Dr. David Shulkin and Executive Director Lou Celli sit down with Cerner Senior Vice President & General Manager Brian Sandager to talk about the electronic health record modernization project. What's going well, what didn't go well, and how they plan to fix it going forward.
Dr. David Shulkin and Executive Director Lou Celli sit down with Cerner Senior Vice President & General Manager Brian Sandager to talk about the electronic health record modernization project. What's going well, what didn't go well, and how they plan to fix it going forward.
So today, as, as you mentioned, the current software that they use is Vista. But there's actually 130, over 130 different versions of that VISTA around the country. And as such, there can be different ways for clinicians all across the VA Health System to deliver care. The way they do a knee replacement on the West Coast may be different than the way they do a knee replacement on the east coast. And in healthcare variants in that care doesn't always lead to optimal outcomes for veterans or for patients. And so we really are helping the VA standardize the way they do care. So it's not just about implementing the software. It's also about green, a green, those right ways of doing care and creating a national standard for the VA across the way they deliver care, which will improve outcomes for veterans and ultimately the success of care that they get.
Announcer:Welcome to the policy beds podcast, engaging with leaders, scholars and strong voices to fill a void in support of policy development for America's veterans. With your hosts, former Secretary of Veterans Affairs, Dr. David shulkin, and former executive director of the American Legion Louis Celli. Today's guest, Ryan sandag, senior vice president and general manager for Cerner government services.
Louis Celli:Well, Mr. Secretary, it looks like it's time to talk about that 900 pound gorilla in the room.
Dr. David Shulkin:Today, our guests Louis, you know, is Brian sandbagger. He's the senior vice president and general manager of Cerner government service, and he's going to talk about the rollout of the electronic health record modernization of VA. I don't know Brian, personally, but frankly, I know he's been in Cerner quite a long time, and is very knowledgeable about this subject. So I'm glad he was able to join us.
Louis Celli:You know, what started out as a $10 billion project quickly jumped to $16 billion. And now it's projected to be $21 billion. And that's a lot of money. Mr. Secretary, is
Dr. David Shulkin:it worth it? Well, you know, these numbers are really hard to get your head around, of course, it's a lot of money. But the most important commitment that I believe that we have to our veterans is to make sure that we're honoring our ability to provide them with the type of services and benefits that they've earned. And that means giving them the best tools. And quite frankly, keeping the VA in a system where we don't upgrade the technology, we don't make the investments that are needed, just means that the VA would fall behind where the private sector is. And that certainly was not acceptable to me. And I don't believe it's acceptable to the current Secretary either. So I think that people need to keep an open mind to keep focused on what's the right thing for our veterans, what's the right thing for taxpayers to make this right decision?
Louis Celli:Well, I mean, to your point, the decision to migrate to a single lifetime electronic health record between DOJ and VA has been a long time coming. I mean, presidential administrations as far back as the Bush administration had charged God and VA to come up with a common interoperable health record that would follow military members from the beginning of their military career right through their post military service at the VA.
Dr. David Shulkin:Yeah, I think that record of calling for the d, o t and VA to work together goes back even further to that I was able to find congressional hearings that I had requested and demanded that the VA and VA, do Dee do this back into the 1990s. But it just never happened. It was too complex, it was too big of a lift, and one one of these large agencies was going to have to give in. And I have personally sat through so many committee meetings where people want to do it, but didn't have the courage to do it. So I'm really glad that this is happening now. And I know and knew that this was not going to be a easy program to oversee. And certainly it's turned out to be just as complex as I think, I thought and other people thought but that doesn't mean that's not the right thing to do.
Louis Celli:That's all true. I remember when you made the decision, and you said that VA system was in dire need of being upgraded and that it wasn't going to be as simple as just upgrading, you know, one VISTA platform but that each Medical Center in their own hybrid version. So you know, you would have been faced with either trying to migrate all those disparate systems, and I think the number was was 138 different versions of VISTA to be able to achieve interoperability with whatever it was God was going to decide to use.
Dr. David Shulkin:Yeah, I think most people, when they think about the VA think that they have a single electronic health record. And I know when I joined VA, first as Undersecretary, that's what I thought, too. But Boy, was I surprised to find out, we didn't have one electronic health record, we had 136 of them. And so thinking about operating a system with 136 different versions, was really mind boggling. And then thinking about how are you going to connect all those systems, to the Department of Defense, where we know where every future veteran is going to come from, and then building in the community providers that 1/3 of all veterans are getting their care by community providers. This is really a complex puzzle to put together. And so finding a single integrated system for the VA, and using that same episode that the DOJ uses, I think simplifies the ultimate problem, how you get there, and how you make that transition is really what we're living through right now.
Louis Celli:You know, as expected, with any project of the size and scope, there's going to be plenty of controversy. I also remember you calling for an outside firm to help evaluate with the decision.
Dr. David Shulkin:Yeah, I knew that this was going to be complex. And I knew that the best way to get this type of program implemented was to get as much advice and experience from large systems that had done a conversion of electronic health record. And fortunately, like I found so often, all you had to do with VA is ask for help. And people from the private sector, those who work in health care and any other part of our economy, we're more than willing to come and help them. So we got an organization, a federally designated research coordinating center called mitre to organize the ability to bring together those experienced in the private sector, that Chief Information Officers, the chief medical officers to come and give us advice. And that I think was really helpful to me and to so many people in the VA, in trying to do the initial planning for how this project work
Louis Celli:is massive as this project is it's it's not hard to understand why you know why VA is so attached to Vista, the VA was an early pioneer, one of the earliest in the country of the electronic, medical, electronic medical record development and adoption.
