All Reports

Date Issued
|
Report Number
23-01450-114
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Topics:  Clinical Care Services Operations ● Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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.

Date Issued
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Report Number
23-00382-100
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Topics:  Electronic Health Records Modernization (EHRM) ● Mental Health

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No. 1
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

Date Issued
|
Report Number
22-03806-162
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)

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.

Date Issued
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Report Number
22-01137-204
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

Date Issued
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Report Number
21-02201-200
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

Date Issued
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Report Number
21-03020-168
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Deputy Secretary completes an evaluation of factors affecting the availability of metrics and takes action as warranted.
Date Issued
|
Report Number
18-04227-91
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

Date Issued
|
Report Number
21-02889-134
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

Date Issued
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Report Number
21-00781-109
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

Date Issued
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Report Number
21-00781-108
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

Date Issued
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Report Number
21-00656-110
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

No. 2
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)

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.

Date Issued
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Report Number
21-00434-233
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Topics:  Appointment Scheduling and Wait Times ● Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)

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.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

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

Date Issued
|
Report Number
20-01930-183
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health explores the establishment of a group of Veterans Health Administration staff comprised of core user roles with expertise in Veterans Health Administration operations and Cerner electronic health record use with data architect level knowledge to lead the effort of generating optimized Veterans Health Administration clinical and administrative workflows.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary establishes an electronic health record training domain that ensures close proximation to the production environment and is readily available to all end users during and following training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary ensures end users receive training time sufficient to impart the skills necessary to use the new electronic health record prior to implementation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary ensures the user role assignment process addresses identified facility leaders and staff concerns.
No. 5
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
The Deputy Secretary ensures Cerner trainers and adoption coaches have the capability to deliver end user training on Cerner and Veterans Health Administration electronic health record software workflows.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary evaluates the process of super user selection and takes action as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary reviews the Office of Electronic Health Records Modernization’s performance-based service assessments for Cerner’s execution of training to determine whether multiple, recurrent concerns are being accurately captured and addressed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary oversees the revision of an Office of Electronic Health Records Modernization training evaluation plan and ensures implementation of stated objectives.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
The Deputy Secretary reviews the Electronic Health Record Modernization governance structure and takes action as indicated to ensure the Under Secretary for Health’s role in directing and prioritizing Electronic Health Record Modernization efforts is commensurate with the Veteran Health Administration’s role in providing safe patient care.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health establishes guidelines and training to capture new electronic health record-related patient complaints, including patient advocacy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures an assessment of employee morale following implementation of a new electronic health record and takes action as indicated.
Date Issued
|
Report Number
20-03185-151
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure an independent cost estimate is performed for program life-cycle cost estimates related to information technology infrastructure costs.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Reassess the cost estimate for Electronic Health Record Modernization program-related information technology infrastructure and refine as needed to comply with VA’s cost-estimating standards. 

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Develop procedures for cost-estimating staff that align with VA cost-estimating guidance.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for all information technology infrastructure upgrades funded by the Office of Information and Technology and the Veterans Health Administration or other sources needed to support the Electronic

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Formalize agreements with the Office of Information and Technology and the Veterans Health Administration identifying the expected contributions from each entity toward information technology infrastructure upgrades in support of the Electronic Health Record Modernization program.

No. 6
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Establish procedures that identify when life-cycle cost estimates should be updated and ensure those updated estimates are disclosed in the program’s congressionally mandated reports.

Date Issued
|
Report Number
20-03178-116
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)

The executive director for the Office of Electronic Health Record Modernization should ensure an independent cost estimate is performed for program life cycle cost estimates including related physical infrastructure costs funded by the Veterans Health Administration.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)

The VA Assistant Secretary for Management and Chief Financial Officer  should ensure the Office of Programming, Analysis and Evaluation, or another office performing its duties, conducts independent cost 

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

 The director of Special Engineering Projects for the Veterans Health  Administration’s Office of Healthcare Environment and Facilities Programs should develop a  reliable cost estimate for Electronic Health Record Modernization program-related physical  infrastructure in accordance with VA cost-estimating standards and incorporate costs for upgrade  needs identified in facility self-assessments and scoping sessions.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The director of Special Engineering Projects should also continuously update physical infrastructure cost estimates based on emerging requirements and identified project needs.

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for physical infrastructure upgrades funded by the Veterans Health Administration or other sources needed to support the Electronic Health Record Modernization program are disclosed in program life cycle cost estimates presented to Congress.

Date Issued
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Report Number
19-09447-136
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Topics:  Electronic Health Records Modernization (EHRM) ● Community Care

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, evaluates the impact of the new electronic health record implementation on productivity and provides operational guidance and required resources to facilities prior to go-live.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, identifies the impact of the mitigation strategies on user and patient experience at go-live and takes action, as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive Director, Office of Electronic Health Records Modernization, in conjunction with the Under Secretary for Health, ensures that clear guidance is given to facility staff on what electronic health record capabilities will be available at go-live.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, reevaluates the electronic health record modernization deployment timeline to minimize the number of required mitigation strategies at go-live.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Director collaborates with facility leaders to implement VA-provided operational guidance and supports required resources needed throughout the transition to the new electronic health record system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Director ensures that positions required for the transition to the new electronic health record system are staffed and trained prior to go-live.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Mann-Grandstaff VA Medical Center Director ensures that community care consults are managed through go-live to ensure accuracy, completeness, and to avoid the need for manual reentry after go-live.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Mann-Grandstaff VA Medical Center Director ensures that patients receive medication refills in a timely manner throughout the transition to the new electronic health record system.
Date Issued
|
Report Number
19-08980-95
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Establish an infrastructure-readiness schedule for future deployment sites thatincorporates lessons learned from DoD.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Reassess the enterprise-wide deployment schedule to ensure projected milestones arerealistic and achievable, considering the time needed for facilities to completeinfrastructure upgrades.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Implement tools to comprehensively monitor the status and progress of medical devicesat the enterprise level.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Standardize infrastructure requirements in conjunction with VHA and the OIT and ensurethose requirements are disseminated to all necessary staff.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Evaluate physical infrastructure for consistency with OEHRM requirements and monitorcompletion of those evaluations.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Fill infrastructure-readiness team vacancies until optimal staffing levels are attained.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Ensure physical security assessments are completed and addressed at future electronichealth record deployment sites.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

Ensure all access points to physical infrastructure are secured and inaccessible tounauthorized individuals.