Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington

Report Information

Issue Date
Report Number
VA Office
Electronic Health Record Modernization Integration Office (EHRM IO)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Electronic Health Records Modernization (EHRM)
Patient Safety
Care Coordination
Major Management Challenges
Healthcare Services
Questioned Costs
Better Use of Funds
Congressionally Mandated


This healthcare inspection report is the second of three associated with implementation of the new electronic health record system (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington. It details OIG findings on a range of allegations regarding clinical care coordination challenges and potential patient safety issues. The OIG found that the new EHR implementation had created difficulties for users in eight areas: 1. Patient record flags, including failures to transfer flags and information related to patients at high risk for suicide 2. Data migration errors leading to inaccurate name, gender, and contact information 3. Scheduling process issues, such as delays in primary care scheduling 4. VA Video Connect problems, including inoperable and misdirected links 5. Referral management deficiencies, including lost or unaddressed referrals 6. Laboratory orders “disappearing” that affected workflow and tracking, and delayed results 7. Patient portal and secure messaging being inaccessible 8. Documentation processes, including creating additional work and limiting providers’ ability to correctly code patient diagnoses Although the OIG did not identify any associated patient deaths during this inspection, future deployment of the new EHR without resolving deficiencies can increase risks to patient safety. The OIG recommended the Deputy Secretary review and address the remaining unresolved deficiencies. Further discussion of allegations related to medication management issues after go-live, ticket process concerns identified by the OIG during evaluation of the allegations, and underlying factors related to all substantiated allegations can be found in the OIG’s companion reports.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
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.