Lawmakers Say 2 Veterans' Deaths Point to VA EHR Patient Safety Issues

The beleaguered VA EHR implementation project has been postponed to June 2023 to resolve system shortfalls that have put patient safety at risk.  

Republican House lawmakers called on Department of Veterans Affairs (VA) officials to share information on the recent deaths of two Ohio veterans to restore faith in the agency's Oracle Cerner EHR, according to reporting from Military Times.

"The [medical records project] has been plagued by safety risks and technical problems in addition to exorbitant costs," Rep Mike Bost, R-IL, ranking member of the House Veterans Affairs Committee, Rep Mike Carey, R-OH, and Troy Balderson, R-OH, wrote in a letter to VA Secretary Denis McDonough. "These two incidents involved different combinations of system and human error."

"While mistakes undoubtedly happen in healthcare, the [new system] is clearly compounding and worsening the potential for human error," they continued. "It was irresponsible to subject our veterans to such a flawed and dangerous system, and the situation in Columbus [Ohio] and the other VA medical centers using it is unacceptable."

VA officials did not respond to MilitaryTimes' requests for information on the deaths, instead referring to an October announcement that the department had postponed all planned Oracle Cerner EHR implementations until June 2023 to address system challenges.

In the letter, the lawmakers said that both deaths pointed to serious problems with the EHR in use at the VA Central Ohio Healthcare System.

In the first case, a veteran connected to the medical center in Columbus and received a prescription for an antibiotic after a hospital visit. However, the veteran never received the medication because "the electronic health record provided erroneous tracking information for the prescription," the lawmakers said.

The veteran later died of medical complications.

In the second case, a veteran missed a regular medical check-up, but that information was not properly transferred into the new system. As a result, "no outreach was attempted to reschedule the appointment."

The veteran showed up several months later at the VA medical center suffering from alcohol withdrawal symptoms, and died a few days later.

Both cases suggest serious EHR system issues, the lawmakers noted. They called on VA officials to "get to the bottom of these patient deaths in Columbus as quickly as possible."

The new system's rollout to unite military and veteran health records has featured various setbacks. Earlier this year, an OIG report found that medical record mistakes harmed at least 148 veterans after VA implemented the system at initial sites in Washington.

Additionally, researchers found that the system had failed to deliver more than 11,000 orders for specialty care, lab work, and other services without alerting healthcare providers that the system had lost the orders.

In an interview with Military Times last week, McDonough acknowledged that "the [records] program and the technology is not living up to the billing. Our vets deserve better."

However, he also said officials are not ready to give up on the program yet.

"This is not going to be a decision that I arrive at through my emotion," he said. "If it's not working for vets, we're not going to do it. But we're also not just gonna throw it away because we get tired. We're gonna stay on this thing to make it work because the idea is so profoundly in the national interest. But if it's not workable, we're not going to just spin our wheels."

In recent weeks, VA officials have sent tens of thousands of letters to patients at medical facilities using the new EHR to inform them that they "may have been impacted by these system challenges" and to ensure they can schedule appointments, receive medications, and fulfill other medical needs.

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