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SPOKANE, WA — Due to the sheer number of complaints received about VA’s rollout of its new electronic health record (EHR) at the Mann-Grandstaff VAMC, the VA Office of the Inspector General (OIG) initiated two separate, simultaneous inspections into the EHR process.
Those investigations resulted in three separate reports that were released concurrently last month and confirmed many of the allegations being made by facility staff since the rollout began: essentially that the rollout increased the risk for patient errors and made it more difficult for staff to do their jobs. The reports also confirmed that the process VA and CERNER—the manufacturer of the EHR—set up to fix these problems was equally flawed.
One report was dedicated entirely to medication management deficiencies within the new system, which made it difficult for staff to ensure that veterans were receiving the medications they were prescribed.
A persistent issue was that data migration problems prevented veterans’ mailing addresses and other patient information from transferring to the new system. That prevented VA’s mail order pharmacy from filling prescriptions.
“Interim measures to manually correct information were unsuccessful as the DoD data remained the primary linked data source,” investigators noted in the report. “Pharmacy staff contacted patients to check on medications and filled prescriptions at the facility pharmacy as needed. Patients alerted facility staff of prescriptions not arriving by contacting providers, the call center, or the patient advocate; or by presenting to primary care or the pharmacy. The additional calls and visits increased facility staff workload.”
According to the report, these data migration issues between DoD and VA’s legacy system were a known issue before the new EHR went live at the facility.
Medication Orders Deleted
Medication orders were also simply deleted. Clinic providers who entered recurring future orders for medications that were supposed to be administered on subsequent outpatient visits found that the EHR could not support the request and automatically discontinued the prescriptions. The EHR did not notify the providers of the discontinuance.
When the patients showed up for their next appointment, nurses would try to fix the problem by entering orders for approval by the provider or removing medications from automated dispensing machines. Providers who were going to be absent arranged for colleagues to write orders for recurring medications.
All of this created inefficiencies, increased risks for orders being missed and created possible patient safety issues, the report states.
The second report released by the OIG focused on care coordination deficiencies and covers a wide array of issues that the VAMC staff faced when trying to connect patients with providers, as well as tracking patient suicide risk.
In addition to substantial errors in data migration of patient information, there were also errors in scheduling and delays in appointments; multiple issues in being able to create and manage referrals; and problems in processing lab orders.
Due to vulnerabilities in the system and lack of training, routing for some lab orders failed. In addition, the orders were not always visible in the system to the staff. As a result, staff were required to develop time-consuming workarounds just to confirm the orders were received at the lab.
The new EHR also failed to carry over some patient record flags denoting a patient was at high risk for suicide or disruptive behavior. Problems with the EHR also impacted VA’s suicide prevention, tracking and reporting tools. The OIG also found that when the new EHR went live many relevant clinical staff lacked access to necessary suicide prevention risk assessment and reporting tools.
The final report in OIG’s trilogy focused entirely on the ticket resolution process. Not only did inspectors substantiate reports from employees who found that their complaints about the system were not being addressed, but OIG discovered that after months of knowing about these issues, VA and CERNER have not addressed the problems with the process.
These problems included that CERNER support staff were unable to view or replicate reported issues; did not communicate ticket status to end users; and closed tickets before they were resolved.
For example, a ticket regarding incomplete patient instructions was closed and remained unresolved with the comment “Closing but are meeting early next week on processes moving forward.” While support staff had a plan of action, the ticket should not have been closed until the problem was actually resolved.
Because of the difficulty in processing tickets, staff began to create workarounds rather than placing tickets, investigators found.
In July 2021, VA released a report with the results of its own strategic review that confirmed deficiencies with the ticketing process and listing potential actions to address those findings. VA and CERNER acknowledged that “ticket process deficits impaired the ability to identify and address patient safety concerns.”
However, months after that review was completed, OIG found that there had been limited change.
“To address the issues in the medication management and care coordination reports, VA must first resolve the issues with the ticketing system and the underlying factors,” the OIG states in the third report.
To accomplish this, OIG provided three sweeping recommendations to VA: complete a full evaluation of the EHR problem resolution process and take action as warranted; complete an evaluation of underlying factors identified in [the three] reports and take action as warranted; ensure the EHR deployment schedule reflects the resolution of these allegations.
Following the reports’ release, many legislators boiled these recommendations down to something they have been demanding of VA for months: Do not roll out the EHR to other facilities until these problems are fixed.
“These reports are unacceptable and make it clear the EHRM program is not where it needs to be,” declared Sen. Jon Tester (D-MT), chair of the Senate VA Committee. “I’ll continue holding VA and CERNER accountable in making necessary changes before expanding the program elsewhere across the country.”
- VA OIG, Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann Grandstaff VA Medical Center in Spokane, Washington, Report No. 21-00656-110, March 17, 2022, https://www.va.gov/oig/pubs/VAOIG-21-00656-110.pdf
