Seven weeks after a missed visit, a veteran overdosed because physicians neglected to assess the veteran’s mental health and medication restart request due to a high-risk flag that had been deactivated in the hospital’s new Oracle electronic health record.
Following an inquiry into a scheduling problem in the new Oracle electronic health record at VA Central Ohio Healthcare System in Columbus, which the agency claimed contributed to a patient’s death, the Office of Inspector General for the Veterans Administration recently released a report.
WHY IT IS IMPORTANT
The OIG stated that it assessed the health system’s shortcomings connected to a coding error in new EHR functionality in the report dated March 21. The report provided the Veterans Health Administration’s Electronic Health Record Modernization Integration Office with five suggestions.
“The OIG reviewed the adequacy of mental health evaluations of the patient, supervision of a psychologist, caring communications management and an internal review of the patient’s care,” the watchdog organization stated.
OIG claims that the Central Ohio Healthcare System neglected to send “patient caring communications” and that a patient’s missed appointment was not put in a queue to initiate rescheduling efforts.
As a result, neither a psychologist nor a nurse practitioner assessed the patient’s request for a medicine refill or their mental health or other important clinical data.
“The OIG would have expected a supervisory psychologist to identify concerns about the patient’s depression, substance use relapse risk and suicidal behavior and ensure follow-up regarding the medication request,” the inspector general stated.
Furthermore, “facility leaders did not communicate a root cause analysis Lesson Learned to staff as expected.”
OIG’s recommendations include requiring the director of the VA Central Ohio Healthcare System Medical Center to perform a thorough examination of the treatment provided to the dead patient and instituting continuous monitoring of scheduling procedures in the new EHR in compliance with VHA guidelines.
Additionally, on March 21, OIG published a management advisory memo alerting VHA to the fact that smaller VA facilities implementing the new EHR have experienced difficulties scheduling patients, and that these issues will likely worsen in larger VA medical centers during future rollouts, necessitating increased staffing and overtime compensation.
THE MAJOR TREND
The new EHR scheduling system was implemented as a stand-alone 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. Back in 2021, OIG discovered a number of issues with the system, including significant process limitations that risked delays in patient care.
Following a string of system failures that prevented multiple federal agencies from updating Oracle medical information for hours, the VA implemented the new EHR at the Central Ohio Healthcare System in April 2022.
OIG Deputy Inspector General David Case informed the House VA Committee last month that veterans’ medication information may be incorrect if they receive treatment at one of five sites using the new EHR and then follow up at a VA medical site on the legacy Vista EHR. This is due to known pharmacy-related patient safety and usability issues, such as sending newly entered allergy and medication information to other VA facilities still running VistA.
“OIG is concerned that the new EHR will continue to be deployed at medical facilities before resolving the remaining issues related to inaccurate medication ordering, reconciliation and dispensing that can affect patient safety,” Case stated during the hearing on February 15.
Case stated that OIG found more issues at the Columbus site, including a backlog of prescriptions.
IN THE RECORD
In the report on the veteran’s death, the agency stated, “The OIG determined that, unlike established care standards, VHA required fewer patient contact attempts following missed mental health appointments.”