Dr. David Shulkin:Well, it that is factual, and that's history. And I think VA should be extremely proud of really being one of the leading forces of bringing electronic health records to all of American health care. And I have to say that I've been a practicing doctor for a long time when I came to the VA. As Undersecretary, I had never used an electronic health record before. And I started to practice in the VA. And I had to use the VISTA system. And I was unbelievably pleasantly surprised at how well this system worked. And I was a big fan of VISTA. And so by switching away from Vista, I don't think anybody should interpret that as VISTA was not a good system. But we're now talking about 2021 and modernizing a system and keeping it updated and fixing it and maintaining it. And to do that as a federal government agency, to hire the contractors and to keep that system going. That in itself is a big, big task. And so I think people need to understand the complexity of running a system that big and the difficulty in making a decision to leave a system as good as Vista, but it was being done for many thoughtful reasons, at least I believe,
Louis Celli:well, in business, you know, there's a lot of discussion around market disruption. And, and what happens, you know, after you essentially blow up everything you knew, and, you know, as you mentioned, there's a huge infrastructure around the Vista Business Model, to include outside contractors that you know, that were hired to maintain that system. You know, as you may mentioned earlier the the the pioneers and some of the physicians who were actually integral in part of developing and helping build that system.
Dr. David Shulkin:Well, it's one of the reasons why these government agencies are so hard to change because people get used to the status quo. And of course, don't want to see a change. But I think what the contractors and private industry needs to recognize is that with change creates all sorts of new opportunities. And this is, in my opinion, going to allow VA to be able to innovate and to be able to be part of the next generation of medical advances and discoveries and just doing a better job. And that's going to open up tremendous opportunities for industry, and small businesses to be able to participate in this. So I would not view this as the end, I would view this as really a new beginning. And you're gonna hear a lot about this term change management. This change from VISTA to Cerner is not a technology project, it really is about changing the way that medicine is practiced, and doing it in a better way. And if you look at this as an evolution of what needs to happen, and the ability to integrate clinical thinking in with new technology, this is really a very exciting and terrific opportunity for not only veterans, but also for the country.
Louis Celli:That's true, but I can't overemphasize the complexity of what's what's on unroll, what's rolling out right now. And while working around the hardware requirement upgrades and installing the new system alongside the existing system, so as not to disrupt operations. It's a massive undertaking.
Dr. David Shulkin:There's no doubt that this is complex, and there's no doubt that mistakes have been made. And what you have to hope for is that by shining some light on this and what we're doing today, that that's going to help make this a better system. But, you know, government, in working with the private sector has done some pretty amazing things. I think we've all watched operation warp speed, in a public private partnership that brought vaccines to the American public into the world in record time. And we've seen tremendous things that government has done in our space programs and with creating the finest military in the world. So I feel confident that with these public private partnerships, that great things can be accomplished, even when they're challenging and difficult like we're seeing here. So let's get Brian in here today to help us understand the situation a little bit better.
Louis Celli:I can't wait. Brian, welcome to the policy. That's podcast. And you know, thanks for taking the time to join us today. Thank you very much for having me. I'm looking forward to the opportunity to talk with you today.
Dr. David Shulkin:Brian, this is David shulkin. And thank you for joining us today, I did want to start by saying that this has been a very tough week for this country. And for those who have served in Afghanistan and their families, and of course, those who still are in Afghanistan, I know how important the military community is to the Cerner family. And so I just wanted to ask you whether you had any comments that you wanted to share about the situation and how you're feeling about what's going on, as you're watching this all play out?
Brian Sandager:Well, you know, thank you, it's, it's really important that we're all have servicemembers, their families and veterans in our thoughts and minds right now. You know, after over 20 years of folks overseas, serving the country, the important thing from my perspective is that we continue to honor those that have heeded the call and served. And so, you know, for me this personally, this is my mission, this is our way to give back to full service and veterans is to make sure that when they do come home that they're well taken care of or even overseas before they come home. And so this is our way to serve, you know, in this difficult time, and we're gonna say really focused on that and making sure we take care of all those that have taken care of us so diligently.
Dr. David Shulkin:Well, thank you, Brian. I know that means a lot to all those who have served and their families and those that will continue to serve to know that type of commitment. Would you mind just telling us a little bit about yourself how long you've been with Cerner and what your scope of work responsibilities are in the company. Sure, thank
Brian Sandager:you very much for the question I I've had the opportunity to work with Cerner for over 20 years now, I can't believe it's been two decades and have served in a variety of capacity over the last two decades, including leading some of our overseas businesses working with large governments, with our NATO allies in Europe and other places. And I've worked with large commercial health systems was formerly a CIO of the health system up in the New England region. And I've been with our government business now for about three years. And I've responsibility for all of our federal clients do D. Va, as well as some of our civilian health agencies like CDC and others? Were Cerner serving today, both in implementing electronic medical health records, as well as using the data from healthcare to help solve some of the biggest problems in healthcare.
Louis Celli:Right, Brian, you know, as you've said, You've led this project from the very beginning. So in addition to di, D, and VA, one of the Federal clients are implementing the Cerner EHR solution right now.
