the public do not have a complete understanding of how much it has cost to develop and maintain VistA. Further, VA lacks the information needed to make decisions on sustaining the many versions of the system.

VA has initiated a number of actions to prepare for the transition from VistA to the Cerner system. These actions include taking steps to establish and begin to staff a program office, forming a governance structure, conducting assessments at the initial sites, preparing program plans to guide the initial system implementation, and setting a program baseline to help guide implementation at the initial sites. The department's actions in these important areas are ongoing. Additional actions are in progress to address GAO's September 2018 recommendation that VA clearly define the role and responsibilities of the joint Department of Defense (DOD) and VA Interagency Program Office in the department's governance plans for the new electronic health record system. VA intends to continue maturing and fully establishing a program management organization and a program governance structure to track program progress.

Why GAO Did This Study

VA provides health care services to approximately 9 million veterans and their families and relies on its health information system—VistA—to do so. However, the system is more than 30 years old, is costly to maintain, and does not fully support exchanging health data with DOD and private health care providers. Over nearly 2 decades, VA has pursued multiple efforts to modernize the system. In June 2017, the department announced plans to acquire the same system—the Cerner system—that DOD is implementing. VA plans to continue using VistA during the decade-long transition to the Cerner system.

GAO was asked to review key aspects of VistA and VA's plans for the new acquisition of the Cerner system. The objectives of the review were to (1) determine the extent to which VA has defined VistA, (2) evaluate VA's annual costs to develop and sustain VistA, and (3) describe the actions VA has taken to transition from VistA to the Cerner system.

GAO analyzed documentation that defines aspects of VistA and identifies components to be replaced; evaluated the reliability of cost data, including obligations associated with the development and sustainment of VistA for fiscal years 2015, 2016, and 2017; and reviewed program documentation related to VA's program, governance, and plans to transition to Cerner.

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GAO is recommending that VA develop and implement a methodology for reliably identifying and reporting the total costs of VistA. VA agreed with the recommendation.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Secretary of VA should direct the Under Secretary for Health and the Assistant Secretary for Information and Technology/Chief Information Officer to develop and implement a methodology for reliably identifying and reporting the total costs of VistA. The methodology should include steps to identify the definition of VistA and what is to be included in its sustainment activities, as well as ensure that comprehensive costs are corroborated by reliable data. (Recommendation 1)
Closed – Implemented
The Department of Veterans Affairs (VA) concurred with our recommendation. According to VA officials, the department established a project team to define the scope of the Veterans Health Information Systems and Technology Architecture (VistA) and to develop a methodology for identifying and reporting the total costs of VistA. In October 2020, this team formally documented a cost methodology that defined the core, peripheral, and associated components of VistA and described how costs were to be captured. Further, VA officials provided the comprehensive costs for VistA for fiscal year 2019 using the documented approach, including costs related to sustainment. As a result of the department's efforts and its cost methodology, VA will be positioned to calculate comprehensive and reliable cost information needed to make critical management decisions for sustaining the system and ensuring an accurate basis for reporting on the return on its investment in replacing VistA.

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