Watchdog finds major foul-ups in VA’s new $16 billion health-records system

Democratic lawmakers raised concerns about patient safety Thursday in the Veterans Affairs’ troubled switch to a new $16 billion electronic health-record system, after a watchdog found problems including the automatic cutoff of regular prescription drugs for veterans, lost lab orders and failure to flag veterans who are at high risk for suicide.

The chairmen of the House and Senate Veterans’ Affairs committees said the foul-ups documented in implementing the electronic health-record system at a major VA hospital in Spokane, Washington, make clear that the 2-year-old program still isn’t ready to be expanded to the rest of the VA network.

“These reports are unacceptable and make clear the [electronic health-records] program is not where it needs to be,” Sen. John Tester, Montana Democrat, said.

House Committee on Veterans’ Affairs Chairman Mark Takano, California Democrat, said his concerns about awarding the contract to Missouri-based Cerner Corp. in 2020 have not been allayed.

“I’m not convinced that VA has solved its issues with the Cerner system and medication management,” Mr. Takano said. He said employees at the Mann-Grandstaff VA Medical Center in Spokane have been diligent in creating workarounds to the system’s problems, but such a labor-intensive solution “is not sustainable.”

“We cannot keep asking these healthcare employees to shoulder the burden for a program that did not take their requirements and needs seriously from the start,” he said.

The VA’s inspector general issued three reports on Thursday detailing flaws in the electronic health-records management system, which crashed three weeks ago in Spokane, halting medical treatments and intakes at the VA hospital.  

Investigators verified that the new electronic system failed to transfer “flags” that are used to alert staff to patients at high risk for suicide and disruptive behavior, “placing patients and staff at increased risk.” The report said some of the problems resulted from the system’s design and others from operators’ lack of adequate training.

“The OIG also found that, when the new [system] went live, relevant clinical staff lacked access to necessary suicide prevention risk assessment and reporting tools,” the report said.

Further, the transfer of patient data to the new system caused “incorrect names, genders and contact information” for some patients.

The investigators said the new electronic system wasn’t compatible with the Defense Department’s records, leading to contact information that “reverted to the outdated DoD data each night at midnight for patients with DoD affiliations.”

“The data migration failures disrupted processes for healthcare staff who rely on accurate contact information to communicate with patients and for the VA mail order pharmacy that relies on correct mailing addresses to fill and mail patients’ prescription medications,” the report said.

The IG found “medication management challenges associated with implementation of the new EHR” system. The investigators reviewed 221 electronic medication-management “tickets” and found that 33% were closed without a documented resolution.

The report identified “ticket process challenges with reporting, tracking and resolving problems. These included Cerner being unable to view or replicate reported issues, tickets being closed before resolution, status not being reported to end users, staff employing workarounds without placing tickets, and an ineffective change request process hindering EHR changes.”

Staff said such tickets went into a “black hole.”

“Although the OIG did not identify any associated patient deaths during this inspection, deployment of the new EHR without resolution of deficiencies may present risks to patient safety and affect providers’ treatment decisions,” the report said.

VA officials said in response that many of the problems identified in the investigations, which date to the first half of 2021, have been resolved or will be addressed in various action plans.

“Bi-directional communication between the Cerner and VA ticketing systems has been expanded to include change requests to provide visibility throughout the process,” the agency said. “In addition, a capability has been added that converts tickets reported as incidents into change requests to ensure they go through the correct resolution process.”

Rep. Frank Mrvan, Indiana Democrat and chair of the House Veterans’ Affairs subcommittee on Technology Modernization, has scheduled meetings with employees from three VA facilities in Washington state on April 5 and a hearing with VA officials and contractors on Capitol Hill on April 26.

“These reports make clear that there are significant issues with the implementation,” Mr. Mrvan said. “We must hear what VA is going to do to make sure this is not an issue going forward.”