OIG: Scheduling error in VA’s EHR had dire consequences


The Veterans Administration’s Office of Inspector General released a report recently, following an investigation into a scheduling error in the new Oracle electronic health record at VA Central Ohio Healthcare System in Columbus that the agency said contributed to a patient’s death.


In the March 21 report, which offered five recommendations to the Veterans Health Administration’s Electronic Health Record Modernization Integration Office, the OIG said it evaluated the health system’s failures related to a coding error in new EHR functionality. 

“The OIG reviewed the adequacy of mental health evaluations of the patient, supervision of a psychologist, caring communications management and an internal review of the patient’s care,” the watchdog agency said.

A patient’s missed appointment was not routed to a queue to prompt rescheduling efforts, according to OIG, and the Central Ohio Healthcare System failed to send “patient caring communications.”

Thus, a nurse practitioner did not evaluate the patient’s medication refill request, and a psychologist failed to thoroughly evaluate their mental health and critical clinical information. 

“The OIG would have expected a supervisory psychologist to identify concerns about the patient’s depression, substance use relapse risk and suicidal behavior and ensure follow-up regarding the medication request,” the agency said.

Further, “facility leaders did not communicate a root cause analysis Lesson Learned to staff as expected.”

OIG’s recommendations include establishing ongoing monitoring of scheduling procedures in the new EHR, in accordance with VHA requirements, and directing the VA Central Ohio Healthcare System Medical Center’s director to conduct a full review of the care of the deceased patient. 

Also on March 21, OIG released a management advisory memo that warned VHA that smaller VA facilities that have gone live on the new EHR have had problems with patient scheduling and that such problems would be magnified in future go-lives at larger VA medical centers – requiring higher staffing levels and overtime pay.


Back in 2021, OIG found a host of problems with the new EHR’s scheduling system, including significant process limitations that risked delays in patient care after it was implemented as a stand-alone product at the Chalmers P. Wylie VA Ambulatory Care Center in Columbus, Ohio, and as part of the full EHR suite at the Mann-Grandstaff VA Medical Center in Spokane, Washington.

In April 2022 – after a subsequent series of system outages during which several federal agencies were unable to update Oracle medical records for hours – the VA rolled out the new EHR at the Central Ohio Healthcare System. 

With known pharmacy-related patient safety and usability issues – like sending newly entered allergy and medication information to other VA facilities still running VistA – OIG Deputy Inspector General David Case told the House VA Committee last month that if veterans get treatment at one of five sites using the new EHR, and then follow up at a VA medical site on the legacy Vista EHR, their medication information may be incorrect.

“OIG is concerned that the new EHR will continue to be deployed at medical facilities before resolving the remaining issues related to inaccurate medication ordering, reconciliation and dispensing that can affect patient safety,” Case said at the February 15 hearing. 

After discovering a prescription backlog at the Columbus facility, Case noted that OIG identified other unresolved high-risk patient safety issues, including medication inaccuracies, workflow challenges for pharmacy-related functions, insufficient staffing and more.


“The OIG determined that, unlike established care standards, for sites using the new EHR, VHA required fewer patient contact attempts following missed mental health appointments,” the agency said in the report related to the veteran’s death. 

Andrea Fox is senior editor of Healthcare IT News.
Email: [email protected]

Healthcare IT News is a HIMSS Media publication.


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