Brian Sandager:In addition to that, we also have the United States Coast Guard that has joined the DOJ in their rollout, which has been great to see and really make sure that, you know, all of the service members get benefit, and we've gone upstream as well. And, and starting at the recruiting stage of the process, and now all of the new recruits coming in to any of the military services, interact with our EMRs as we go forward, which is a great thing as well speeded up that recruiting process, making sure it's all integrated from the very beginning. Outside of the electronic medical health record, we also have work that we're doing with other government agencies like the CDC, NIH, FDA and others around potentially leveraging, you know, data from healthcare to help with their decision making. And recently, with the pandemic, there's a lot of opportunity to streamline the way data is presented to the federal government to help them react to pandemics and other international emergencies.
Dr. David Shulkin:Nobody thought this implementation at the Department of Veteran Affairs was going to be easy, Brian, this is the largest implementation, I believe anywhere in the country. The VA is a very complex organization. You've testified before Congress a couple times you've seen the VA his report just recently that they released with their internal review of how the rollout of the Cerner program is going at VA, you've told Congress that or VA has told Congress that they're going to redo the entire rollout schedule. Can you give our listeners an understanding, from your perspective about what's happened with this implementation, whether it's met your expectations, and a little bit about what you think this new strategy by VA is going to mean, for the continued implementation of the Cerner program,
Brian Sandager:I appreciate the opportunity to talk a little bit about that, you know, this is unique in many ways, as you, as you said, largest in terms of scale on that servers ever seen today, although God recently with some of their big implementations are definitely setting some records as well. But the VA, you know, started from the very beginning, with the largest data migration, I believe in the history of health care, um, you know, migrating over 20 Million Veteran records. And that that really started off this program. And the original intent of the deployment is I believe you and many listeners may know was to make sure that servicemembers and veterans had seamless care. So as they transition from active service into the VA, or de Scott care, in different environments that that came across, really seamless to the veteran or the service member. And so the initial deployment schedule logically followed the D o t deployment, starting in the Pacific Northwest and moving counterclockwise around the country. Unfortunately, you know, three plus years ago, when we started this endeavor, we never foresaw a pandemic, and we definitely didn't foresee that it would impact the Pacific Northwest and, and really the whole Pacific seaboard, initially with the greatest level of acuity. So it was really necessary for the VA to quickly pivot where they were deploying initially and to look at some other sites in the Midwest where there was opportunities to deploy where their acuity was, wasn't as high. And I think the VA is strategy now to look at not just where they're ready, technically for deployment, where the infrastructure has been put in all the networking hardware has been put in, but also looking at, you know, where the individual facility is in terms of their readiness. You know, how's the acuity of their caseload You know, putting in a large EMR is, is a big effort and making sure that the team is ready to do that. And then that they're not dealing with an unusually high caseload, or having another distraction, you know, from the endeavor, I think is really important. And so the VA is new approach to the schedule of being informed by the readiness of the site, not just technically, but also from a change management and from a workload perspective, I think is an important adjustment that they've made to deal with, you know, recent events in the country is gone through.
Louis Celli:Brian, the Secretary and I, as you know, have been deeply involved in this for for a long time, since the beginning of the of the discussions of this transformation and implementation. There's been a lot of coverage recently in about the environment about the EHR transformation. So without getting too in the weeds. I mean, we know but our listeners understand why is this important for them? What advantages does migrating to the Cerner platform have for veterans in the VA? Why is it worth it?
Brian Sandager:You know, this is something that I'm really excited about is bringing these benefits to the veterans. And I'll give you a couple of examples of some of the great benefits that a single system allows, you know, one is, is that when a service member veterans transitions between two venues of care if they're seen at a military facility, and then show up the next day, at a VA facility, that modern electronic health record is able to not only see the information, because they have some of those capabilities today with a read only legacy viewer, but legacy viewer, excuse me, but the ability to act on that information. So if I'm given a prescription at one facility, and a physician at another facility, orders a prescription that's counter indicated for that, it fires rules that stop that from happening, and really interject in the care process. You know, same with more modern tool sets that our platform provides, we have algorithms that search all of the data out there on on Veterans and servicemembers and identify, you know, areas of risks. As many of you know, substance use disorder and mental health are two areas that can cause an increased risk for suicide. And, you know, our systems allow have tools built into them to allow identification of that. And if a veteran or servicemember presents for an opioid, you know, we're able to say, hey, this person has a higher risk of substance use disorder, and, and really help the physician and the clinician look at alternative therapies. And there's already been hundreds of veterans that have benefited from those technologies, and had their care plans changed based on those modern technologies. So those are just a couple of things that really help. One last point is just at the enterprise level, when you have a single integrated system over time, that also allows you to plan better for resources to be able to understand where resources are, which makes access to care better, because you make sure that that veteran has what they need, when they walk through the doors and that they're ready to service them. So we've seen reductions and things like wait times, you know, as a byproduct of some of these tools and technologies that are helpful. And the VA is better prepared to be able to, to look at their data across the enterprise as this programs expands over time.
Dr. David Shulkin:I think what you've just said makes a lot of sense. It may be confusing to people, because you've described it in a in a pretty sophisticated way. But I think to summarize what you've really said, I know so many people believe that our veterans deserve the very best and most modern types of technology that this country can offer. And I think I think that's what you're working to do. But when you've described this, in your answer so far, use some industry buzz terms that I'm not sure everybody really understands. One of them in particular is change management. Why isn't this just as simple as we're switching out a piece of software? We're going to remove the current VA EHR called Vista. And we're going to replace it with servers technology, what what is this change management mean? And why does this have to be so complicated? And take so long and be so expensive? Can you just give people a sense about what what this really means that you're trying to work with the VA on?
