An OIG investigation found that change management leaders’ lack of due diligence impeded assessment of the electronic health record system training process.
Two Department of Veterans Affairs’ senior staffers responsible for training employees of the Mann-Grandstaff VA Medical Center to use the agency’s Cerner Millennium electronic health record system gave inaccurate data to inspectors reviewing the implementation of the software, according to a report conducted by the VA’s Office of Inspector General.
The report was initiated after OIG investigators reviewing the rollout of the first commercial EHR system at Mann-Grandstaff in Spokane, Washington in October 2020 experienced “significant challenges” in receiving detailed information about efforts to train staff on the new software, as well as data on staffers’ proficiency with the new program.
The OIG report found that the executive director and the director for training strategy of the Change Management group at what was then known as the VA Office of Electronic Health Record Modernization, or EHRM, “failed to provide timely, complete and accurate information and data to the OIG, which impeded oversight efforts.” The Change Management team was responsible for overseeing the training of staffers on the EHR system and ensuring that they were proficient in using the new program.
While the report cleared the two senior staffers of intentionally misleading OIG’s inspectors, it found that “the leaders’ lack of due care and diligence resulted in misinformation being submitted” to investigators assessing the EHR training process.
OIG found that the senior staffers submitted data to investigators which suggested that 89% of employees passed their proficiency tests in three attempts or less, without disclosing that the reported figure excluded all failure data. The error resulted in the proficiency check pass rate being more than double the actual rate of 44%. The report faulted the senior staffers for “failing to recognize red flags and confirm accuracy prior to reporting the revised results.” OIG also found that the Change Management leaders submitted a slide to investigators describing a training evaluation plan without disclosing that it was a draft version that had not been approved for use.
The report was released along with another OIG report which found that the agency’s EHR software at Mann-Grandstaff had a flaw which did not alert clinicians when clinical orders were routed to the system’s “unknown queue,” which stores orders that have incomplete routing information. That investigation found that over 11,000 clinical orders were directed to the unknown queue, which had a detrimental impact on patient medical care and directly harmed at least 149 veterans in Eastern Washington.
Sen. Jerry Moran, R-Kan., ranking member of the Senate Veterans’ Affairs Committee, said in a press release that both reports “illustrate patient safety issues that can be traced directly to failures at the highest levels at VA, including the department’s failure to ensure that personnel are candid and open with OIG investigators working to uncover problems in the system.”
“Patient safety and honesty within the VA should be the top priorities, and without those two things, we cannot even begin to address issues with the EHRM system,” Moran added.
The EHR system has been plagued with problems since Cerner received a multi-billion dollar contract in 2018 to replace the VA’s health record database with a streamlined system that could be shared across the agency’s medical facilities, as well as the Department of Defense, the U.S. Coast Guard and other community healthcare providers. Last month, Oracle closed its more than $28 billion acquisition of Cerner and its EHR business.
VA medical employees using the EHR system have reported low morale as a result of the transition to the new program. In a survey of 833 employees at Mann-Grandstaff conducted by the VA National Center for Organization Development and obtained by Nextgov last year, two-thirds of the medical center’s staff said they were considering leaving their jobs because of the software.
The VA announced last month that it was delaying additional rollouts of the EHR system at new medical centers, following a series of ongoing technical and logistical issues with the program. The delays came after a series of outages—11 reported from April to June of this year, including an outage in April that knocked the system offline for almost three hours—underscored serious flaws in the system and affected veterans’ medical care.
The ongoing issues with the implementation of the EHR system have led to increased congressional scrutiny and calls for additional oversight. Last month, President Joe Biden signed the VA Electronic Health Record Transparency Act, which will require the VA to submit quarterly reports to Congress on the cost and performance of the EHR system.