VA watchdog warns EHR issue puts 250,000 veterans at risk of medication mix-ups

A VA watchdog says hundreds of thousands of veterans treated at sites using the VA's EHR are at risk of receiving the wrong medication.

A Department of Veterans Affairs watchdog says hundreds of thousands of veterans treated at sites using the VA’s electronic Health Record (EHR) are at risk of receiving the wrong medication.

The VA Office of Inspector General (VA OIG) told members of the House VA Committee on Thursday that if veterans see treatment at one of five sites using the department’s new Oracle-Cerner EHR, then receive care at a VA facility using its legacy Vista EHR, their medication information may be incorrect.

Among the risks, VA providers may be checking for drug interactions and allergy checks based on inaccurate or outdated information.

Deputy IG David Case told lawmakers that about 250,000 veterans since September 2023 have received medication orders or medication allergies documented in the new Oracle-Cerner EHR.

“They may be unaware of the potential risk for a medication or allergy-related event if they visit a legacy EHR site,” Case said.

Case told lawmakers that when the VA’s legacy system goes to access data from the Health Data Repository, records entered from the new EHR may be duplicative, or not accurate, or missing.

“The result is when this check occurs when a veteran has gone to the new EHR, and is now at the old EHR getting a prescription, it could be based on inaccurate information,” he said.

In one incident, a veteran in a VA residential treatment facility was repeatedly denied his medication because it was showing as inactive in the system.

Neil Evans, acting program executive director of VA’s EHR Modernization Integration Office, said the legacy Vista EHR warns providers if a patient receives care at a site using the new Oracle-Cerner EHR.

The VA, he added, will notify impacted veterans about this issue, but said the “most important person to be aware is that prescribing provider.”

“It is the prescribing provider who’s going to have to take the action, to make sure that they’re verifying the medication list, and that they are then making sure that there are no drug interactions for that particular patient,” Evans said.

“Notifying the patients is important, and it’s something we will do. It’s also very important that the providers are aware of the need for the extra vigilance in this circumstance,” he added.

Case, however, told lawmakers that VA OIG has not “seen evidence that VA has sufficiently notified legacy EHR providers about this issue, and the mitigations to safely care for these new EHR site patients.”

“While VA is taking efforts to reduce this potential, we remain concerned that patients have not been informed of their individual risks, essentially being excluded as full participants in their care,” he said.

VA providers still using the Vista EHR have been performing manual medication safety checks for patients who have their data in the new EHR.  But Case said these manual safety checks are “complex and rely on the vigilance of pharmacist frontline staff.”

At the VA Medical Center in Columbus, Ohio, a prescription backlog required a permanent 62% increase in clinical pharmacists.

Case said pharmacy leaders had to create their own workarounds and education materials, and pharmacy staff were burned out and had low morale.

“These findings are troubling given the mitigations for pharmacy failures rely on staff vigilance,” Case said.

Subcommittee Chairman Matt Rosendale (R-Mont.) said sites using the new EHR have had to increase their pharmacy staffing by at least 20% to navigate all the bugs and workarounds — just to process roughly the same volume of prescriptions.

“Simply put, the medical centers using the Oracle Cerner EHR have been turned upside down,” Rosendale said.

According to Rosendale, VA projects that large, complex medical centers will have to increase their pharmacy staffing by as much as 60% to mitigate the software’s problems.

Mike Sicilia, executive vice president of Oracle Global Industries, said Oracle is aware VA has increased pharmacy staffing at sites using the new EHR, and that the vendor “will continue to partner with VA to find efficiency opportunities while maintaining the benefits of the new capabilities.

“It’s not unusual that, when you have a major go-live for a very complicated system, that extra staff are required. This happens in commercial markets, this happens all the time. What is unusual is that you have sustained that staff for a long period of time,” Sicilia said.

Sicilia said Oracle since June 2022 has made pharmacy-related EHR fixes its top priority.

“When we took it over, it was unstable, was unacceptable,” he said. “We listened, we received the required changes on contract from VA and delivered them in an expedited fashion.”

Unlike in private-sector health care, VA pharmacists and pharmacy staff are fully integrated into patient care teams.

“The division that exists between the health system and retail pharmacies in the private sector simply doesn’t exist in VA,” Evans said.

Sicilia told lawmakers “it is a unique process, and it has been the most difficult and the most challenging to get it right.”

The VA has put future rollouts of the Oracle-Cerner EHR on hold, until VA deals with underlying issues in the system for more than 10,000 VA users using the system at five medical centers, 22 clinics and 52 remote sites using the new system.

“We’re committed to getting this right,” Evans said, adding that VA has made “incremental, but steady progress,” and that Oracle-Cerner has made all but one of seven top-priority EHR pharmacies software updates, which are now in place.

A final feature, to automate the synchronization of prescription information between the Oracle provider and pharmacy applications, has been installed, but it’s not yet enabled.

The VA’s ability to resume the EHR rollout will depend, in large part, on the success of the system’s launch in March 2024 at the Capt. James A. Lovell Federal Health Care Center in Chicago.

The facility is jointly run by the VA and the Defense Department, which is much further ahead in its own deployment of the same Oracle-Cerner EHR.

Sicilia said a successful go-live at the Lovell Federal Health Care Center would demonstrate the EHR will work at larger, more complex facilities, and that it will be a “good baseline” for improvements to the new EHR.

“We should see a marked improvement in satisfaction, we should see a marked improvement in system reliability,” Sicilia said

Subcommittee Ranking Member Sheila Cherfilus-McCormick (D-Fla.) said she’s “extremely concerned” VA and DoD are moving ahead with the Lovell go-live “before the objectives of the reset have been met.”

“I understand the DoD is motivated to finish this deployment; that cannot come at the expense of our veterans or VA providers,” Cherfilus-McCormick said.


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