The Department of Veterans Affairs put patients\u2019 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\u2019s millions of retired armed services members.<\/p>\n\n\n\n
In a stinging report, the VA\u2019s inspector general, its internal watchdog, said a complaint about prescription backlogs at a veterans\u2019 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.<\/p>\n\n\n\n
\u201cThe 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,\u201d the new report concluded.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
\u201cThe 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,\u201d the report said. \u201cAlthough 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.<\/p>\n\n\n\n
You can read the full report here.<\/p>\n\n\n\n
While raising serious concerns about the system\u2019s 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.<\/p>\n\n\n\n
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 \u201cwill continue development of rapid and reliable processes for quickly identifying and resolving issues within the new EHR.\u201d<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
\u2018The OIG determined that the chief of pharmacy prepared for challenges with the new EHR. However, pharmacy staff\u2019s workload increased due to the new EHR\u2019s operational inefficiencies,\u201d the report noted. \u201cThis 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.\u201d<\/p>\n\n\n\n
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. \u201cThis error created the potential for medication-related patient safety events,\u201d the report said.<\/p>\n\n\n\n
The data inaccuracies were \u201cresulting in inaccurate medication, allergy, and adverse drug reaction information\u201d and they \u201ccreated the potential for medication-related patient safety events,\u201d the report warned.<\/p>\n\n\n\n
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 \u201cnot confident\u201d that responsible VA leadership has the necessary control and oversight.<\/p>\n\n\n\n
\u201cThe 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,\u201d the report pointedly warned. The inspector general also warned that veterans being treated at impacted sites have not been alerted to the problems.<\/p>\n\n\n\n
\u201cPatients who receive care at new EHR sites have not been notified of the risk of harm secondary to data transmission issues,\u201d the report said.<\/p>\n\n\n\n