All Reports

Evaluate which staff should have access to and should update the Consult Toolbox when records are requested or received and update the “Consult Business Rules and Uses of the Consult Package Standard Operating Procedure” to reflect necessary changes.

Include controls within the Consult Toolbox to prevent errors and improve data quality, including controls on administrative closure of low-risk consults and documenting the records-retrieval method.

Update consult closure policies and procedures to clarify requirements for administrative closure and determine whether metrics for the percentage of records received should be a requirement and included in policy.

Determine whether Veterans Health Administration facilities’ community care offices should continue to be required to use the administrative closure report for oversight of administratively closed consults, and if not, determine what reports should be required.

Evaluate the workload of community care staff to determine the most efficient way to structure and execute their duties.

Determine if there are mechanisms to identify standardization opportunities and increase efficiency for improving records return processes.

Ensure community care staff follow procedures to reduce duplicate records received.

Evaluate ways to increase use of provider electronic records portals to reduce reliance on electronic fax when retrieving medical records.

Consider increased implementation of technologies to improve records processing once received to reduce the manual renaming of electronic files and uploading of records into the electronic health record.

Ensure records from the Joint Longitudinal Viewer are uploaded into the electronic health record.

Assess electronic health record major performance incident data needs and contractually commit to real-time data sharing that will provide greater awareness of system operations.

Develop a formal procedure for verifying performance metrics and associated credits to ensure the department receives the remedies it is due under the contract.

Update the process for prioritizing major performance incidents to ensure that notification and resolution occur in a consistent manner.

Develop effective notification and resolution metrics that consistently capture results for all major performance incidents, regardless of the owner, and enforce them.

Identify the information needed in post-resolution reports, such as corrective and preventative actions, and require the contractor to consistently collect, verify, and report that information as a contract deliverable.

Develop a plan to ensure all clinicians are familiar with the national downtime procedures.

Identify the appropriate backup system and develop a training strategy to ensure clinicians can use the system during downtime.

Assess facilities’ patient safety reports identified during this audit to determine if additional actions need to be taken and, if so, provide an action plan.

Develop a mechanism to better identify major performance incidents and negative patient outcomes and provide a plan to prioritize and address their causes.

The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.

The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.

The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.

The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.

The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.

The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.

The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.

The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites

The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.

The Deputy Secretary establishes ongoing monitors to ensure that scheduling procedures in the new electronic health record are functioning in accordance with Veterans Health Administration requirements.

The Under Secretary for Health evaluates minimum scheduling effort requirements for mental health appointments and takes action to ensure the implementation of standardized policy and procedures in the best interest of patient care.

The VA Central Ohio Healthcare System Medical Center Director conducts a full review of the care of the patient provided by the nurse practitioner and psychologist 1, and the supervisory psychologist’s oversight, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

The VA Central Ohio Healthcare System Medical Center Director ensures compliance with the Caring Communication Program including the initiation and cessation of caring communications as required.

The Under Secretary for Health considers establishing written guidance related to documentation, leaders’ review, follow-up actions, and tracking of Lessons Learned in root cause analyses.

Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness

Consider updating VA Manual 21-4 to reflect that quality assurance measures include addressing failures to consider all Veterans Health Administration records as directed in the Adjudication Procedures Manual that are subject to an enterprise-wide search in the Compensation and Pension Records Interchange system whether or not directed to those records by the claimant and ensure staff are advised of the changes.

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.

Issue a clarifying communication to the office’s personnel that all staff have a right to speak directly and openly with Office of Inspector General staff without fear of retaliation, and that, irrespective of any processes established to facilitate the flow of information, Electronic Health Record Modernization Integration Office personnel are encouraged to communicate directly with OIG staff when needed to proactively clarify requests and avoid confusion.

Provide clear guidance that the office’s personnel must provide timely, complete, and accurate responses to requests for all data or information without alteration, unless other formats are requested, with full disclosure of the methodology, any data limitations, or other relevant context. This includes prompt OIG access to entire datasets consistent with the Inspector General Act of 1978, as amended.

Determine whether any administrative action should be taken with respect to the conduct or performance of the executive director of Change Management.

Determine whether any administrative action should be taken with respect to the conduct or performance of Change Management’s director for training strategy.

The Deputy Secretary completes an evaluation of gaps in new electronic health record metrics and takes action as warranted.

The Deputy Secretary completes an evaluation of factors affecting the availability of metrics and takes action as warranted.

We recommend that the Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs review the actions of the Federal Electronic Health Record Modernization Program Office and direct the Federal Electronic Health Record Modernization Program Office to develop processes and procedures in accordance with the Federal Electronic Health Record Modernization Program Office charter and the National Defense Authorization Acts.

The executive director of the Electronic Health Record Modernization Program Management Office complies with internal guidance and ensures the development of an integrated master schedule for the Electronic Health Record Modernization program that complies with standards adopted from GAO for scheduling.

The executive director of the Electronic Health Record Modernization Program Management Office takes action to improve stakeholder coordination in the development of the program schedules to ensure activities from all relevant VA entities are included.

The executive director of the Electronic Health Record Modernization Program Management Office develops procedures for when and how staff should perform an initial schedule risk analysis for the program and conduct periodic updates as needed.

The executive director of the Electronic Health Record Modernization Program Management Office ensures consistency between contract language and program office plans or other guidance identifying the entity or individuals responsible for developing and maintaining the program’s work breakdown structure and integrated master schedule.

The executive director of the Electronic Health Record Modernization Program Management Office evaluates the contract requirements for schedule management and modifies as needed to ensure clear roles and expectations for further development and maintenance of the program’s integrated master schedule.

The executive director of the Electronic Health Record Modernization Program Management Office complies with the Federal Acquisition Regulation and issue guidance to accept deliverables not separately priced before invoice payment.

The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.

The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.

The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.

The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.

The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.

The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.

Continue to make improvements to the scheduling training as needed to address feedback from schedulers.

Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed

Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.

Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.

Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.

Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.

Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.

Provide guidance to schedulers to consistently address system limitations until problems are resolved.