Senators: “We have serious concerns that the issues and system defects identified by GAO and the VA OIG have yet to be adequately addressed, ahead of this more aggressive rollout timeline. Our top priority is—and has always been—patient safety. VA and Oracle Cerner must ensure that the new EHR system is ready to integrate into VA, and those who are using the system are trained and ready to implement it, before it is deployed in more locations.”
WASHINGTON POST: VA staff flag dangerous errors ahead of new health records expansion
***LETTER HERE***
Today, U.S. Senator Patty Murray (D-WA), Vice Chair of the Senate Appropriations Committee and a senior member and former chair of the Senate Veterans’ Affairs Committee, Senator Richard Blumenthal (D-CT), Ranking Member of the Senate Veterans’ Affairs Committee, and Senator Elissa Slotkin (D-MI) sent a new letter to U.S. Department of Veterans Affairs (VA) Secretary Doug Collins, expressing concern with VA’s plan to move forward with the deployment of the Electronic Health Record modernization (EHR, or EHRM) program at 13 new sites next year, despite serious issues and system defects that remain unaddressed.
“VA embarked on the EHRM program in October 2020 with the goal of improving the quality of care for veterans by updating the outdated VistA system to allow for better communication between the Department of Defense, VA, and community care providers,” Murray, Blumenthal, and Slotkin wrote. “While we should always strive to innovate and improve the quality of care for veterans, in practice, the rollout of EHRM has been so problematic that it created life-threatening problems and ongoing upheaval for veterans’ ability to get the health care they need.”
According to a VA Office of Inspector General (OIG) report from 2024, VA’s EHR system played a role in the 2022 death of a veteran in Ohio, due to errors in the scheduling function that resulted in staff not following up with patients who missed their appointments. Following a litany of serious implementation problems across hospitals in multiple states after the initial rollout in 2020—and repeated calls from Senator Murray to stop the rollout of EHR until it was fixed—VA announced a “reset” period in April 2023 where it paused the expansion of EHR to additional VA hospitals to focus on improving sites where EHRM is currently in use. In December 2024, VA announced that it was beginning early-stage planning to deploy the EHR system to four facilities in Michigan. In March, VA announced that it will complete nine additional medical facilities—bringing the total to 13 facilities expected to go live in 2026. According to VA, complete deployment of the system is anticipated at all VA medical facilities anticipated as early as 2031.
“VA providers continue to report that they struggle to learn the new system, and that when they try to seek help, they have difficulty accessing the helpline and communicating with support staff,” the Members wrote in their letter to VA today. “The OIG report also found unmitigated high-risk patient safety issues, patient medication inaccuracies, unresolved usability challenges, inaccurate medication data, the creation of numerous workarounds to provide patient care, overwhelming educational materials for pharmacy-related functions, and pharmacy staffing challenges. None of this is acceptable—implementing a new electronic health record should not result in dire staff burnout nor should it endanger VA patient safety.”
A Government Accountability Office (GAO) report in March 2025 found that 58 percent of users of the modernized EHR system believed the new system increased patient safety risks. The GAO report also found that VA had not addressed over half of the configuration changes that administrators had requested, leaving a backlog of 1,800 changes unaddressed as it proceeded with implementation. The report made three new recommendations to VA—only one of which has been implemented this year—and stated that VA still has not responded to or implemented 14 previous EHR recommendations that it called “critical to reducing EHR risks and delivering a quality system.”
“We have serious concerns that the issues and system defects identified by GAO and the VA OIG have yet to be adequately addressed, ahead of this more aggressive rollout timeline. Our top priority is—and has always been—patient safety,” the senators continued.“We have all seen how the deployment of new technology without adequate planning, training, and support can have disastrous consequences for patients and providers alike. In Spokane and Walla Walla, the rushed deployment of the new EHR system was nothing short of a disaster for veterans and their health care providers—increasing wait times, leading to serious errors in veterans’ treatment, and eroding productivity. We cannot afford to repeat these mistakes.”
“Our veterans need an electronic health system that works with and for them—not against them. After sacrificing so much for our nation, they deserve to have the best health care experience possible,” the senators concluded.
In their letter, the senators also requested a staff briefing and answers by January 19th to a number of questions about VA’s rollout plan for EHR, staffing levels, whether VA plans will implement outstanding recommendations from the GAO report, and the guardrails VA has in place to ensure patient safety as it expands EHR to new states.
Senator Murray has been conducting oversight of the flawed Electronic Health Record system rollout in Washington state since the Trump administration first negotiated the contract with Cerner (later acquired by Oracle), and at every point in the process since then. Murray has consistently pushed VA on its failed implementation of EHR—conducting oversight, holding the administration accountable, and, in 2022, calling on VA to halt the deployment of EHR in Washington state until it was fixed. In March 2023, Murray introduced comprehensive legislation that would require VA to implement a series of EHR reforms to better serve veterans, medical personnel, and taxpayers. In the Fiscal Year 2024 funding bills that Senator Murray negotiated and passed as then-Chair of the Senate Appropriations Committee, Murray secured key provisions (pp. 41-42) to better hold VA and Cerner accountable for the rollout of the EHR system. In May 2024, she sent a letter urging VA to consider feedback on the system from providers and veterans in Spokane and Walla Walla and reiterating that VA must not move forward on the rollout of EHR until the myriad issues that have plagued the system are fixed. Earlier this year, Senator Murray grilled Secretary Collins during his confirmation hearing on how he would prioritize fixing the issues with the EHR system before deploying it to more sites, and she has continued to press Secretary Collins throughout the year to fix unresolved issues with the EHR system.
