All Reports

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.

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.

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

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 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.

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.

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

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. 

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

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

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.

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.

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.

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 

 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.

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

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.

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

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

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

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

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

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

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

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