Brian Sandager:Yeah, it's a lot more than just replacing the software. And it's not a you know, take out one piece of software and put in another because we're really working in partnering with the VA across all of the VA to standardize the way that they do care. So today, as as you mentioned, the current software that they use is Vista, but there's actually 130 over 130 different versions of that VISTA around the country. And as such, they're can be different ways for clinicians all across the VA Health System to deliver care, the way they do a knee replacement on the West Coast may be different than the way they do in the replacement on the east coast. And in healthcare variants in that care doesn't always lead to optimal outcomes for veterans or for for patients. And so we really are helping the VA standardize the way they do care. So it's not just about implementing the software, it's also about green, a green, those rights, ways of doing care and creating a national standard for the VA across the way they deliver care, which will improve outcomes for veterans and ultimately the success of the care that they get. So it is very complex. As you well know, health care is a complex area. And so you know, the change of those workflows within the Electronic Health Record system. That is, as a big part of that implementation is making sure that providers understand those changes and the benefit of it.
Dr. David Shulkin:Thank you for saying that. I'm really glad that you mentioned that, to me, this is the single biggest thing that I think that people need to understand. And again, you've said that I just want to say it in a different way. The VA is the largest health system, the country does not have a single way of doing things, even though they study their results. And they learn the best way to do something, they learn what we call best practices. And they're amazing at that they don't have an effective way of implementing that. When you go from 136 different electronic health records to one, it forces you to make decisions on how medicine should be practiced, and the best way to do things. And that's where you see such incredible gains in quality and outcomes for our veterans. And that's the reason you've said this is so complex. So I, I couldn't agree with you more, this is the biggest opportunity for improving the care for our veterans anywhere in the country. So thank thank you so much. Thank you appreciate that.
Louis Celli:There have been a number of oversight reports between the Government Accountability Office and the VA Office of the Inspector General, who've raised a number of issues, you know, looking to the findings, it really looks like most of the findings are surrounding Medical Center user experience, which really goes back to what what you were just talking about. So between training and complaints about functionality that wasn't included in misunderstandings regarding where notifications are located not, you know, recognize that that the solutions are complex, and that there's no easy answer, but can you help our listeners Understand? What will be different moving forward? How will all of these clinicians who are used to using over 100 different variations of the software that that they're used to how are they all going to get on the same page?
Brian Sandager:Well, that's a great question. And I think there's a couple aspects to that, you know, one is understanding some of those nuances that are different in the VA, versus the 1000s of other clients that we have around the world and other governments and agencies we work with, like the DOJ and being able to really understand you know, where they're starting from, and where that change is taking them to. And I'll use a kind of a specific example of something we ran into that was a good lesson learned in today, in some of the VA facilities, when they message between caregivers, that the doctor and the nurse, they send those kind of messages internal to their EMR person, a person. So Brian, I'm sending that to Nancy, or to Bob, you know, modern views of that really would say use pool systems. That way, if Nancy or Bob are out on vacation, somebody picks that up, right. So making sure that we understand that and help them with the adoption of what we call pools, which is just a universal box that people can access to be able to move in and out and make sure veterans get care even when people are on vacation. That change was actually something you know, that we saw that took a little bit longer to adopt early on. So we're beefing up our training and some of our change management around that for future sites as an example. But there's those nuances of workflow that as you get past your initial site, and that's why we do an initial operating capability or IOC, really to make sure we learn those things and put those best practices in place. So I think that was one of the lessons learned that we had is really just understanding those nuanced VA workflows and helping them with not just the training around that, but also understanding really the value of that. Here's why you use pools and that's to ensure that veterans still get great care and great communication, even when Have one of one of the care members are on are on vacation. So just a little example of one of the areas where I think we'll continue to see improvement at future sites as as we deploy.
Dr. David Shulkin:I want to stay a little bit on this Office of Inspector General report. And I know that too many people, they were very concerned about this, there was something in the report, if I recall, that said that they training that was being given to VA clinicians on the mock system was very different than the one that was actually installed. In the VHS. Do you? Do you have a sense? How different were these two systems and and why were they different?
Brian Sandager:Yeah, absolutely. So there, there was some nuances between the two systems as the first side's going live, you know, you're building the software configurations, up until the go live. So we were starting with the initial do D system, because it is a shared system across vn d. d, one unique system. And so we started that as the as the initial point. And he, as you talked about earlier, you know, one of the big efforts around this was having the VA really define a single workflow for all of their core workflows across the country. So we did a series of national workshops, we reviewed over 1000 workflows, we built all of those workflows in, and then we put those into a copy of the production system, our training system. But as those national workflows were getting designed some of those decisions on what the final workflow was, was going to be, were a little bit late, because the team was working through trying to understand that the VA was trying to make those decisions. And so as such, you know, any of those decisions or changes in those decisions late in the game, some of those didn't make it into training right before go live. And so I think as we go forward, the great news is, is that, you know, we now have a copy of the production system that they are using unmanned Grandstaff today. And so any nuance from that from site to site will be the only adjustments required. So there'll always be a very small delta between, you know, your production environment and your training environment, because they're just some things you don't want in a non production environment to train on, like a live system connected to a patient, you know, your medical devices, and some things like that, that are nuanced. But by and far, we've overcome that challenge as we've gone forward. And that was unique to the first site.
Louis Celli:One of the things you talked about was, like an initial site survey, the IOC. How, how much of a challenge has it been to begin this implementation through different administrations, so you had a complete team that you worked with, you know, when you first accepted this, you know, this job, and now you're implementing it, under now, really your third? You know, leadership change? And how has that affected the, the rollout and, and how that's, you know, been been able to, to work with you?
