The VA's New Health Record Is Still Putting Patients at Risk

Deficiencies in the multibillion-dollar electronic health records system being implemented by the Veterans Affairs Department are continuing to create patient safety risks, according to three reports released on Thursday by the agency's Office of Inspector General.

The reports focus on the implementation of the Cerner electronic health record at the Mann-Grandstaff VA Medical Center in Spokane, Wash. – the initial go-live site for the software overhaul that will eventually cover the entire VA enterprise. 

Many of the issues identified in the reports – pharmacy errors, patient data problems, interruptions in the coordination of care and long delays in contractor staff responding to help desk requests have been identified in previous oversight efforts and were examined in a "strategic review" conducted by VA when it paused the deployment schedule in March 2021.

However the OIG reports, based on investigations that took place between January and June 2021, provide a 360-degree view of technical, clinical and management challenges that have apparently hindered VA leadership and its Office of Electronic Health Records Modernization from fully solving problems at Mann-Grandstaff in advance of future deployments.

"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," VA IG Michael Missal said in an emailed statement. "Our office will continue its oversight work related to electronic health record modernization with the hope that improvements can be made to this and future implementations of the system."

The issues identified are so serious and pervasive that VA leadership has pledged to examine its current deployment schedule in light of the reports and issue any revisions by March 26. The Cerner record system has been live at Mann-Grandstaff since Oct. 24, 2020.

According to the first report, covering pharmacy care and medication management, basic patient contact information was often not accurately maintained in the Cerner system, in part because nightly updates would overwrite correct VA patient information with outdated information from a Department of Defense database. Additionally, the Cerner system was not configured to accept post office boxes as legitimate addresses, delaying mail-order medication for many patients. VA pharmacy staff developed time-consuming work-arounds to make sure patients received mail-order prescriptions in a timely fashion.

Additionally, the Cerner system was not configured to accommodate the VA practice of managing patient medications by approving future orders for recurring prescriptions or clinical treatments, such as medications administered as part of regular patient visits for substance abuse treatment or mental health care. Such orders were discontinued under the Cerner system and were also the subject of work-arounds by VA caregivers.

Medications sent by mail order frequently included confusing instructions that were not comprehensible to patients, and some instructions were never imported from VA's legacy electronic health record system VistA. 

One Mann-Grandstaff employee, who was helping train colleagues on the new system as a "super user," told OIG the problem was in the software.

"The functionality is that the software was not written to accept and understand the information that was incoming. You can't take Microsoft and put it into an Apple without some sort of translator," the staffer said. "There was nothing there to translate CPRS [Computerized Patient Record System] language to Cerner language so that it would work."

VA Deputy Secretary Donald Remy, in reply comments on the medications report, noted that three of the 21 unresolved allegations identified in the report have already been resolved, and he set a target date of May 10 for addressing the 18 outstanding allegations.

A second report on coordination of care found deficiencies in scheduling, appointment reminders, telemedicine access, laboratory orders, referral tracking and other factors that could degrade patient care.

The Cerner system did not consistently apply patient record flags used to identify patients at increased risk of suicide and disruptive behavior. According to the report, "interoperability issues affected functionality of established [Veterans Health Administration] suicide prevention tracking and reporting tools." This issue and several others that hampered clinical staff from identifying and monitoring patients at risk of suicide were resolved by June 2021. But an issue raised by staff about the visibility of such flags in patient records remains unresolved, according to the report. 

Many of the same data formatting and structuring issues that plagued pharmacy orders and delivery are responsible for the coordination of care issues. 

In his reply comments, Remy said that five issues had been addressed, and 11 other allegations would be resolved by May 10. He also requested more information on issues identified with laboratory order workflows.

The interaction between Cerner contract staff and VA clinicians appears to be an ongoing issue that is hindering the timely resolution of problems with the implementation of the new system.

The third report, detailing trouble ticket and help desk activities, depicts a widening disconnect between clinical staff and contractors in which Mann-Grandstaff caregivers created error-prone and often time-consuming work-arounds for problems in the Cerner system rather than wait for the change request process to run its source.

One key issue is that Cerner staff was not able to replicate a portion of reported issues because they lacked access to the version of the Cerner system with the configurations in place for use at Mann-Grandstaff. Trouble tickets that could not be replicated by Cerner staff were closed, often with a notation that the issue was "not reproducible." 

Additionally, a VA leadership report based on a May 2021 site visit indicated that Mann-Grandstaff clinicians were complaining of "unhelpful…and even rude interactions with the Cerner help desk."

According to the OIG report, many clinicians stopped filing trouble tickets and relied on work-arounds to solve problems.

Remy, in his reply memorandum to the trouble ticket report, pledged to complete an evaluation of the help desk process by March 18. Additionally, he said that by March 26, the current Cerner deployment schedule will reflect concerns raised in the report. Remy also said that work addressing some of the underlying data interoperability issues will be completed by May 10.

"These reports are unacceptable and make clear the EHRM program is not where it needs to be," Sen. Jon Tester (D-Mont.), chairman of the Senate Veterans Affairs Committee said in a statement. "For years, I have aggressively pushed VA under the Trump and now the Biden Administrations to address deficiencies and challenges within this program that can disrupt the delivery of care to our veterans. As Chairman, I’ll continue holding VA and Cerner accountable in making necessary changes before expanding the program elsewhere across the country -- to ensure providers can safely deliver our nation's veterans the care they need and earned."

Rep. Mark Takano (D-Calif.) who chairs the House VA committee noted that the reports are "in line with what we have been hearing from employees in Mann-Grandstaff all along." Takano added: "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 [Denis] McDonough’s leadership, these issues will be resolved."