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VA put veterans’ safety at risk with bungled roll out of new health records platform, probe finds

Despite some fixes, internal watchdog warns there are still "unmitigated high-risk patient safety issues" related to prescriptions and health records.

Published: March 31, 2024 11:15pm

The Department of Veterans Affairs put patients’ safety at significant risk with a bungled rollout of its new electronic health records (EHR) system that created inaccuracies in medicine and prescription data, an internal investigation found in the latest black eye for the federal agency that cares for America’s millions of retired armed services members.

In a stinging report, the VA’s inspector general, its internal watchdog, said a complaint about prescription backlogs at a veterans’ facility in Columbus, Ohio led to the discovery of massive problems in the EHR system nationwide and it pointedly warned that some of the issues still persist.

“The OIG found unmitigated high-risk patient safety issues, patient medication inaccuracies, unresolved new EHR 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,” the new report concluded.

The inspector general said many of the safety and usability problems it uncovered were previously flagged by VA safety experts and that it is concerned the VA will keep rolling out the EHR system to other facilities before all necessary corrective actions are taken by the contractor who built the system, Oracle Health.

“The OIG determined that previously-identified NCPS patient safety issues were a factor in 32 percent of the facility pharmacy-related patient safety reports and EHR usability was a factor in 66 percent,” the report said. “Although Oracle Health has since resolved some of the previously-identified NCPS issues, the OIG is concerned that the new EHR will continue to be deployed at Veterans Health Administration (VHA) sites prior to resolving the remaining issues.

You can read the full report here.

While raising serious concerns about the system’s flaws, the watchdog credited caring VA staff for working long hours to try to fix issues or create workarounds to reduce risks and prescription backlogs.

The report made six recommendations to ensure patients are protected an the system achieves permanent corrections, and the VA agreed with all of them while promising to allocate the resources to get the job done without further risks to veterans being treated by the VA. The agency said it “will continue development of rapid and reliable processes for quickly identifying and resolving issues within the new EHR.”

The OIG has repeatedly flagged serious issues inside the VA system over the last decade, ranging from benefits and treatment delays to inaccurate diagnoses and medical errors. It also had issued prior warnings about the new electronic records projects.

The report provides a case study in how a system designed to modernize and streamlining care inside the VA had the opposite effect, both because of flaws and confusing training materials.

‘The OIG determined that the chief of pharmacy prepared for challenges with the new EHR. However, pharmacy staff’s workload increased due to the new EHR’s operational inefficiencies,” the report noted. “This contributed to the prescription backlog and the need to hire nine full-time clinical pharmacists, which represented a 62 percent increase. The OIG would have expected the new EHR's implementation to result in more efficient pharmacy processes.”

The watchdog said one of the more serious problems occurred with a software coding error which cause the new system to scramble and send inaccurate medication data to VA centers that were not yet moved to the new system. “This error created the potential for medication-related patient safety events,” the report said.

The data inaccuracies were “resulting in inaccurate medication, allergy, and adverse drug reaction information” and they “created the potential for medication-related patient safety events,” the report warned.

While internal warnings were issued quickly to alert frontline staff of the safety issues and fixes were put in place, the watchdog said the system is not yet fixed entirely and it “not confident” that responsible VA leadership has the necessary control and oversight.

“The OIG remains concerned for the safety of new EHR site patients who receive care from a legacy EHR site, as the information transmission issues may result in new EHR site patients being prescribed contraindicated medications and legacy site providers making clinical decisions based on inaccurate data,” the report pointedly warned. The inspector general also warned that veterans being treated at impacted sites have not been alerted to the problems.

“Patients who receive care at new EHR sites have not been notified of the risk of harm secondary to data transmission issues,” the report said.

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