This year, as Vice Chair of the Senate Appropriations Committee, Senator Murray fought to secure provisions (pp. 63-64) in the Senate Military Construction, Veterans Affairs, and Related Agencies (MilCon-VA) appropriations bill for fiscal year 2026 that improve oversight and accountability of EHR. The legislation—which passed the Senate in November—provides $3.48 billion to improve the EHR modernization effort and makes 25 percent of funds contingent upon the VA Secretary providing to Congress detailed information including: an updated life-cycle cost for the program, a facility-by-facility deployment schedule, certification on healthcare performance baseline metrics for facilities where the EHR has already been deployed, projected staffing levels necessary to support the schedule proposed, and the certification of four safe successful deployments without any adverse events. The Senate-passed legislation also directs GAO to conduct quarterly performance reviews of EHR deployment and to report to Congressional committees each quarter.
The full text of the letter to Secretary Collins is available HERE and below.
Dear Secretary Collins:
We are writing with regards to the Department of Veterans Affairs’ (VA) plans to move forward with the deployment of the Electronic Health Record (EHR) modernization program at 13 new sites in 2026. VA embarked on the EHRM program in October 2020 with the goal of improving the quality of care for veterans by updating the outdated VistA system to allow for better communication between the Department of Defense, VA, and community care providers. While we should always strive to innovate and improve the quality of care for veterans, in practice, the rollout of EHRM has been so problematic that it created life-threatening problems and ongoing upheaval for veterans’ ability to get the health care they need. The Mann-Grandstaff VA Medical Center in Spokane, Washington was the first VA site to implement the new system and since then, EHRM has expanded to several other hospitals in Washington state, Ohio, Oregon, and Illinois.
The initial EHR rollout was plagued with significant issues that have harmed both providers and their veteran patients. VA providers continue to report that they struggle to learn the new system, and that when they try to seek help, they have difficulty accessing the helpline and communicating with support staff. While user satisfaction has slightly improved since the system was first implemented, a March 2025 Government Accountability Office (GAO) report revealed that only 13 percent of users believed that the modernized system made VA as efficient as possible. In addition, 58 percent of users believed the new system increased patient safety risks.
A March 2024 VA Office of Inspector General (OIG) report found that the new EHR system was causing scheduling-related patient safety issues at the VA site in Columbus, Ohio. Specifically, the OIG pointed to an error in the scheduling function that resulted in staff not following up with patients who missed their appointments. According to the OIG report, these issues played a role in the 2022 death of a veteran who failed to receive adequate outreach from the hospital system to reschedule a missed appointment. The OIG report also found unmitigated high-risk patient safety issues, patient medication inaccuracies, unresolved usability challenges, inaccurate medication data, the creation of numerous workarounds to provide patient care, overwhelming educational materials for pharmacy-related functions, and pharmacy staffing challenges. None of this is acceptable—implementing a new electronic health record should not result in dire staff burnout nor should it endanger VA patient safety.
In March, VA announced that it would expand its 2026 EHR deployments beyond the planned four sites in Michigan to nine additional VA medical centers and their associated clinics in Kentucky, Ohio, Indiana, and Alaska. We have serious concerns that the issues and system defects identified by GAO and the VA OIG have yet to be adequately addressed, ahead of this more aggressive rollout timeline. Our top priority is—and has always been—patient safety. VA and Oracle Cerner must ensure that the new EHR system is ready to integrate into VA, and those who are using the system are trained and ready to implement it, before it is deployed in more locations.
We have all seen how the deployment of new technology without adequate planning, training, and support can have disastrous consequences for patients and providers alike. In Spokane and Walla Walla, the rushed deployment of the new EHR system was nothing short of a disaster for veterans and their health care providers—increasing wait times, leading to serious errors in veterans’ treatment, and eroding productivity. We cannot afford to repeat these mistakes. VA providers should be supported in learning to confidently operate within the system before the system is deployed at more facilities.
Our veterans need an electronic health system that works with and for them—not against them. After sacrificing so much for our nation, they deserve to have the best health care experience possible. We request you provide our staff a briefing and answer the following questions by January 19, 2025:
- Earlier this year, you said you were going to make the implementation of EHR a “priority.” Please explain what actions VA is taking to make a successful EHR rollout a priority within the Department and what this means in terms of oversight and support of new rollout sites.
- How many super users are being assigned to the new sites?
- Please describe what the training will look like and how it is different from prior trainings.
- Have you received any feedback from VA providers on expanding the system? If so, what was that feedback?
- The most recent GAO report, which was published in March 2025, made three recommendations, but only one has been implemented. What is the status of the other two recommendations?
- Does VA have plans to implement the remaining two recommendations? If not, why?
- What guardrails does VA have in place to ensure patient safety and health care performance metrics are preserved as it accelerates EHR deployment to new sites?
- What are the projected Federal VA staffing levels, contract support, and other relevant activities required to meet the accelerated deployment schedule?
- How does VA plan to ramp up staffing levels and training to meet the accelerated deployment schedule?
- Given the VA OIG’s findings regarding medication inaccuracies, pharmacy workflow disruptions, and overwhelming training materials at EHR deployment sites, what specific corrective actions has VA taken to ensure medication orders, reconciliation, and dispensing are accurate and safe before expanding EHR implementation to additional facilities?
As VA continues its deployment of the new EHR system, we respectfully remind you that patient safety must always be the number one priority. Veterans’ lives are on the line—VA cannot afford to get this wrong and we stand ready to work with you to ensure the best outcomes for the veterans we all serve. Thank you for your attention to this important matter, and we look forward to your prompt and thorough response.
Sincerely,
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