Patient Safety Risked Through VA Electronic Health Record Rollout, Watchdog Finds

Spokane Veterans Affairs Medical Center.
Active duty and Air National Guard leadership from Fairchild Air Force Base, Wash., visit the Spokane Veterans Affairs Medical Center to meet veterans and the medical staff in Spokane Wash., Feb. 14, 2014. (Staff Sgt. Alexandre Montes/U.S. Air Force photo)

The Department of Veterans Affairs' new electronic health records system failed to flag patients who had been identified as suicide risks, gave doctors inaccurate information about patients' medications, and caused delays in scheduling appointments, the department's watchdog said Thursday.

Those are just some of the patient safety issues identified in a scathing series of three reports released by the VA's inspector general about the electronic health records program's rollout at its test site at a VA hospital in Spokane, Washington.

While investigators could not identify any serious health problems or deaths resulting from the issues with the electronic records, the reports add to a pile of concerns lawmakers have about a $16 billion program that is supposed to receive a wider rollout in the coming weeks.

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"We found serious deficiencies and failures in the implementation of the new electronic health record at the Mann-Grandstaff VA Medical Center, which increased the risks to patient safety and made it more difficult for clinicians to provide quality health care," VA Inspector General Michael Missal said in a video statement.

The new system, built by health technology powerhouse Cerner, was launched at the Mann-Grandstaff VA Medical Center in November 2020. It is scheduled to be rolled out at the VA medical center in Walla Walla, Washington, by the end of next week.

It is the same system used by the Defense Department, which has no recent reports of issues similar to those experienced during the VA rollout. The idea behind the VA adopting the program, a move announced by then-President Donald Trump in 2017, was to provide veterans a more seamless health record that could follow them from their military career to their post-military life.

But the program has been plagued by reports of glitches and shortcomings for months, including crashing earlier this month and causing the hospital to temporarily pause treatments and intakes.

This week's inspector general reports focus on medication management, care coordination and technical support challenges the program has faced at Mann-Grandstaff.

Some of the issues have been resolved, but the majority are outstanding, according to the reports.

Among the issues, patients who had been flagged as being at high risk for suicide or disruptive behavior in the old system weren't flagged when the records were transfered to the new system, according to one of the reports. Staff also were unable to access suicide prevention risk assessment and reporting tools.

Inadequate, time-consuming or incorrect training for staff on the new system caused delays in scheduling primary care appointments, investigators found, with one primary care staff member saying scheduling requests were initially "going into the abyss." Additionally, many virtual appointments, which were in demand because of the COVID-19 pandemic, did not work correctly because links to access the video feed were broken.

Names, genders and contact information for patients also did not transfer over to the new system correctly, making it hard to contact patients to schedule appointments, sending links for virtual appointments to the wrong email addresses, and "increasing risk for patient distress" by referring to transgender patients with the wrong name or gender, the report said.

The incorrect contact information also caused issues for the mail order pharmacy in sending prescriptions out, according to another of the reports. Doctors also did not have a full view of patients' medical histories because medications that were expired, discontinued or administered at the clinic weren't listed in the new system.

Investigators also found that the system's printable directions for taking medication weren't patient-friendly, including some that used Latin abbreviations instead of English to say how often the drug should be taken, while other medication instructions were missing altogether.

Staff put in more than 38,700 requests for technical support from the program's launch in November 2020 through the end of March 2021, but they reported that many of the tickets "entered a 'black hole'" and went unaddressed, one of the reports said.

In responses included with the report, Deputy VA Secretary Donald Remy agreed with many of the inspector general's recommendations and said the department is working to address them by mid-May. But he took issue with a recommendation to report any future issues with medication management to the inspector general as too open-ended.

"VA anticipates that the number and nature of patient safety reports will fluctuate as potential patient safety events in areas such as care coordination and medication management are identified, reported, investigated and resolved," Remy wrote in the response.

Lawmakers, particularly those representing Washington state, had already been calling on the VA to slow the rollout of the electronic health records, or EHR, program to other facilities and used the new inspector general reports to reiterate those demands.

"It's absolutely unacceptable to me that VA knew about widespread, egregious patient safety risks associated with its ongoing rollout of its Cerner Electronic Health Record System -- but in conversations with my office, VA has been expressing confidence and readiness for the go-live date at the Walla Walla VA," Sen. Patty Murray, D-Wash., said in a statement.

"To be clear once again: I do not want to see the EHR system move so much as an inch further in Washington state until VA has proven to me that it's fixed the problems in Spokane and provided clear, objective data showing resolutions to concerns raised by the Inspector General's reports," she added.

The House Veterans Affairs Committee's technology modernization subcommittee plans to hold a roundtable April 5 to hear from leadership and staff in Spokane and Walla Walla, as well as Columbus, Ohio, where the system is scheduled to launch at the end of April, the committee announced Thursday. The subcommittee is also planning a hearing April 26 specifically to discuss the inspector general reports.

"The front-line workers at VA have gone through so much over the past two years with the COVID-19 pandemic, and I applaud their efforts to create workarounds to make the system work in Spokane, but this is not sustainable," House Veterans Affairs Committee Chairman Mark Takano, D-Calif., said in a statement. "I look forward to hearing from VA staff at our upcoming roundtable, but let me be clear -- I am committed to making sure that this implementation is done correctly, and most importantly, safely."

-- Rebecca Kheel can be reached at Follow her on Twitter @reporterkheel.

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