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Electronic Health Records: Challenges with VA's New System Call for Management Improvements

GAO-23-106785 Published: May 09, 2023. Publicly Released: May 09, 2023.
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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.

We testified that the new system has presented issues for some users. For example, many users said that they weren't adequately trained to use the new system. Users also said that the pharmacy-related part of the system contributed to patient safety risks.

VA hasn't established goals to assess user satisfaction with its new IT system. Until it does so, VA won't have enough information to determine if the system can be deployed to additional locations.

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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-23-106785

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 expressed dissatisfaction with the new system. VA's surveys showed that users were not satisfied with the system's performance and training. About 79 percent (1,640 of 2,066) of responding users disagreed or strongly disagreed that the system enabled quality care. In addition, users in GAO's structured interviews said the pharmacy-related system module presented challenges, such as incorrect medication orders and increased prescription processing times, which contributed to patient safety risks. 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 validate that the system is operationally suitable and effective.

Subsequent to GAO's review, 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. 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 recent review 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. For its recent review 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 and related data regarding VA's service level agreement with its contractor.


GAO made 10 recommendations to VA in its recent review to address change management, user satisfaction, system trouble ticket, and independent operational assessment deficiencies. VA concurred with the recommendations.

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Best practicesBusiness systems modernizationChange managementElectronic health recordsHealth careHealth care administrationHealth care standardsHealth care systemsInformation technologyOrganizational changeVeteransVeterans affairs