A Feb. 15 hearing of the House Committee on Veterans’ Affairs Subcommittee on Technology Modernization highlighted ongoing pharmacy-related patient safety issues with the transition to the new Oracle electronic health record. 

Last April, the Department of Veterans Affairs announced that all deployments in its EHR Modernization effort would be halted while it prioritized improvements at the five sites that currently used the new EHR, as part of a larger program reset.

David Case, deputy inspector general of the U.S. Department of Veteran Affairs, testified about a draft Office of Inspector General report on the pharmacy-related issues. He said an OIG team reviewed pharmacy-related patient safety issues facing VHA providers, noting that VA has corrected one of a series of issues related to the transmission of inaccurate medication information into a database called the HDR (Health Data Repository), which stores clinical information about every patient’s medications and allergies. “However, we are concerned about unresolved, insufficiently communicated pharmacy-related patient safety issues,” Case said. “Legacy EHR sites may have inaccurate medication information for patients treated at both legacy and new EHR sites.”

Case said that OIG believes the system implementers did not test for medication and allergy data accuracy after that information was transmitted to the HDR from new EHR sites. “Thus, patients seen at both new and legacy EHR sites may be prescribed contraindicated medications, and legacy EHR providers may be making clinical decisions based on inaccurate data,” he said. 

Case’s written statement discusses a veteran who had a delay in receiving critical medication due to this issue. As of September 2023, there have been approximately 250,000 veterans who either receive medication orders and/or had medication allergies documented in the new EHR. They may be unaware of the potential risk for medication or allergy-related events if they visit a legacy EHR site, he added.

Although VA is taking efforts to reduce this potential, OIG remains concerned that patients have not been informed of their individual risks, essentially being excluded as full participants in their care, Case said. “Nor have we seen evidence that VA has sufficiently notified legacy EHR providers about this issue and the mitigations to safely care for these new EHR side patients.” 

Legacy site leaders were told to have providers perform manual medication safety checks to replace the automated checks for new EHR patients, Case explained. “These manual safety checks are complex and rely on the vigilance of pharmacist frontline staff. At Columbus, we found a prescription backlog required a permanent 62 percent increase in clinical pharmacists,” he explained. “Pharmacy leaders had to create their own workarounds and education materials, and pharmacy staff were burned out and had low morale. These findings are troubling given the mitigations for pharmacy failures rely on staff vigilance.”

Neil Evans, M.D., acting program executive director, U.S. Department of Veterans Affairs, testified that in part based on lessons learned since the initial implementation of the Oracle Health Record at the Mann-Grandstaff VA Medical Center in Spokane, the VA has been working to continuously improve the Oracle Health software solutions and VA pharmacy operations as they leverage the new software. 

Over a year ago a VA Pharmacy Council along with Oracle Health helped identify critical early items to be sequentially addressed through code upgrades, which are delivered through joint VA/DoD block releases, Evans said. Improvements have been delivered in each of the last three block upgrades —blocks eight, nine and 10 in February and August 2023, and finally, this past weekend. 

“So where are we? We’ve made incremental but steady progress,” Evans said. “The most significant improvements have been realized in system performance and in the clinician ordering experience. There have also been several enhancements delivered to improve the pharmacy fulfillment process but this is an area where further work remains to enable increased efficiency for pharmacy staff,” he added. 

“As of today, all but one of the initially identified priority enhancements have been delivered,” Evans continued. “The final feature, which will automate the synchronization of prescription information between the Oracle provider and pharmacy applications, has been installed but is not yet enabled. Both Oracle and VA recognize that we’re not yet done. As I already mentioned, an area of considerable focus will be increasing how efficiently pharmacists and pharmacy techs can complete necessary tasks within the software suite among other improvements.”