Brian Sandager:Well, that's, I think one of the things that's important to understand, you know, in this program, especially, is, those three changes came in the first few years of the program as well, which are always challenging, you know, later in the lifecycle of a program of this magnitude, a little bit less challenging, but that is the nature of, of our democracy. And part of, you know, the way our government functions. And so we're adjusting to that very quickly. And we've been very thankful for both the new secretary and Deputy Secretary, that they've actively engaged that they've had a very open dialogue, that they've been very open to our feedback and to to sharing and some of our experiences, you know, given that we've done this, you know, at scale with large countries and organizations around the world, and so we've been very appreciative of every administration's, you know, engagement with us. That does help. But I think one of the things that we're continuously working on is, how do we bring people up to speed that are new to the VA or to, you know, the hill or anywhere else, there's a lot of oversight and appropriately and a lot of stakeholders in the community. And we always want to be educating them quickly and efficiently so that they can get up to speed and get aligned with the program and we can adjust to their needs as appropriate.
Louis Celli:Something else that the clinicians complained about? Was it in their words? You know, they were they felt that the Cerner trainers weren't asking users about or that the sorry that the VA was, you know, asking Cerner trainers, you know about workarounds? it was the other way around that, that the the Cerner trainers were, in fact asking VA users what they What they were doing to work around certain issues and the question came up, were the Cerner trainers adequately trained.
Brian Sandager:You know, I think that one of the things that we were very proud of doing in the implementation and the initial site was leveraging a lot of veteran owned and service disabled on small businesses and their trainers. Because we really believe, you know, having veterans involved in the process was really important. And we did a great job, I think training those folks and making sure they were up to speed. So there was a lot of really high quality trainers that were out there. I think, you know, one of the terms of workarounds that folks got stuck out a little bit was also around, just changes in workflow. So back to that example I gave earlier of pools, you know, it's a different way of working, and then an older system. And so, sometimes that gets classified as a work around when, in fact, it's just a different way of working. And so that's another thing that we learned in this initial site was, you know, changing the terminology a little bit to help folks understand that, and really making sure that we also have the super users that are brought along from the local sites as a part of the process in those training events so that they can help explain, you know, why a decision was made to design the system the way it was, you know, back to earlier, there's a lot of enterprise designs that are changing the way the local sites do workflow has nothing to do with the software, that's just a decision in the changing workflow. And so often, those were misconstrued as workarounds. And it was just a part of educating them. Versus the trainers were really there to train them on, you know, how to do the workflow end to end and, you know, truly end to end workflow. And so I think that's, that's a lesson learned is making sure we've got a good interjection of the subject matter experts from the local sides. Because there's nothing like sharing with your fellow providers, hey, this is why we made the decision because in addition to the net national councils, there were also local councils that participated in those workflow design. So sharing that back from the right person to the end user, I think is an opportunity that will we'll definitely leverage as we go forward as well.
Louis Celli:Yeah, well do D and VA clearly have a symbiotic relationship there. There's a fundamental difference in the culture and do D physicians, they rotate, right? They they move, you know, sometimes every every couple of years to every three years, and I understand that rotating physicians that a do D are actually requesting to be assigned to facilities that have the Cerner platform already installed. We had Lieutenant General Ron place on here from the defense health agency a couple of weeks ago, and, and he tells us a deal D, really, I mean, went through the same growing pains that VA is going through now. Where were you seeing user satisfaction to do D today,
Brian Sandager:we've seen tremendous user satisfaction. And to your point, we've got folks that are requesting to go to facilities that have the Cerner platform. And, you know, frankly, we're already seeing that on the VA as well, the VA has a number of providers that come from the commercial space. And I, you know, I've been on a number of sites, both those that are live and those that are in the future to go live. And there are providers that have worked, you know, with our solutions in the commercial world that are very excited, you know, about us bringing that platform forward. So we're seeing that there's other providers in the VA that have been on VISTA for a long time. And like all of us, we're humans, and, you know, if you've been using something for 10 or 20 years, you know that that change can be challenging. So that is that is a balance point, I do want to point out, you know, with all technology, there's an adoption curve. And once you get past that first 10 to 20% of users using the system, you know, they call it crossing that chasm, that adoption chasm that exists in the early phases of adoption of technology, then you really see what we're seeing in DSD. And now that they're, you know, third deployed, where you really get momentum, you know, in your deployments, because there's a critical mass of population that knows how to use the system. And when you talk to a friend, they're like, Oh, yeah, it's great, you know, and you get a little bit less of that anxiety and adopting the new technology. So there's a lot of psychology, there's whole books written about it, you know, but ultimately, if you get past that, that first, initial third of your deployments, you get a lot more speed in your implementation that's just normal with the implementation of any technologies.
Dr. David Shulkin:Brian, I want to stay focused a little bit on this department of defense and Department of Veteran Affairs, transition when somebody leaves the service and then comes to the VA. And, you know, as Secretary and even as Undersecretary, I would practice in the VA and take care of veterans and I saw even with joint legacy viewer, how challenging was sometimes to get the information between these systems. One of the potential advantages of the Cerner implementation is, is having the ability to seamlessly get information between the Department of Defense and the Department of Veteran Affairs. Have you seen that actually work yet? Is that is that something that's still theoretical? Or is that something that really we know we can do?
