VHA manages one of the largest health care delivery systems in the United States and is responsible for overseeing the provision of health care at VA medical facilities. VA relies on its EHR system—VistA—to document the delivery of health care services to veterans. To facilitate care, clinical providers access patient medical records and document the care they provide in EHR systems. Patient information needs to be accessible and consistent to prevent risks to patients’ safety, particularly when shared between providers. Information that is electronically exchanged from one provider to another must adhere to the same standards to be consistently interpreted and used in EHRs. In our prior work, we found that EHR technology has the potential to improve the quality of care that patients receive and to reduce health care costs. VistA has served as VA’s EHR system for more than 30 years. Over the last several decades, it has evolved into a technically complex system that comprises about 170 modules that support health care delivery at more than 1,500 medical facilities. In addition, customization of VistA, such as changes to the modules by the various medical facilities, has resulted in approximately 130 versions of the system VA-wide. Furthermore, as we have reported, VistA is costly to maintain and does not fully support VA’s need to electronically exchange health records with other organizations, such as DOD and community providers. VA and DOD have historically operated separate EHR systems. In addition to patient data from its own EHR system, VA relies on patient data from DOD to help ensure that it has access to the necessary health information that could assist clinicians in making informed decisions to provide care to service members transitioning from DOD to VA’s health care system. We have previously reported on VA’s challenges in managing health information technology and modernizing VistA. In 2015, we designated VA health care as a high-risk area for the federal government, in part due to its information technology challenges. Specifically, we identified limitations in the capacity of VA’s existing information technology systems, including the outdated, inefficient nature of key systems and a lack of system interoperability, as contributors to the department’s challenges related to health care. In our 2019 update to the high-risk series, we stressed that VA should demonstrate commitment to addressing its information technology challenges by stabilizing senior leadership, building capacity, and finalizing its action plan for addressing our recommendations, and by establishing metrics and mechanisms for assessing and reporting progress. We also have issued numerous reports over the last decade that highlighted the challenges facing VA in modernizing VistA and improving EHR interoperability with DOD. VA created the Office of Electronic Health Record Modernization in 2018 to lead its EHRM program effort, which was intended to result in a more modern EHR system that would improve providers’ ability to deliver care, and share health data, including between VA and DOD and between VA and community providers. For example, with improved interoperability, medical providers would have the ability to query data from other sources while managing chronically ill patients, regardless of geography, or the network on which the data reside. In June 2017, the VA Secretary at the time announced that the department planned to acquire and configure the same EHR system that DOD is currently implementing across the military health system. According to the VA Secretary, the department decided to acquire the same system as DOD because it would allow all of VA’s and DOD’s patient data to reside in one system, thus assisting the departments in their goals of enabling seamless care between VA and DOD without the exchange and reconciliation of data between two separate systems. As VA planned to implement the same system DOD is implementing, experts recommended that VA and DOD coordinate to ensure that the departments could leverage efficiencies and minimize variation between the departments’ EHR system configurations when practical. DOD’s initial implementation of the Cerner EHR system occurred between February and October 2017 at four military treatment facilities in the state of Washington. In September 2019, the system was implemented at four additional military treatment facilities in California and Idaho. DOD plans to continue to implement the EHR system in 23 phases through 2023 with the next implementation expected to take place at eight additional military treatment facilities in California and Nevada. VA’s EHRM program originally planned to implement the Cerner EHR system at two VA medical facilities in spring 2020 with a phased implementation of the remaining facilities over the next decade. The EHRM program chose the Mann-Grandstaff VA Medical Center in Spokane, Wash. and the VA Puget Sound Health Care System in Seattle, Wash. as its initial operating capability sites. Information gathered from these sites will be used to help VA make EHR system configuration decisions and standardize work processes for future locations where the commercial EHR system will be implemented. In August 2019, the EHRM program adjusted its schedule to implement the commercial EHR system at these two sites in two phases, known as capability sets 1 and 2: Capability set 1 includes key EHR functionalities necessary to implement the system at the Mann-Grandstaff VA Medical Center, a level 3—that is, less complex—facility. Capability set 1 was originally scheduled for