Issues with VA’s new EHR have contributed to patient harms and one death, watchdog says

Scheduling errors and pharmacy-related coding problems with the Department of Veterans Affairs’ new electronic health record system have contributed to patient safety incidents at VA medical facilities and presented new challenges for future deployments of the software, according to three separate reports released by VA’s Office of Inspector General on Thursday. 

The latest batch of critical inspections from OIG comes as VA continues its ongoing “program reset” to address previously identified technical issues and patient safety concerns identified at the five VA medical facilities currently using the department’s new Oracle Cerner EHR system. 

Under the reset, VA has paused additional rollouts of its new software to fix operational concerns at the current sites, with the exception of a joint rollout of the new software with the Department of Defense earlier this month at the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois. The modernized EHR system is meant to replace VA’s legacy system and be interoperable with DOD’s similarly new Oracle Cerner software.

Previous OIG reports have also identified serious issues with VA’s new EHR, including finding that the Oracle Cerner software deployed at the first VA medical facility to receive the modernized system — the Mann-Grandstaff VA Medical Center in Spokane, Washington — routed over 11,000 veterans’ clinical orders to an “unknown queue,” which resulted in direct harm to at least 149 veterans. VA has subsequently addressed that issue. 

Scheduling errors factored into patient death

The watchdog found that “a system error” in the functionality of the new EHR software at the VA Central Ohio Healthcare System in Columbus, Ohio, contributed to the accidental overdose of a patient in 2022, roughly seven weeks after the veteran missed their scheduled appointment. As a result of the software problem, the veteran’s missed appointment “was not routed to a queue to prompt rescheduling efforts.”

When a patient does not report for their appointment, relevant healthcare staffers at VA medical facilities using the new EHR software are required to update the appointment status to “no show” in the system. This information is then routed to a “request queue” for relevant personnel to reach back out to the patient to reschedule their appointment.

OIG found, however, that while the patient’s status was updated to “no show,” it was not subsequently routed to the request queue, which resulted in schedulers not being asked to conduct their outreach efforts. 

“The OIG concluded that the lack of contact efforts may have contributed to the patient’s disengagement from mental health treatment and, ultimately, the patient’s substance use relapse and death,” the report said.

The Oracle Cerner software issues were exacerbated by other problems that OIG identified, including staff failing to evaluate requests from the patient, staff failing to send appropriate communications to the veteran and a psychologist failing to “thoroughly evaluate or address the patient’s depression.”

The watchdog made five recommendations, including for officials to monitor the functionality of the Oracle Cerner EHR scheduling software and “to evaluate minimum scheduling effort requirements.” VA concurred with all of the report’s recommendations.

Scheduling issues point to challenges with future deployments

In a management advisory memo issued shortly after its longer report on the new software’s scheduling errors was released, OIG warned that “scheduling system challenges experienced during deployment of the new electronic health record at smaller VA medical facilities could be exacerbated at larger, more complex medical centers.”

The watchdog noted that “new concerns continue to arise” at the five VA medical facilities using the Oracle Cerner EHR system, such as the identified issues with rescheduling missed appointments and difficulties when it comes to providers and schedulers sharing necessary information. And these existing challenges, it found, were exacerbated by staffing shortages and the need for VA officials to increase hiring or overtime for schedulers.

“The results of the team’s review suggest that future sites need to be prepared to address known scheduler shortages before deployment and potentially increase hiring and overtime for appointment scheduling, OIG said, adding that “large facilities that handle higher patient or appointment volumes should especially be aware of staffing needs to mitigate the additional time and impact of manual work-arounds needed to deploy the EHR.”

While the report cited identified issues with the EHR system, however, it also said that “[Veterans Health Administration] staff anticipate that positive outcomes are still achievable if facilities take the time to learn from previous deployments, applying lessons learned to either alleviate challenges or better manage them, thereby decreasing the impact to staff and patients.”

Pharmacy-related safety issues still a concern

A VA official told lawmakers in February that approximately 250,000 veterans who visited both VA medical facilities using the new Oracle Cerner software and those still using the department’s legacy system were at risk of receiving contraindicated medications due to interoperability issues between the two systems.

Although Thursday’s report noted that the issue — which it attributed to “an error in software coding” — was fixed within a week of its discovery, it said the software patch “did not resolve incorrect prescription data sent prior to the patch.”

OIG also reiterated that the “affected patients have not been notified of their risk of harm” and added that it “remains concerned for their safety.”

The watchdog also said that the Veterans Health Administration “sent a series of notifications about the new EHR transmission issues and outlined recommended actions to mitigate the risk of harm for patients,” but failed to “identify outcome measures” in those messages.

Beyond the identified interoperability issues, VA said the new EHR system “challenged pharmacy staff to provide safe medication management and avoid patient harm.” This resulted in prescription backlogs, “numerous workarounds and educational materials to complete pharmacy work processes” and pharmacy staff burnout and job dissatisfaction.

OIG proposed nine recommendations to VA, including notifying patients who were potentially affected by the software coding issue, ensuring that pharmacist staffing levels “are assessed and addressed” before future EHR system deployments and addressing other pharmacy-related issues identified in the report. VA concurred with all of the watchdog’s recommendations.