Brian Sandager:We've actually seen it work. And I get a little bit of goosebumps talking about it, because there's actually over 700 veterans and service members that have received care at one facility on the deity side and gotten follow up care on the VA side, or vice versa. As you well know, even you know, active duty members transition back and forth, as do veterans. And so being able to get care at that alternate facility is really important. You know, and I'll just highlight it, it's not just getting a COVID shot at one falling up at another, but you may have, you know, a procedure at the DMV, and then you need more acute care at the VA, and has such right that that sharing of that information at a discrete level, right at a numeric level, not in a big free text read only type of format is really important, because that makes it actionable. And one of the quotes I love from one of the end users, when I was out rounding was, you know, I've had a hard time, you know, getting used to not having to log into six different systems in a day to be able to sit see one patient right and, and to your point, that joint legacy viewer was a great thing by the VA and di D to solve a problem years ago, to be able to see that record across both sets. But it's view only it's like a PDF, right? You can action that so if you're if you identify an allergy in the D o t, and that that service member or veteran shows up in the VA, and you're going to prescribe that medicine that they're allergic to, right, it won't fire any rules to stop that prescription, it's on the provider to remember to go in there and look at the other view and to be able to action that so it really burdens the provider with that point of action, which can lead to you know, can lead to mistakes. And so I'm really excited about that there's, you know, 700 plus people that have gotten better care already today. And that's only with one site live. So that's really why we're here. And the value that a modern system brings is being able to add, you know, action
Louis Celli:information built on your plant. I remember when when Secretary shulkin was working through the analysis and negotiation with Cerner. And one of the things that he was most vocal about most adamant about was the ability to incorporate Community Care medical providers into the ecosystem. So can you tell us a little bit about that? And how's that? How's that working?
Brian Sandager:Yeah, absolutely. I think that's one of the things that's really important for folks to understand, you know, is many, many veterans get their care and service members in the community. And that interaction between not just between di, D and VA, but out in that community provider hospital is critically important, you know, to overall care, there's a lot of VA centers that don't have the same level of acuity of services. So they may not have a full surgical suite in a small rural hospital, but the local commercial hospital does. And so if the veteran, you know, is transferred there to have a surgery or any other procedure, making sure both the veterans information, you know, goes out into the community. And then once that's done, that the community information comes back to the veteran is really important. And I can attest as a, as a CIO for a health system. You know, we had veterans, we weren't in an area where we had a VA right next to us, but we had veterans show up in our emergency department. And because we didn't have access to the VA records, we didn't know their diagnosis is we didn't know their problems. And so we were they were presenting to us like a brand new patient, right. And so that challenged us to provide the ultimate best care for that veteran in that environment, because there's things that the commercial, you know, providers don't automatically assume, you know, of a veteran that a VA provider would. So that integration has been really helpful. And as you know, one of the pioneers in what they call an industry, that interoperability, that ability to share electronic medical records, you know, across platforms, you know, we've really pushed for this, you know, as a standard. And when you look at the number of connections the VA has, it's grown exponentially hundreds of 1000s you know, additional opportunities to share data, we now pass over 5 billion electronic health records across the US every year between different organizations and that really helps with that care. You know, and I'll just share one more, you know, little data point along that is when you when you pass that information back and forth, not only does it help the VA identify care, you know, in those episodes that those individual instances of it, but it gives them a better overall picture of the veteran, right. And that allows them to proactively, you know, engage that veteran. So if, if they haven't been seeing a VA for years, but you're seeing that they're having in a community health system, maybe a substance use challenge, or a mental health challenge that the VA is uniquely positioned to be able to help with, they can reach out and try and pull that veteran back into the VA as appropriate to get that care. So I think there's a lot of opportunities to continue to leverage that great technology. You know, and I'm a big advocate for an open architecture for sharing that technology.
Dr. David Shulkin:In Washington, it won't come as a surprise that there's really no shortage of finger pointing. And there are lots of critics out there. And certainly, Cerner has a number of people who are pointing at this program and blaming Cerner. I wonder whether you might share a little bit about what lessons you think you may have learned from the implementation so far, and how that may focus efforts going forward?
Brian Sandager:Yeah, absolutely. I think one of the things that, you know, makes us different from a lot of companies out there, as you know, we solely focus on healthcare, we solely focus on, you know, transformation of healthcare through technology, and other means. And so, as such, we know that healthcare is always evolving, always changing. And so we're constantly having to evolve and change. And so, you know, to your point, there's always some, you know, fingers that get pointed, but we're always looking for opportunities to get better. And so we really are reflective of you know, any implementation, but especially, what is important is this, to say, what can we learn, and what can we take for, and there's a couple of things that I think we can learn and take forward. One, as I talked about earlier, is really understanding, from an end user perspective, the areas that are very different in the VA, and where those, they're not a lot, right, most of the medicines actually pretty similar. But what are different and really doubling down on the training for those elements, and really explaining to folks the why, you know, most providers in the VA, care deeply about veterans, and they, if you really explain to them, Hey, this is a little different from what you're used to, but here's how it's gonna improve care for veterans. We think that that'll help with adoption and future sites. You know, secondly, I think that, you know, frankly, we were very respectful of our clients. And we want to make sure the VA is successful. And when we first stepped in, you know, and did a lot of these national designs, we allowed, you know, the VA to over engineer some of those workflows. And I don't think we were vocal enough and saying, Hey, this is creating a pretty complex workflow. And so yes, it may give you every day elements, you know, that you could ever possibly want at the enterprise level, but it's going to burden the end user write, you know, a great example of that is the initial migration of data. They brought in years and years of medications, right decades of medications, and presented that to the clinicians, you know, the medication that I was on, you know, 10 or 20 years ago, probably not super relevant for today. And so, as opposed to mass migrating all of that information, you know, we can write algorithms to thin that down to the most relevant medications, which is our commercial best practice, you know, that we do with our commercial sites. And so being able to help the VA understand that I think that's another lesson learned. And we need to be more direct, you know, as a partner with the VA to say, Hey, you know, we can do this, right, we can configure the system, the way that you're asking us to configure it, you know, but we don't recommend it because of these things. And we tried to say that, but I think, you know, to your point, we got to say things in a little different way, sometimes here to make sure that that were heard and, and learning the nano government's language to speak in their terms. I think it's really important as well, that, that we've spent a lot of time and effort making sure that we're speaking in a way that other people can understand so that they understand that the pros and cons of choices that are determine,
Dr. David Shulkin:Brian, thank you for that answer. I'm going to ask you just a few sort of quick, rapid fire questions about what you just said. So first of all, one of the things you said is is that is that you feel like you're going to have to be a little bit more directive about trying to give advice to the VA about what they can and cannot do in terms of making this successful. Do you feel that there's the right dialogue Do you feel Do you have enough open channels of communication with VA leaders to make that work?