implementation in March 2020. Capability set 2 includes remaining functionalities necessary to implement the system at the VA Puget Sound Health Care System, a level 1—that is, highly complex—facility, in the fall of 2020. In February 2020, VA postponed the implementation of the Cerner EHR system at the Mann-Grandstaff VA Medical Center until July 2020. According to VA officials, the additional time will allow Cerner to develop and establish a more complete and robust training environment, as requested by VHA clinicians and other facility staff. In addition, according to VA EHRM program officials, the implementation delay will allow VA and Cerner to have time to develop additional interfaces between the Cerner EHR system and other VA systems, such as VA’s mail-order pharmacy system. These officials told us that the delayed implementation of the Cerner EHR system at the Mann-Grandstaff VA Medical Center was not expected to impact VA’s timeline for implementing the EHR system at the VA Puget Sound Health Care System in the fall of 2020. In April 2020, the VA Secretary announced that the department had shifted priorities to focus on caring for veterans in response to the pandemic created by the Coronavirus Disease 2019 (COVID-19). Further, the Secretary directed the EHRM program to allow clinicians who had been participating in EHRM program activities to focus on caring for veterans. According to program officials, they paused the implementation of the EHR system and were assessing the impact of the COVID-19 pandemic on VA’s planned implementation schedule. VA’s EHRM program used a multi-step process to make EHR system configuration decisions for the Cerner EHR system being implemented at the VA Mann-Grandstaff Medical Center and Puget Sound Health Care System. This process included forming EHR councils and convening these councils at national and local workshops to make configuration decisions used by VA’s contractor, Cerner, to configure the new EHR system. The EHR councils also assessed the compatibility of the EHR system with the processes VA clinicians and staff follow in delivering care. EHR councils. In fall 2018, VA’s EHRM program established 18 EHR councils, based upon specific clinical and administrative areas, to make VA-specific EHR system configuration decisions for these areas. Each EHR council included subject-matter experts from VA, such as health care providers in various clinical areas and other staff, as well as non-VA participants from DOD and Cerner. According to VA EHRM program officials, Cerner’s typical process for configuring its EHR system was modified to accommodate VA’s needs, which VA officials stated were more complex than those of Cerner’s commercial clients. According to Cerner officials, Cerner does not typically establish councils as part of its EHR system configuration process. National workshops. VA’s EHRM program planned and held eight national workshops from November 2018 to October 2019, during which members of all 18 EHR councils met to make standardized EHR system configuration decisions for the VA health care system. VA’s EHRM program utilized DOD’s version of the Cerner EHR system—MHS Genesis—as its starting point for the EHR system configuration process. During the workshops, Cerner assigned consultants to facilitate these workshops, who highlighted Cerner’s commercial best practices and prepared workflow designs, according to VA EHRM program and Cerner officials; facilitated EHR system configuration decision discussions and noted input from EHR council members and other session participants such as DOD representatives; held sessions that involved members from different EHR councils for system configuration decisions that required coordination between councils. For example, the Business Operations Council and the Ambulatory Council held joint sessions to address scheduling appointments for oncology patients; was responsible for identifying and documenting recommendations for EHR system configuration decision differences between VA sites, and each medical facility specialty/department; and provided weekly progress updates to VA that reflected overall progress of expected decisions to be completed compared to the actual approved EHR system configuration decisions during national workshops. Over the course of the eight national workshops, EHR council members were responsible for making EHR system configuration decisions in given clinical and administrative areas and communicating them to Cerner; providing progress updates to VA’s EHRM program and VA leadership; and notifying appropriate governing bodies (e.g., VHA program offices— such as the Office of Primary Care) of any local, state, federal, VISN, and department policies that impact configuration decisions. More specifically, each council discussed VA’s work processes and documented relevant information that informed the configuration of the EHR system, including: (1) “workflows”—”process maps” that capture the start-to-finish sequence and interactions of related steps, activities, or tasks for each work process that VA medical facilities follow. For example, VA has a medication administration workflow for describing the sequence of tasks needed for scanning a patient’s wristband and administering medication. (See fig. 1.) (2) “design decision matrices,” which are compilations of decisions and discussion topics that identify and resolve workflow questions to inform configuration decisions and support implementation of the EHR system. For example, the medication administration design decision matrix documents that clinicians should not be prevented