Report Summary

This report details the OIG’s concerns with the new electronic health record system (new EHR) process for resolving problems and requests for assistance through “tickets.” It also examines the underlying factors that contributed to deficiencies found by the OIG in prior inspections of medication management and care coordination at the Mann-Grandstaff VA Medical Center in Spokane, Washington.

From October 24, 2020, through March 31, 2021, new EHR end users placed over 38,700 tickets. Of the 221 medication management tickets reviewed, the OIG found that 33 percent were closed without a documented resolution. The OIG reviewed 210 tickets related to care coordination and found that 1 percent of tickets were closed without a documented resolution.

The OIG identified ticket process challenges with reporting, tracking, and resolving problems. These included Cerner being unable to view or replicate reported issues, tickets being closed before resolution, status not being reported to end users, staff employing workarounds without placing tickets, and an ineffective change request process hindering EHR changes. These challenges impaired the ability of Cerner service desk support staff to address end users’ problems, led to end users’ disengagement, and prompted workarounds that may increase patient safety risks.

This report also details five factors that the OIG found contributed to the problems identified in its two prior healthcare inspections on how the new EHR complicated medication management and care coordination.

1. EHR usability problems

2. Training deficits

3. Interoperability challenges

4. Post-go-live fixes and refinement needs

5. Problem-resolution process challenges

Resolving these underlying factors and addressing OIG-identified deficiencies before further deployment of the new EHR can help reduce risks to patient safety.

VA concurred with the OIG’s three recommendations to evaluate and address EHR problem-resolution processes, redress the underlying factors of previous OIG-identified EHR deficiencies, and create a deployment schedule that reflects corrective actions.