OIG Details Additional VA EHR Implementation Patient Safety Concerns

The Department of Veterans Affairs (VA) EHR implementation has presented patient safety and care coordination challenges at the pilot site, according to an OIG report.

The healthcare inspection report is the second of three associated with the Cerner EHR implementation at the Mann-Grandstaff VA Medical Center in Spokane, Washington, which went live in October 2020.

OIG found that the new EHR implementation has created difficulties for users in critical areas such as clinical documentation and referral management.

In particular, the report found that data migration errors led to inaccuracies in patient demographic information such as name, gender, and contact information.

OIG also noted that clinical documentation processes have posed challenges to end-users, including creating additional work and limiting providers’ ability to code patient diagnoses correctly.

The report found that the EHR implementation has presented scheduling process issues as well, which has led to delays in primary care scheduling.

The authors noted that certain patient record flags, including those related to patients at high risk for suicide, failed to transfer accurately in the new EHR system, posing concerns for patient safety.

Further, OIG’s inspection revealed that some laboratory orders “disappeared” in the new system, leading to delayed results. Similarly, the system has presented referral management deficiencies, including lost or unaddressed referrals.

Lastly, the report found challenges related to VA Video Connect, including misdirected links.

The report authors noted that although the OIG did not identify any associated patient deaths during this inspection, future deployment of the new EHR without resolving such deficiencies will increase risks to patient safety.

The OIG recommended the deputy secretary review and address the remaining unresolved shortcomings.

“Further discussion of allegations related to medication management issues after go-live, ticket process concerns identified by the OIG during evaluation of the allegations, and underlying factors related to all substantiated allegations can be found in the OIG’s companion reports,” the authors noted.