from proceeding with medication administration if a patient’s wristband cannot be scanned. (See fig. 2.) (3) “data collection workbooks,” which capture all of the data needed to inform how the EHR system should be configured to support each workflow, such as user privileges and preferences. For example, a data collection workbook for medication administration includes data on user preferences and prescribing privileges. (See fig. 3.) The EHR system configuration decisions each council needed to make varied significantly in quantity and topic. For example, the Ambulatory Council, charged with focusing on primary care decisions, had over 200 EHR system configuration decisions to make, while the Behavioral Health Council had about 100. Once configuration decisions were made, the EHR councils assessed the compatibility of the configuration of the Cerner EHR system with VA work processes. To do so, VA’s EHR councils reviewed the capabilities of the system and identified work processes that the Cerner EHR system did not support (or only partially supported). For example, according to VA Mann- Grandstaff Medical Center staff, the Cerner EHR system did not originally interface with VA’s Patient Centered Management Module, which supports VA’s work processes for establishing provider-patient relationships. However, in March 2020, VA EHRM officials told us that the interface between the two systems would be available when the Cerner EHR system is implemented at the Mann-Grandstaff VA Medical Center, which was planned for July 2020. In addition, according to VA EHRM officials, Cerner is in the process of developing EHR system capabilities for prosthetics to support VA work processes. Furthermore, according to VA EHRM officials, Cerner has been documenting and tracking needed capabilities for EHR implementation and updating VA’s EHRM program accordingly. According to EHRM program officials, Cerner plans to include functionalities not available in capability set 1 in either capability set 2 or future capability sets, although the development of these capabilities is an ongoing process. Although the eight national workshops have concluded, since October 2019, these EHR councils have continued to meet as necessary, virtually, and in person, to complete capability set 1 and 2 configuration decisions. According to Mann-Grandstaff VA Medical Center staff, as of February 2020, VA still needed to make EHR system configuration decisions to address online prescription refills and assigning patients to primary care panels. Local Workshops. After standardized EHR system configuration decisions were made at the national workshops, they were reviewed at local workshops for site-specific needs. To do this, from December 2018 to October 2019, VA’s EHRM program held eight local workshops at each of the initial operating capability sites—the Mann-Grandstaff VA Medical Center and the VA Puget Sound Health Care System. Local workshops allowed VA and Cerner to identify variances from standardized EHR system configuration decisions made at the national workshops as well as manual processes that needed to be accounted for at local medical facilities. If variances were identified, Cerner reported them to the appropriate EHR councils. While VA tried to minimize the variances in system configuration decisions, in certain cases, necessary alternatives to these configuration decisions were approved for local medical facilities if practicable. For example, according to a Cerner official, the national emergency room triage workflow originally called for an emergency department registrar to register a patient; in response to input from a local workshop, VA developed an alternative workflow, in which an emergency department registered nurse completes the step if a VA facility does not have an emergency department registrar. If there were no variances, EHR system configuration decisions were approved and reported to Cerner to configure the EHR system. According to EHRM program officials, VA plans to hold local workshops in advance of the Cerner EHR system implementation at future VA medical facilities to focus on site-specific configuration decisions. Cerner will continue to facilitate these future local workshop sessions and configure the EHR system based on decisions made at these sessions. Figure 4 provides an overview of the EHR councils’ process for making system configuration decisions. VA met its schedule for making EHR system configuration decisions for capability set 1, which was scheduled for initial implementation at the Mann-Grandstaff VA Medical Center in July 2020. In addition, VA has formulated a schedule for remaining EHR system configuration decisions for capability set 2, which it planned to implement at the VA Puget Sound Health Care System in the fall of 2020. Our review of VA progress data shows that VA met the schedule for making EHR system configuration decisions it had established, which required VA’s 18 EHR councils to make at least 70 percent of decisions needed for capability set 1 by October 18, 2019. An EHRM program official stated that this threshold was required to enable Cerner to configure the EHR system for the Mann-Grandstaff VA Medical Center in anticipation of the system’s initial implementation. According to VA’s progress data, collectively, the 18 EHR councils met the requirement to make at least 70 percent of their total expected EHR system configuration decisions for capability set 1. Specifically, as of early November 2019, VA data for EHR configuration decisions needed for capability set 1 indicated that the EHRM program had developed: 