Brian Sandager:We do. And we, we really believe that we think that that's continuing to improve. I mean, one of the things that's, that's really important to the success of any program of this size is governance and making sure that there's the right decision makers in place to balance those trade off decisions, right. And if you think about, you know, very well, having led both commercial, and government, you know, healthcare systems, there's always a balance between, you know, maximizing for the patient, the veteran service member, maximizing for the end user, and for the enterprise, right, and making sure that those are in balance. So service members are never waiting for care, that it's efficient for the end user, but also that the enterprise gets the data that they need. And so that's, that's a lot of different organizations within the VA that that impacts. And so the governance structure that the Secretary and new Deputy Secretary are putting in place, you know, to really modernize as we go forward. Again, not not anything negative to the past, but you know, when you're designing for the initial site, that's one thing you learn a lot. But then as you start to roll out over the entirety of the VA, you really need those decision makers to in the room to be able to pull those levers and make that those balance informed choices. So, you know, I think a we're getting access to more of those decision makers, which I think is really important. And B, I think that that VA is putting and improving their governance structure to try and make sure that there's clarity in roles and responsibilities around who's making those decisions, which I think is also a great thing.
Dr. David Shulkin:Knowing what you know, now, did you bite off more than you could chew is this project going to take longer and be more expensive than you originally thought it was going to be?
Brian Sandager:I don't think that we bought off bit off more than we could chew. I think this is absolutely doable. You know, it is going to be record setting that every turn, right. So the largest healthcare data migration in history, the largest expansion of health information exchange in history, it'll be the largest healthcare system in history when it's all done. And so, you know, anytime you're doing the first of anything, it's going to be hard. And we don't take that on lightly. But absolutely, this is doable. And we feel very confident that we can we can execute on this, you know, on the cost side of it, I think that that is also one of those areas where making sure that folks are talking apples to apples is really important. So the VA, as you probably know, had a lot outdated, you know, laptops, desktops, hardware, network closets, whether they would have moved to Cerner or they would have stayed on Vista, they would have had to modernize all of that, you know, end user devices, as we call them, regardless, so a lot of what you've seen in cost overruns are really around, you know, the technical debt that exists, you know, in the organization, to modernize those things. So far, we have not guided that we're outside, you know, of our ability to deliver on what we bid for the contract. That being said, you know, speed to delivery is important. And so, you know, set earlier with multiple changes in administration, and reviews, all of which are necessary, important that were fully supportive. Those make sense. But if you have ongoing delays for a long period of time, that will impact cost. And so, you know, we did see that with other large governments and agencies, you know, God took a little longer to get going up front, you know, but over and over, over all, they're actually now, you know, got to finish on time. And, you know, and they'll do more implementations in the last third of the program than they did in the first two thirds, you know, everybody plans for a little bit of a linear delivery, but it's a little bit more of a curve on the back half. So I still think that there's an opportunity to control the costs on this. But it really comes back to our previous discussion on making sure we're getting good governance and good decision making and clarity and alignment on goals. You know, so that we can deliver together when you change in a requirements, you know, those, though, increase costs for taxpayers, and we're very sensitive to taxpayer costs. I mean, all of us are taxpayers, you know, we're here for the veterans and delivering value for them. So that's important to us.
Dr. David Shulkin:You've said that you feel confident that this is going to be implemented well, and yet there are still people in Washington around the country who have their doubts. So on a scale of one to 10, with one being you're uncertain and 10 being very confident. Give us a number about your level of confidence that this the Cerner implementation is going to be able to be complete and successful throughout the VA system.
Brian Sandager:I'd say, you know, I have a 10 that will be able to be successful and complete within the system. I think my only hesitations at all are just around time and the number of bumps that between here and there, but I think one of the things we're very confident in is that the system can meet the veterans and VA needs. You know, we've seen that when you look at the over 1000 workflows that they designed at an enterprise level, there's 42 that we're reviewing right now. Right, so, you know, 96 plus percent of the workflows, you know, we haven't had to revisit, right, because they, we put them in and they worked, right. So you know, to have that kind of 4% that you got to review at an initial operating capability site. That's a great thing. You know, that doesn't mean those 40 workflows aren't impactful to those clinicians absolutely are. And we got, we got work to do to get that right. But we've already, you know, just in the, in the nine months since we initially went live, we've already fixed almost all of those and are just working through the last handful. Now.
Dr. David Shulkin:If you had a magic wand, which I know you don't have, but you had the chance to have one do over since the beginning of this program with VA. What would it be?
