The Veterans Administration’s Office of Inspector General recently released a report following an investigation into a scheduling error in Oracle’s new electronic health record at VA Central Ohio Healthcare System in Columbus that the agency says contributed to the death of a patient.
WHY IT MATTERS
In the March 21 reportwhich made five recommendations to the Veterans Health Administration’s Electronic Health Record Modernization Integration Office, the OIG said it was evaluating the health care system’s errors related to a coding error in the new EHR functionality.
“The OIG reviewed the adequacy of patient mental health evaluations, psychologist supervision, caring communications management, and an internal review of the patient’s care,” the watchdog agency said.
A patient’s missed appointment was not placed in a queue for rescheduling, according to OIG, and the Central Ohio Healthcare System failed to send “caring patient communications.”
For example, a nurse practitioner failed to evaluate the patient’s refill request, and a psychologist failed to thoroughly evaluate their mental health and critical clinical information.
“The OIG expected a supervising psychologist to identify concerns regarding the patient’s depression, risk for substance use relapse and suicidal behavior and to provide follow-up regarding the medication request,” the agency said.
Further, “facility leaders did not communicate a root cause analysis to staff as expected.”
OIG’s recommendations include establishing ongoing monitoring of scheduling procedures in the new EHR, consistent with VHA requirements, and directing the director of the VA Central Ohio Healthcare System Medical Center to conduct a full review to care for the deceased patient.
Also on March 21, OIG issued a management advice note that VHA warned that smaller VA facilities that have gone live on the new EHR have had issues with patient scheduling and that such issues will be magnified with future go-lives at larger VA medical centers – which will require increased staffing and overtime .
THE BIG TREND
In 2021, OIG found numerous issues with the new EHR scheduling system, including significant process limitations that threatened delays in patient care after it was implemented as a standalone product at the Chalmers P. Wylie VA Ambulatory Care Center in Columbus. Ohio, and as part of the full EHR suite at the Mann-Grandstaff VA Medical Center in Spokane, Washington.
In April 2022 – after a subsequent series of system outages that left several federal agencies unable to update Oracle’s medical records for hours – the VA rolled out the new EHR to the Central Ohio Healthcare System.
With known pharmacy-related patient safety and usability issues — such as sending newly entered allergy and medication information to other VA facilities still using VistA — OIG Deputy Inspector General David Case told the House VA Committee last month that if veterans’ treatment at one of five locations If they use the new EHR and then access the older Vista EHR at a VA medical site, their medication information may be incorrect.
“OIG is concerned that the new EHR will continue to be deployed in medical settings before remaining issues related to inaccurate ordering, reconciliation, and dispensing of medications, which can impact patient safety, are resolved,” Case said during the 15 hearing February.
After discovering a prescription backlog at the Columbus facility, Case noted that OIG identified other unresolved high-risk patient safety issues, including inaccurate medications, workflow issues for pharmacy-related functions, inadequate staffing and more .
ON THE RECORD
“The OIG determined that, contrary to established standards of care, for sites using the new EHR, VHA required fewer patient contact attempts after missed mental health appointments,” the agency said in the report regarding the veteran’s death .
Andrea Fox is editor-in-chief of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.