877 of 966 (or 91 percent) of workflows; 1,397 of 1,412 (or 99 percent) of design decision matrices; and 1,364 of 1,610 (or 90 percent) of data collection workbooks. After the EHR councils collectively met VA’s goal to make 70 percent of EHR system configuration decisions by October 18, 2019, efforts continued to make the remaining decisions for capability set 1. In March 2020, VA data indicated that, combined, the EHR councils had developed an additional: 9 percent of workflows—874 of 878 (or nearly 100 percent); 1 percent of design decision matrices—1,459 of 1,467 (or nearly 100 10 percent of data collection workbooks—1,746 of 1,751 (or nearly 100 percent). (See Appendix I for additional details on specific changes from November 2019 to March 2020 by EHR councils.) As noted earlier, though the workshop process has concluded, a VA EHRM program official stated that they had plans to hold virtual—over teleconference or videoconference—meetings to allow the EHR councils to make remaining EHR system configuration decisions for capability set 1 at the Mann-Grandstaff VA Medical Center, by March 2020. VA’s EHRM program has formulated a schedule for making EHR system configuration decisions for capability set 2, which are necessary to support the implementation of the Cerner EHR system at the VA Puget Sound Health Care System planned for the fall of 2020. Specifically, VA’s EHRM program is continuing to make EHR system configuration decisions outside of the workshop process, which concluded in October 2019. Currently, EHRM program officials have plans to hold smaller meetings, about a fourth of the size of the national workshops, to make EHR configuration decisions that require input from multiple councils for capability set 2. According to EHRM program officials, the program set a goal of developing capability set 2 workflows, design decision matrices, and data collection workbooks by May 2020 so that the EHR councils could start validating the system configuration decisions at that time. EHRM program officials anticipate that this schedule for capability set 2 gives Cerner enough time to configure the EHR system and establish a training environment to enable implementation of the EHR system at the VA Puget Sound Health Care System planned for the fall of 2020. According to program officials, capability set 2 is composed of about 90 percent of configuration decisions for capability set 1 and 10 percent of additional workflows and data collection workbooks. These officials also told us that, as part of the process of making capability set 2 configuration decisions, they would determine the effectiveness of these decisions based on the implementation of capability set 1 at the Mann-Grandstaff VA Medical Center and make any necessary changes. VA’s EHRM program established EHR council decision-making procedures that were generally effective. In addition, the councils included a wide range of stakeholders, in terms of geographic representation and representation from VA central office, VISNs, and medical facilities. However, according to EHR council participants, VA did not always ensure adequate representation at local workshops. VA’s EHRM program’s decision-making procedures for the EHR councils were generally effective as demonstrated by adherence to applicable federal standards for internal control. According to these standards, management should establish an organizational structure, assign responsibility, and delegate authority to achieve the entity’s objectives. In addition, according to our leading collaboration practices, clarity can come from agencies working together to define and agree on their respective roles and responsibilities and participating agencies should document their agreement. VA’s EHRM program established the organizational structure, assigned responsibility, and delegated authority for system configuration decisions to the EHR councils. Specifically, the EHRM program developed a charter for the councils that outlined each council chair’s responsibility for managing council membership and ensuring it is consistent with guidelines for broad representation; outlined council member roles and responsibilities, such as participating in face-to-face meetings and conferences, providing subject matter expertise, and guiding EHR system configuration decisions; and delegated authority for EHR system configuration decisions from the EHRM Chief Medical Officer to the council chair and members. According to EHRM program documentation, VA established decision- making authority at the lowest level possible, beginning with the EHR councils, to ensure timely and appropriate decision-making. Based on our observations of national council workshop meetings, if a council had questions that involved coordination with another council, the Cerner consultant present would take note of the issue and coordinate a meeting with the relevant councils to discuss the issue. For example, participants from the Ambulatory Council met with participants from the Rehabilitation and Acute Clinical Ancillaries Council to discuss the EHR system configuration decisions for ordering glasses and contacts. Based on our review of the Functional Governance Board charter and meeting minutes, when a decision required coordination and could not be made at the EHR council level, it was identified and escalated to the Functional Governance Board. The Functional Governance Board provided guidance on addressing issues or, in turn, escalated unresolved issues to the higher-level Governance Integration Board, or if appropriate, to a joint VA and DOD coordination