Electronic health records: VA must identify and report system costs

What GAO found

The Department of Veterans Affairs (VA) has various documents and a database that describe parts of the Technology Architecture and Veterans Health Information Systems (VistA); however, the ministry does not have a complete definition of the system. For example, VA identified the components that make up VistA, identified system-related interfaces, and collected system user guides and installation manuals. VA has also conducted analysis to better understand the customization of VistA components in various medical facilities. However, the existing information and analysis does not provide a deep understanding of the local customizations reflected in approximately 130 versions of VistA that support healthcare delivery at more than 1,500 locations. Program officials said they had not been able to fully define VistA due to the decentralization of system development for over 30 years. Cerner’s contract to deliver a new electronic health record system to VA calls for the company to perform comprehensive assessments to identify site-specific requirements where its system is slated to be deployed. Three site assessments have been completed and additional assessments are planned. If these assessments provide a deep understanding of the 130 versions of VistA, the service should be able to define VistA and be in a better position to transition to the new system.

VA identified costs for VistA and its related activities totaling approximately $ 913.7 million, $ 664.3 million and $ 711.1 million during fiscal years 2015, 2016 and 2017, respectively, for a total of approximately $ 2.3 billion over 3 years. However, of the $ 2.3 billion, the department could not demonstrate that about $ 1 billion of these costs were sufficiently reliable. Additionally, the department omitted VistA costs from the total. Part of the lack of a sufficiently reliable and complete total cost for VistA is the failure to follow a well-documented methodology that describes how the ministry determined the costs of the system. Due to incomplete cost data and data that could not be deemed reliable enough, the ministry, lawmakers and the public do not have a full understanding of the cost of developing and maintaining VistA. In addition, VA does not have the information necessary to make decisions about maintaining 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 staffing a program office, forming a governance structure, conducting initial site assessments, preparing program plans to guide implementation. initial system implementation and definition of a baseline to help guide implementation at initial sites. . The ministry’s actions in these important areas are continuing. Further steps are underway to address GAO’s September 2018 recommendation that the VA clearly define the roles and responsibilities of the Department of Defense (DOD) and the VA Interagency Program Office in the department’s governance plans for the new electronic health record system. VA intends to continue to mature and fully establish a program management organization and program governance structure to monitor 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 over 30 years old, expensive to maintain, and does not fully support the exchange of health data with DOD and private health care providers. For almost 2 decades, VA pursued multiple efforts to modernize the system. In June 2017, the ministry announced its intention to acquire the same system, the Cerner system, that the 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 Cerner system acquisition. The objectives of the review were to (1) determine how well VA has defined VistA, (2) estimate the annual costs of VA to develop and maintain VistA, and (3) describe the actions VA has taken to move from VistA to identify. system.

GAO has analyzed the documentation that defines aspects of VistA and identifies components to be replaced; assessed the reliability of cost data, including obligations associated with the development and maintenance of VistA for fiscal years 2015, 2016 and 2017; and reviewed program documentation related to the program, governance and transition plans from IL to Cerner.


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