OIG: VA EHR system issues have led to patient harm, one patient death

A system error in the new Department of Veterans Affairs (VA) EHR contributed to the accidental overdose of a patient in 2022, according to a VA Office of Inspector General (OIG) report.

The patient died approximately seven weeks after a missed appointment at the VA Central Ohio Healthcare System in Columbus.  

The OIG conducted an internal review of the patient's care to assess the adequacy of mental health evaluations of the patient, supervision of a psychologist, and caring communications management.

The OIG found that due to the system error, the EHR did not route the patient's missed appointment to a queue for rescheduling efforts.

The watchdog also determined that the Veterans Health Administration (VHA) required fewer patient contact attempts following missed mental health appointments for sites using the new Oracle Health EHR compared to established care standards.

The OIG made one recommendation to the Deputy Secretary to monitor EHR scheduling functionality. The OIG also made two recommendations to the Under Secretary for Health to evaluate minimum scheduling effort requirements and establish Lessons Learned guidance. Additionally, the OIG made two recommendations to the Facility Director to review the patient's care and Caring Communication Program compliance.

In a separate OIG management advisory memo released shortly after the OIG report, the watchdog warned that larger, more complex medical centers could experience exacerbated EHR scheduling challenges.

While VA has paused additional EHR deployments until it is confident in the platform's functionality, the deployment at the Captain James A. Lovell Federal Health Care Center (Lovell FHCC) proceeded as planned earlier this month.

Lovell FHCC is the first large, complex VA facility to use the new EHR.

Provided to VHA ahead of that deployment, the memo aimed to assist in deciding whether additional actions are needed to fix EHR scheduling issues prior to or during future implementations.

These concerns include the need for additional staff to meet or exceed pre-deployment appointment volumes, displaced appointment queue functionality, challenges related to providers and schedulers sharing data, inaccurate patient information, difficulties changing appointment types, and the inability to mail appointment reminder letters automatically.

At VA facilities currently using the new Oracle Health EHR, these issues have led to workarounds, increasing the potential for scheduling errors.

"Consequently, at future go-live facilities, assessing staffing levels and overtime usage prior to deployment and preparing staff with approved workflow best practices may help to reduce employee resistance and facilitate successful adoption of the system," the memo noted.

A third VA report released on the same day outlines an inspection at the VA Central Ohio Healthcare System to review an allegation that the new EHR led to a prescription backlog.

While reviewing the allegation, the OIG found that facility leaders took "timely and sustainable steps" to manage the concern. However, the OIG identified additional pharmacy-related patient safety issues at the facility and national levels.

OIG found that the EHR implementation at the Colombus facility, despite known pharmacy-related patient safety and usability issues, contributed to ongoing patient safety risks and usability challenges.

The new EHR also contributed to pharmacy-related patient safety challenges nationally, as a software coding error resulted in inaccurate medication and allergy information transmission from new EHR sites to legacy EHR sites.

"Affected patients were not notified of their risk of harm and the OIG remains concerned for their safety," the report authors wrote. "The OIG learned VHA communicated recommendations to providers to mitigate the risk of harm to affected patients; however, the recommendations were non-sustainable."

Additionally, the new EHR's operational inefficiencies required additional clinical pharmacist staffing, as well as the creation of workarounds and educational materials to complete pharmacy processes. The inefficiencies also led to pharmacy staff burnout, job dissatisfaction, and decreased staff morale.

The OIG made three recommendations to the Deputy Secretary related to addressing patient safety and usability issues.

The OIG also made six recommendations to the Under Secretary for Health. One recommendation focuses on accurate patient medication data, and three recommendations address patient and provider awareness and evaluation of the risk of harm related to data exchange issues.

Another recommendation is related to pharmacy staffing, and one focuses on the underlying technical and functional issues requiring workarounds to perform pharmacy processes.