process. According to EHRM program officials, as of February 2020, there were no issues escalated from the Functional Governance Board to the Governance Integration Board because the council governance structure strived to make decisions at the lowest level possible. Figure 5 provides an overview of the EHRM program’s decision-making procedures. With respect to collaboration, because VA is using the same system as DOD, VA has had to coordinate with DOD on some decisions. Although both departments have procedures for configuring the Cerner EHR system for their individual needs, VA EHRM program officials noted the importance of coordinating to design a system that would allow sharing of information and tasks between VA and DOD. According to VA EHRM program officials, for example, VA and DOD coordination is necessary for workflows pertaining to durable orders for life-sustaining treatments—medical treatments intended to prolong the life of a patient who would die soon without the treatment (e.g., artificial nutrition and hydration, and mechanical ventilation). VA and DOD’s practices differed on how to address such treatment, and Cerner’s process did not accommodate VA’s need to maintain durable orders across patient encounters, so they would not need to be re-written every time a patient changed care setting or location. VA requested changes to the Cerner EHR system to allow it to continue to follow its current process for documenting life-sustaining treatments, but according to DOD officials, the proposed changes did not align with DOD’s position on such treatments, specifically resuscitation statuses. After multiple discussions between the VA and DOD clinicians, the two departments plan to adopt an interim solution. According to VA and DOD officials, VA and DOD’s joint decision-making body, the Functional Decision Group, has met weekly to address coordination issues since early 2019. These officials said that the joint Functional Decision Group determined whether it could make a decision, or whether additional information was needed and a team should be established to work on dispute resolution between the departments. VA EHRM program officials said that the coordination procedures for the joint Functional Decision Group would be formalized and that the roles and responsibilities for coordination between VA and DOD would be clearly defined, in response to a recommendation we made in a previous report. Specifically, VA and DOD have developed a charter for the joint Functional Decision Group, which was signed in April 2020. According to EHR council participants, VA and DOD had been developing their coordination procedures as system configuration decisions were made, and decisions that required input from both departments may not have been as timely as they could have been. According to EHRM program officials, the departments ultimately were able to address most decisions and coordination on remaining decisions was ongoing as of March 2020. VA’s EHRM Program Largely Met EHR Council Charter Goals for Representation VA generally included a wide range of stakeholders in its 18 EHR councils. Specifically, VA was largely in line with its EHR councils’ charter goals to include about 60 percent of council members from the field, with the remainder from the central office, and to have representatives from a range of geographic locations and with sufficient experience and expertise: VA data show that EHR councils had about 58 percent (607 of 1,039) of its members representing the field and about 40 percent (415 of 1,039) representing VA’s central office, roughly in line with VA’s goals. The councils included participants from a variety of geographic regions, including each of its 18 VISNs, with the most participants representing VISN 20, which oversees the two medical facilities where the new EHR system is scheduled to be initially implemented. Participants primarily represented the most complex level of VA medical facilities. Specifically, VA data show that about 83 percent (861 of 1,039) of participants represented level 1 VA medical facilities, whereas about 3 percent (33 of 1,039) and 7 percent (75 of 1,039) represented medium (level 2) and low (level 3) complexity VA medical facilities, respectively. EHRM program officials said that the majority of participants represented higher-complexity facilities because participants were drawn from national experts and published authors, and often performed VA-specific processes. Furthermore, smaller medical centers had fewer resources so clinicians were more likely to be needed to continue providing patient care at those facilities and less likely to be available to serve on councils. According to a voluntary questionnaire VA asked council participants to complete, about 37 percent of the 304 participants who completed the survey had at least 6 years of experience at VA; 29 percent had at least 16 years of experience; and, 19 percent had more than 25 years of experience. In addition to participants from the VA, we observed that EHR council national workshop meetings included participants from outside of the department—such as clinicians from DOD sites and commercial health care systems that had already implemented Cerner’s EHR system. These participants provided support for discussions and insight into industry best practices. While the EHR councils included a wide range of participants, in September and October 2019, council participants from both of the initial operating capability sites raised concerns that the councils did not include adequate representation from specialty areas at national workshop