Sen. Murray Calls for Halt of VA EHR Rollout in Walla Walla
Three new reports from the VA Office of the Inspector General (OIG) identified deficiencies in medication management, ticketing and care coordination associated with the new electronic health record at the Mann-Grandstaff VA Medical Center in Spokane, Wash. “After hearing from the VA Office of Inspector General, it’s clear to me that VA is not ready for go-live of the EHR system at the VA Medical Center in Walla Walla and we need to put a pause on this rollout right now, said U.S. Sen. Patty Murray (D-WA), a senior member of the Senate Veterans’ Affairs Committee, in a statement.
“It’s absolutely unacceptable to me that VA knew about widespread, egregious patient safety risks associated with its ongoing rollout of its Cerner Electronic Health Record System—but in conversations with my office, VA has been expressing confidence and readiness for the go-live date at the Walla Walla VA,” she said. “This was simply not the case.” Murray noted that veterans in Spokane have been getting the wrong medication mailed to them. In other cases, she said, the EHR has failed to alert providers about patients at risk for suicide. “The allegations substantiated by the Inspector General must be addressed immediately, and frankly I am furious that VA leadership and Cerner seem to be minimizing very serious problems or wrongly claiming that ongoing issues have been resolved,” she said. “I do not want to see the EHR system move so much as an inch further in Washington state until VA has proven to me that it’s fixed the problems in Spokane and provided clear, objective data showing resolutions to concerns raised by the Inspector General’s reports.
“Just this month, I made clear to VA that if they were not ready to continue the rollout of the Cerner EHR, they needed to stop the train in its tracks. It is time to stop the train.”
The OIG reports determined that the root cause of the problems was due to five underlying factors:
• EHR usability problems
• Training deficits
• Interoperability challenges
• Post go-live fix and refinement needs
• Problem resolution process challenges
OIG concluded that resolving the underlying factors common to the substantiated allegations would resolve many of the problems identified by frontline staff.
During the course of the two inspections, the OIG recognized challenges with identifying, tracking, and resolving problems with the new EHR after go-live at the facility.
The OIG report gave an example of a problem with medication orders. “One of the several medication order deficiencies that occurred after go-live affected future clinic orders. Some clinic providers entered recurring future orders for medications that would be administered on subsequent outpatient visits. The new EHR was not configured to support future clinic orders and automatically discontinued them. Providers were not notified of the discontinuance. Upon the patient’s arrival to clinic, nurses attempted to accommodate administration of the recurring medication to the patient by entering orders for approval by the provider and removing medications from automated dispensing machines as a work-around.”
OIG found that, in the new EHR, medication alerts, which are messages sent to providers to aid in clinical decision-making, were confusing. Providers reported difficulties discerning their urgency. Providers reported not receiving training or receiving incomplete training related to alerts. The issue was unresolved at the time of the OIG’s inspection.
The OIG identified multiple deficiencies and challenges with the ticket process and problem resolution:
• Cerner service desk support staff were not able to view and replicate reported issues.
• Cerner service desk support staff closed tickets prior to resolution.
• Cerner service desk support staff did not communicate ticket status to end users.
• Facility staff created workarounds instead of placing tickets.
• The ineffective change request process hindered needed EHR modifications.
Despite the patient safety issues identified, OIG noted that facility staff and clinicians remained undeterred and dedicated to serving patients despite the added burden of COVID-19 pandemic stressors. “The OIG recognized the hard work of all involved and the challenges associated with implementing the new EHR for the largest integrated healthcare system in the United States.”
