The Department of Veterans Affairs Office of Inspector General released three reports on Thursday detailing scheduling and pharmacy issues with the agency’s new Oracle electronic health record, including a problem that may have contributed to a patient’s death.
The latest reports come as the VA and technology giant Oracle try to get their joint EHR project back on track, after years of controversy and patient safety concerns. Cerner first won the multi-billion dollar contract to update the VA’s EHR in 2018, and was acquired by Oracle about four years later.
Only six medical centers are currently using the new EHR. The agency halted deployments of the record in April last year, except for a recent rollout to a site jointly run by the VA and the Department of Defense in North Chicago, Illinois.
The VA also renegotiated a tougher contract with the tech firm last year that includes stronger performance expectations and larger financial credits to the VA if Oracle doesn’t meet requirements.
Scheduling error contributes to patient death
The OIG found a rescheduling error with Oracle’s EHR may have contributed to the death of a patient who accidentally overdosed.
The veteran, who had history of substance use disorder and suicidal ideation, overdosed after missing a scheduled follow-up appointment at the VA Central Ohio Healthcare System in Columbus in spring 2022.
In the new EHR, schedulers are supposed to update appointments with a no-show status, which routes the patient’s information to a request queue so staff know to begin outreach. The watchdog determined the patient’s appointment status was updated, but the case wasn’t routed to the queue — so schedulers weren’t prompted to complete three telephone calls on separate days as required.
The patient overdosed about seven weeks after the missed appointment.
“The OIG concluded that the lack of contact efforts may have contributed to the patient’s disengagement from mental health treatment and ultimately the patient’s substance use relapse and death,” the report said.
The report also found that the Veterans Health Administration had put in place new EHR minimum scheduling effort procedures that required fewer contact attempts in May 2022.
The new record didn’t readily track contacts for specific appointments, and the scheduling efforts were cut down “to make this workable,” a director with the VHA Office of Integrated Veteran Care told the OIG. The watchdog argued the different scheduling procedures could create disparities in access to care depending on whether a medical center used the new or legacy EHR.
Pharmacy-related issues pose ‘high risk’ to patient safety
Months after the first VA medical center went live with the new EHR, the VHA was aware of pharmacy-related safety and EHR usability issues, but continued to deploy the system at new sites, according to the OIG.
Previously identified problems included patient records not matching pharmacy software, pharmacy technicians being unable to initiate prescription refills and errors that could allow providers to order unavailable medications.
After the new EHR was rolled out at at the VA Central Ohio Healthcare System in April 2022, some previously identified problems were still an issue, adding strain and increasing burnout among pharmacy staff, according to the OIG.
The report also cited national pharmacy-related patient safety issues relating to the new EHR that could affect hundreds of thousands of patients.
An issue in Oracle’s code caused the “widespread transmission” of incorrect medication identifiers from new to legacy EHR sites. That could throw off system safety checks that monitor whether new prescriptions are compatible with previous medications or patient allergies.
The tech giant applied a patch a year ago, but the OIG said incorrect identifiers stored as far back as 2020 weren’t fixed because the prescription data would expire in April 2024.
As of September, the transmission errors could affect about 250,000 patients at new EHR sites who had also received services at a legacy facility, according to the OIG. The unresolved issues present a “high risk” to patient safety, the watchdog said.
“Further, the responsibility to protect patients from harm rests on legacy site providers’ ability to accurately perform a series of manual, complex, time consuming, and unmonitored mitigations of which they may or may not be aware,” the authors wrote.
More complex care sites could exacerbate scheduling problems
Another OIG report highlights scheduling problems with the new EHR that could become more challenging as the agency moves to deploy the EHR at larger, more complex medical centers.
The VA had previously rolled out the new EHR to five medical centers before the expansion was put on hold nearly a year ago. Those facilities are all “low or medium complexity,” serving about 200,000 veterans combined, according to the OIG.
The agency recently deployed the new EHR at the Captain James A. Lovell Federal Health Care Center — a more complex joint center run by the VA and the DoD that provides care to about 75,000 patients each year.
The report noted problems that hadn’t been resolved, like inaccurate patient demographic information, difficulties changing the type of appointment (like switching from telehealth to in person) and an inability to automatically mail appointment reminder letters.
“The impact of these limitations will continue at future deployment sites unless they are resolved,” the report said. “They will also only become more pronounced at larger, more complex facilities that provide more services and care for more patients.”
The OIG report also documented other issues. In one example, scheduling staff can place a block on a provider’s availability if they need to take time off, which should push currently scheduled visits onto a displaced appointment queue for rescheduling.
But schedulers said appointments sometimes disappeared from the queue or weren’t routed there at all — so they couldn’t depend on the system to tell them which appointments needed to be rescheduled. The VA’s Electronic Health Record Modernization Integration Office said it was aware of the issues, and updates were scheduled for February and April to fix the problem.
The OIG also noted issues with sharing patient information, as medical facility staff were given access to different EHR applications based on their roles. Providers sometimes couldn’t see schedulers’ notes, like the reason an appointment was canceled.
Oracle did not respond to a request for comment.