Brian Sandager:I think, you know, if I had to do over it would probably be in terms of that first slot site not being in the Pacific Northwest. I you know, I joke all the time. For those of you that know federal contracting or contracting right, there's a term for smudger, which is rough Latin for acts of God. Right. And so, you know, generally, you know, bad things happen on everywhere in the world, and you'll get a hurricane or, or an earthquake or something like that. But in this initial site, we had not only the pandemic, which was, you know, challenging to deliver in, in that world. There were wildfires in the Pacific Northwest, we had a freak snowstorm in October, that night of go live that collapse tense, we had a power outage tonight, we cut over, you know, and then on top of that, you know, when we had to virtualize some training, you know, due to the pandemic, we had a hurricane that hit our one of our training centers and core locations where the trainers were. And so, you know, we had five force majeure events on on one implementation, which is a little disproportionate. So I would say that would be the one do over I'd have is avoid all those, you know, other than that, I think there's a lot of little things I'd love to take a mulligan on, you know, being able to know now, hey, those, you know, those pools, workflows, the meds, and making sure that you know, we're not taking all that history over, we're a little more vocal, some of those other things we talked about, love to have a do over on those those items as well, because you really want to get things absolutely perfect. We know that that is isn't is not an achievable goal, that they'll we'll never get to perfect on an implementation. It's just too big of a change in too big of a shift, you know, to hit perfect, but you know, we never, we never strive for anything less than that. So I'd love to have a couple little muggins do those over again. But I think all in all, you know, proud of the work the team did, especially for an initial site.
Louis Celli:We're gonna wrap up here in a second. But to be fair, the Pacific Northwest was selected, specifically in on paper was the right selection to make because it followed in the steps of do D. And that was where you were most likely to have success for transformation. Right?
Brian Sandager:Correct, that the initial site selection at the time made perfect sense, right, that was the first DND facility, it made sense that that would provide the most benefit for veterans. Right, but we just didn't know that, you know, that we would have a worldwide pandemic. And Seattle in California would be the first hit, you know, by those pandemics, right in the middle of, you know, National Design of an enterprise system. So that was that was a unique one and any implementation. This one's unique to start with. But I you know, I think that, in hindsight, if you went back three, four years, not having that foresight, we wouldn't have made any different decision. But that is one of the things that's really important. I think, in the spirit of our partnership with the VA, we categorize this as a multi generational, you know, effort, we hope that, you know, this will impact generations to come. And as such, you know, we'll need to continue to adjust based on the vas needs and the country's needs, as it evolves. And, and, you know, now almost, you know, two years into, into a pandemic, you know, we, you know, we need to be able to adjust to that, and we're happy to and we'll modernize and change the schedule as required. That's not unusual with large health systems. We've run into that in the past, you know, there's operational things that get in the way and you got to adjust the next site to go so but yes, sir. Absolutely right. The original site was designed for purpose in a very good one.
Louis Celli:This conversation has 100% been conducted in the media in In policy, at the congressional level at the administration level, I think it's time to pull the veteran community into this conversation. So we're out of time. And before we go, Brian, I want to give you the last word, I want to give you a chance to speak directly to veterans and stakeholders, and bring them into this conversation, and help them understand what they're going to get from this, why why is this important to them? And why should they be paying attention? And, you know, if, if a lawmaker would jump up tomorrow and say, you know, let's just pull the plug on this whole thing? What What do veterans stand to lose? Why should they be involved?
Brian Sandager:Well, I think that it's very important for veterans to understand. And we've done a lot of work and engaging veteran service organizations to both share this message and get their voice back. But it's important to understand, although the veterans may not see a lot of the end user technology, it is providing safer care for them. So that information flowing from God to VA, the fact that our system can improve their care by catching those near miss events, you know, with the algorithms we have in place, that's first and foremost, it's better care to is it should expedite access to care, it's going to improve access to care. And we've seen that already with reductions and wait times, at our initial facilities, when we can see better information about providers, how they're using the systems, the amount of time they're spending in the EMR, or electronic medical record, and help them you know, with their scheduling, how it goes faster, etc, that's going to improve their access to care. And then thirdly, I think it really is also a huge benefit to veterans that are transitioning from DOJ to VA, not carrying that record across being able to see their total health care from beginning to end, from the time they joined the military, until the time their their time here is over. You know, in the VA, it really is that important seamless one record, and the ability to take that with them, you know, into the community as well. So you know, better access to care, you know, better quality of care, right, and the portability of their records so that they can get care where they need it, whether that's with VA or do D or in the community. Those are the three things that I think are really important for veterans to understand. And lastly, I would ask that message to veterans, as you know, please engage with us, we have teams out there working with VSOs. And we want to get feedback. You know, if there's things that that trends are seen, that we can improve on, we're all ears to that. That's how we get better. And we really appreciate their engagement. I've personally had the chance to speak with lots of veterans and and really have appreciated all of their feedback. So thank you for the opportunity to share that message with them.
Louis Celli:Yeah, Brian, thank you so very much. This has been an extremely important discussion, and one that will really help inform the community and, and the policymakers. Thank you so much.
Brian Sandager:Thank you very much for the time and for taking the interest. We really appreciate it. Thank you, Brian.
Louis Celli:Well, that is really all the time that we have for today. We hope you found this update as important as we did. He listened. Join us next week is where we're speaking with Miss Linda Bilmes. Linda is a Harvard lecturer who's been studying the cost of war for decades. She is going to let us know how much this 20 year war is going to cost us over the next 20 years. You're not going to want to miss this. See you next week.
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