Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus

Report Information

Issue Date
Report Number
23-01450-114
VISN
State
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Clinical Care Services Operations
Electronic Health Records Modernization (EHRM)
Patient Safety
Major Management Challenges
Healthcare Services
Information Systems and Innovation
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted an inspection at the VA Central Ohio Healthcare System (facility) in Columbus to review an allegation that implementation of the new electronic health record (EHR) led to a prescription backlog. While reviewing the allegation, the OIG determined facility leaders took timely and sustainable steps to manage the issue. However, the OIG identified other facility and national pharmacy-related patient safety issues.

The OIG found implementation of the new EHR at the facility, despite known pharmacy-related patient safety and usability issues, contributed to ongoing patient safety risks and usability challenges at the facility. The new EHR contributed to pharmacy-related patient safety issues nationally as a software coding error resulted in inaccurate medication and allergy information transmission from new EHR sites to legacy EHR sites. Affected patients were not notified of their risk of harm and the OIG remains concerned for their safety. The OIG learned VHA communicated recommendations to providers to mitigate the risk of harm to affected patients; however, the recommendations were non-sustainable. 

Additionally, the new EHR's operational inefficiencies required increased clinical pharmacist staffing and development of workarounds and educational materials to complete pharmacy processes. The inefficiencies also led to pharmacy staff burnout, job dissatisfaction, and decreased morale.

The OIG made three recommendations to the Deputy Secretary related to resolution of patient safety and usability issues. The OIG made six recommendations to the Under Secretary for Health. One recommendation focuses on accurate patient medication data and three recommendations address patient and provider awareness and evaluation of the risk of harm related to data transmission issues. Another recommendation is related to pharmacy staffing, and one focuses on the underlying technical and functional issues requiring workarounds and educational materials to perform pharmacy operations.

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