meetings. Specifically, these officials said that an insufficient number of specialty physicians, including pulmonologists and gastroenterologists, were included. In addition, VA’s summary from the last workshop, national workshop 8, observed that additional subject matter experts representing medical specialties should be included in the EHR system configuration decision process to enhance collaboration and decision- making. EHRM program officials, including the Chief Medical Officer and Ambulatory Council chairs, said they had not included certain specialists and scheduled workshops on specialty areas, such as pulmonology and gastroenterology as they decided to focus first on more foundational decisions, such as those for primary care. Starting in November 2019, following the completion of the eight national workshops, VA EHR councils continued to meet, as necessary, to complete capability set 1 and 2 configuration decisions and had begun to include clinicians from specialty areas in these meetings. VA plans to continue these meetings through September 2020. VA’s approach of including clinicians from specialty areas in ongoing configuration decision meetings is generally consistent with our leading collaboration practice that agencies should ensure that all relevant participants be included in any collaborative effort they undertake. By including relevant participants, the program increases the likelihood that it has considered input from participants with unique knowledge, skills, and abilities. Further, including relevant participants increases the likelihood that when implemented, the EHR system will be properly configured to meet the needs of clinicians, and effectively support their efforts to deliver care. VA’s EHRM Program Did Not Always Include Key Stakeholders at Its Local Workshops Local workshops at the Mann-Grandstaff VA Medical Center and VA Puget Sound Health Care System did not always include representation from relevant stakeholders, including facility clinicians and staff. Specifically, multiple participants in the local workshop meetings, including clinicians and department leads, at these facilities said that VA’s EHRM program did not always effectively communicate information about local workshop meetings to facility clinicians and staff to facilitate the designation of staff to participate and ensure relevant representation at local workshops. Local workshop participants stated that they did not always know which local workshop meetings they needed to attend, because they did not receive adequate information about the session topics. This is inconsistent with key collaboration practices identified in our prior work to ensure that relevant participants be included in any collaborative effort and that participating entities have agreed on common terminology. Furthermore, standards for internal control in the federal government call for effective communication and information sharing. Local workshop participants, including clinicians and department leads from medical facilities said that differences in the use of terminology between VA and Cerner sometimes made it challenging to identify the clinicians and staff that should attend local workshop meetings. For example, some officials reported that they did not believe that a meeting on “charge services” would be relevant to their work given that VA does not typically bill veterans for services. However, they later learned that the meeting actually covered topics beyond billing, such as capturing workload data that was relevant to their work. Because Cerner and VA did not always effectively communicate regarding workshop content for local workshops, local workshops did not always include all relevant stakeholders. As previously stated, VA plans to hold local workshops in advance of the Cerner EHR system implementation at future VA medical facilities. However, VA has not indicated how it will improve the ways in which it describes the topics of these workshops, including providing sufficient detail and defining key terms. If VA improves communication on workshop meeting topics, the EHRM program can increase the likelihood that it will obtain appropriate input from facility clinicians and staff at local workshops to consider in design decisions for the implementation of the EHR system. VA met its schedule for making the needed system configuration decisions that would enable the department to implement its new EHR system at the first VA medical facility, which was planned for July 2020. In addition, VA has formulated a schedule for making the remaining EHR system configuration decisions before implementing the system at additional facilities planned for fall 2020. VA’s EHRM program was generally effective in establishing decision- making procedures that were consistent with applicable federal standards for internal control. However, VA did not always ensure the involvement of relevant stakeholders, including medical facility clinicians and staff, in the system configuration decisions. Specifically, VA did not always clarify terminology and include adequate detail in descriptions of local workshop sessions to medical facility clinicians and staff to ensure relevant representation at local workshop meetings. Participation of such stakeholders is critical to ensuring that the EHR system is configured to meet the needs of clinicians and support the delivery of clinical care. We are making the following recommendation to VA: For implementation of the EHR system at future VA medical facilities, we recommend that the Secretary of VA direct the EHRM Executive Director to