GAO Report Outlines EHRM Change Management Issues, Low User Satisfaction

The Department of Veterans Affairs (VA) needs to address user satisfaction and change management activities for the EHR Modernization (EHRM) program, according to a Government Accountability Office (GAO) report.

In June 2017, VA initiated the EHRM program to replace its legacy EHR system with the same Oracle Cerner platform the Department of Defense (DoD) was acquiring. 

GAO completed a review to evaluate VA’s use of organizational change management strategies for the EHRM.

The report found that VA was partially consistent with the following seven leading practices for organizational change management:

• Developing a vision for change
• Identifying and managing stakeholders
• Communicating effectively
• Assessing the readiness for change
• Identifying and addressing potential barriers to change
• Establishing targets and metrics for change
• Evaluating the results of change

The report noted that “partially consistent” indicates that VA conducted organizational change management activities based on some leading practice criteria but did not follow certain key aspects.

For instance, while the EHRM program defined a communication plan to engage with stakeholders involved with the implementation, users said that VA did not effectively communicate information on system changes after deployment. One user stated that a system update caused changes to their clinical workflows without being notified before the update.

Further, GAO found that VA was inconsistent with leading practices for the change management strategy of “increasing workforce skills and competencies.”

While the program outlined training objectives, site preparation steps, key milestones for training, and a continuous improvement process, training has been a weakness for the EHRM. GAO officials said EHR training was a concern for users at Mann-Grandstaff in change readiness questionnaires.

Further, the VA’s Office of Inspector General (OIG) identified numerous issues with training in a July 2021 report, including insufficient time for training, limitations with the training domain, challenges with user role assignments, and gaps in training guidance.

“Until the program fully implements the eight leading practices for change management, future deployments are at risk of continuing change management challenges,” officials wrote in the report. “These challenges hinder effective use of the new EHR system, impede users’ knowledge of new workflows, and limit the utility of system improvements.”

GAO also reviewed the results of VA surveys to determine end-users’ satisfaction with the EHR.

Officials found that most users have voiced dissatisfaction with the new EHR. VA’s 2021 and 2022 surveys showed that end-users were unsatisfied with the system’s performance or training.

Additionally, only about 6 percent agreed that the EHR enabled quality care, and 4 percent of end-users said the system made them as efficient as possible. Further, VA has not created targets to evaluate 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,” GAO representatives wrote.

Lastly, GAO’s review revealed that VA did not adequately identify and address system issues. Specifically, VA did not ensure that its contractor resolved trouble tickets for the new EHR within timeliness goals.

While VA later worked with the contractor to reduce the number of tickets over 45 days old, the number of open tickets has increased steadily since 2020.

“Accordingly, it is critical that system issues be resolved in a timely manner,” the report authors wrote. “Additionally, although VA has assessed the system’s performance at two sites, as of January 2023, it had not conducted an independent operational assessment.”

GAO said that without an independent assessment, VA will be restricted in identifying, tracking, and resolving key operational issues.