VA EHR rollout increased ‘risks for errors’ in veteran health care, watchdog warns

The IG reports found the rollout of the new EHR sometimes failed to indicate to providers that patients were flagged as being at high risk of suicide and gave V...

The Veterans Affairs Department’s first facility to adopt its new Electronic Health Record (EHR) is running into more problems that make it harder for some health care providers to treat patients, and more challenging for veterans to seek care.

The VA inspector’s general office, in a series of reports released Thursday, substantiated many of the EHR concerns that agency employees reported at the Mann-Grandstaff VA Medical Center in Spokane, Washington. The new EHR went live at that facility in October 2020.

The IG reports found new EHR sometimes failed to indicate to providers that patients were flagged as being at high risk of suicide and gave VA providers an incomplete picture of patients’ health care data.

Auditors also found health care providers’ requests for patients to receive lab work through the new EHR platform didn’t always reach the facility’s laboratory.

The EHR platform also suffered from data migration issues that prevented veterans from logging onto an online patient portal, and sometimes led to links to telehealth appointments being sent using outdated contract information.

The IG office during its inspections did not identify any patient deaths linked to the EHR problems, but warned unresolved issues will continue to put patients at risk.

“The OIG is concerned that deployment of the new EHR without resolution of the deficiencies presents risks to patient safety,” the report states.

The IG office’s reports document challenges with care coordination, medication management and staff processing ticketing requests for IT help after the EHR rollout in Spokane.

VA Inspector General Michael Missal said in a statement his office will continue its oversight work related to EHR modernization.

“These three reports 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,” Missal said.

The reports found that VA staff not having a full picture of a patient’s health data “may negatively affect the coordination of care and provider efficiency, as well as increase risks for errors and decrease staff perceptions of system usability.”

VA executives told the IG’s office that the agency has fixed or is in the process of fixing several of the IT issues highlighted in the report.

The IG reports, however, found insufficient end-user training was the “main source” of difficulties and misperceptions for certain EHR functions.

Deputy VA Secretary Donald Remy told the IG office that the Electronic Health Record Modernization Integration Office (EHRM IO) and the Veterans Health Administration are working on a “Get Well” plan to address the outstanding problems in the IG report.

Remy said the VA will review and address substantiated and unresolved allegations documented in the IG reports by May 10.

Lawmakers said the IG reports indicate Congress needs to further scrutinize VA’s EHR rollout.

Senate VA Committee Chairman Jon Tester (D-Mont.) said the committee will ensure VA and EHR vendor Cerner make “necessary changes before expanding the program elsewhere across the country.”

“These reports are unacceptable and make clear the EHRM program is not where it needs to be,” Tester said.

House VA Chairman Mark Takano (D-Calif.) said the IG reports “are in line with what we have been hearing from employees in Mann-Grandstaff all along.”

“While I think there were some lessons learned and changes made during the strategic pause, I’m not convinced that VA has solved its issues with the Cerner system and medication management—however, I hope that under Secretary McDonough’s leadership, these issues will be resolved,” Takano said.

It remains unclear what impact, if any, the reports will have on VA’s plans to roll out the new EHR to its other facilities.

The VA announced last year that it would pause future EHR rollouts, after a strategic review revealed a wide array of problems at the first go-live site in Spokane.

The agency delayed the EHR go-live date at its medical care facility in Columbus, Ohio, to April 30. The agency previously expected the system would go live at that facility on March 5.

The VA pushed back the second rollout of its Electronic Health Record (EHR) system because of a shortage of employees available for training amid an uptick in COVID-19 cases.

VA’s Under Secretary for Health Steven Lieberman told the IG’s office that the Veterans Health Administration concurs with the action plan developed by the Office of Electronic Health Record Modernization “and is committed to supporting it.”

VA Northwest Network Director Teresa Boyd told the IG’s office that her office “remains committed to a safe implementation of the new electronic health record and will support actions to effectively address the recommendations.”

EHR failed to notify VA providers about at-risk vets in some cases

The IG found patient record flags denoting patients at high risk for suicide and disruptive behavior failed to activate for some patients in the new EHR system.

The IG also found that clinical staff lacked access to necessary suicide prevention risk assessment and reporting tools when the new EHR went live, and interoperability issues affected the functionality of VHA suicide prevention and tracking tools that were already in place prior to the EHR rollout.

The launch of the new EHR also created challenges for VA medical facilities still using the legacy EHR, including displaying inaccurate information on patient record flags.

The OIG found some of the patient record flag functionality in the new EHR “stemmed from the design of the system, while other concerns were related to deficits in training on processes needed to support the workflow of the new system.”

The IG also found data migration errors in the EHR rollout, including incorrect patient names, genders and contact information.

Outdated data from the Defense Department’s Defense Enrollment Eligibility Reporting System (DEERS) overwrote data from VHA’s legacy EHR system for some patients during the migration to the new EHR.

“The problems associated with inaccurate data migration present significant concerns for VA plans to implement the new EHR at other VHA sites. If left unresolved, this issue could affect care of veterans across VHA sites,” the report states.

The IG reports also note some diagnostic codes were not available in the new EHR, which “hindered the ability of staff to precisely document management of diseases and health conditions.”

Some employees were also unable to view a patient’s service-connected conditions in the new EHR, while others ran into issues managing referrals to outpatient medical specialists.

The IG also found that vulnerabilities in the EHR system, as well as deficits in staff training, meant that routing for some laboratory orders failed and did not reach the facility laboratory.

The IG report finds VA staff developed “time-consuming workarounds to confirm receipt of orders by laboratory staff.”

Data migration issues impacted veterans’ access to care

The IG also found scheduling problems after the launch of the EHR system. Some appointment reminders didn’t mention whether the scheduled appointment was for a virtual or in-person visit. This led to some patients mistakenly showing up in-person for telehealth visits.

The IG also found issues with the setup of the new EHR’s self-scheduling tool led to some patients in Spokane inadvertently scheduling appointments in Ohio.

The IG reports said the VA disabled the self-scheduling tool after problems materialized, and that the VA OEHRM staff is working to fix the underlying system configuration.

The IG office found that between October 2020 and March 2021, new EHR end-users placed over 38,700 tickets requesting fixes to some aspects of the new EHR implementation.

The rollout of the new EHR also disrupted the use of VA Video Connect technology for patients and providers, which created problems for telehealth appointments early on in the adoption. The IG notes, however, that the issues appear to have been resolved.

Data migration issues resulted in VA Video connect appointments going to invalid email addresses. Auditors found the new EHR didn’t have a process to alert staff when delivery of the email containing an appointment link failed.

The VA completed an update in March 2021 to correct mapping of a patient’s location to ensure telehealth appointments scheduled through the new EHR displayed in the correct time zone.

These data migration issues resulted in patients not receiving two-factor authentication messages to their current phone numbers or email addresses, and were unable to sign in to the VA patient portal.

When the new EHR went live, many patients were unable to access the patient portal, affecting access to tools that supported the coordination of care, such as secure messaging and online prescription refills.

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