clarify terminology and include adequate detail in descriptions of local workshop sessions to facilitate the participation of all relevant stakeholders including medical facility clinicians and staff. (Recommendation 1) We provided a draft of this report to VA and DOD for comment. In its comments, reproduced in appendix II, VA concurred with our recommendation and described steps that it planned to take to address it. Specifically, VA noted that it planned and designed its workshops to enable collaboration between clinical and administrative experts and end- users so that the EHR system is designed, validated, and configured to promote interoperability and quality care for veterans. VA stated that it is further refining local workshop agendas and descriptions to facilitate VA subject matter expert identification and participation. VA also provided technical comments on the report, which we incorporated as appropriate. DOD provided technical comments on the report, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretaries of VA and DOD, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact Debra A. Draper at (202) 512-7114 or DraperD@gao.gov or Carol C. Harris at (202) 512-4456 or HarrisCC@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. In addition to the individuals named above, Mark Bird (Assistant Director), Michael Zose (Assistant Director), Merry Woo (Analyst-in-Charge), Bianca Eugene, and Paris Hawkins made key contributions to this report. Also contributing were Jennie F. Apter, Giselle Hicks, Monica Perez- Nelson, and Ethiene Salgado-Rodriguez.

Summary: VA's existing EHR system is antiquated, costly to maintain, and does not fully support VA's need to exchange health records with other organizations, such as the Department of Defense. As a result, VA has undertaken a modernization effort to replace it. As VA prepares to transition from its existing EHR system to a commercial system, it has the opportunity to design standardized work processes to support the delivery of care and ensure information on veterans' care is consistently captured, regardless of site of care. GAO was asked to review VA's EHR system configuration process. This report examines, among other objectives: (1) how VA made EHR system configuration decisions and assessed the compatibility of the commercial EHR system with its work processes; and (2) the effectiveness of VA's decision-making procedures, including ensuring key stakeholder involvement. GAO observed national and local workshop meetings; visited planned initial implementation sites; reviewed documentation on the processes and schedule; and interviewed VA, DOD, and contractor officials. The Department of Veterans Affairs (VA) used a multi-step process to help ensure that its future commercial electronic health record (EHR) system is configured appropriately for, and is compatible with, its clinical work processes. To configure the EHR system, which VA planned to implement initially at the Mann-Grandstaff VA Medical Center, in Spokane, Washington, in July 2020, and at the Puget Sound Health Care System in the fall of 2020, VA established 18 EHR councils comprising VA clinicians, staff, and other experts in various clinical areas and held eight national workshops between November 2018 and October 2019. At these workshops, the councils decided how to design the functionality of the EHR software to help clinicians and other staff deliver care and complete tasks such as administering medication. VA also held eight local workshops at both medical centers to help ensure that the EHR configuration supported local practices. As of March 2020, the EHR councils were continuing to meet to complete configuration decisions. Furthermore, VA plans to hold local workshops in advance of the EHR system implementation at future VA medical facilities. In April 2020, the VA Secretary announced that the department had shifted priorities to focus on caring for veterans in response to the pandemic created by COVID-19. According to program officials, at that time, they paused the implementation of the EHR system and were assessing the impact of the COVID-19 pandemic on VA's planned implementation schedule. GAO found that VA's decision-making procedures were generally effective as demonstrated by adherence to applicable federal internal control standards for establishing structure, responsibility, and authority, and communicating internally and externally, but that VA did not always ensure key stakeholder involvement. Specifically, the councils included a wide range of stakeholders from various geographic regions. However, according to clinicians from the two initial medical facilities for implementation, VA did not always effectively communicate information to stakeholders, including medical facility clinicians and staff to ensure relevant representation at local workshop meetings. As a result, local workshops did not always include all relevant stakeholders. VA has not indicated how it plans to describe these future sessions and define key terms to ensure key stakeholder participation in local workshops. By ensuring that all relevant stakeholders are included, VA will increase the likelihood that it is obtaining input from a wide range of clinicians and staff who will use the EHR system and will increase the likelihood that when it is implemented, the EHR system will effectively support the delivery of care at VA medical centers. GAO is recommending that VA ensure the involvement of all relevant medical facility stakeholders in the EHR system configuration decision process. VA concurred with GAO's recommendation.