A photo of improper cable management in room A105A of the main hospital at the Mann-Grandstaff VAMC, taken during the audit team’s inspection.

WASHINGTON — The VA Inspector General released two long-awaited reports last month examining problems with the roll-out of VA’s new electronic health record system at its pilot site, the Mann-Grandstaff VAMC in Spokane, WA, and the news was not good.

One report found that, while the department announced delays in the go-live date for the EHR pilot relatively recently, the problems that led to the delays were known about over a year ago. The other report found that, had the system gone live as scheduled, it would have led to a significant decrease in patient care and have put veterans’ health at risk.

The IG found that the original go-live date of March 28 was not only unrealistic but had been set before VA had a sense of what infrastructure changes needed to be made at the Spokane facility to prepare for the new system. That infrastructure includes changes to electrics, cabling, heating, ventilation, air conditioning, as well as the network components and end-user services like desktop computers, tablets, monitors and medical devices.

VA set the March 28, 2020, date in June 2018. But according to the report, it was not until May 2019 that VA conducted facility infrastructure assessments at the pilot site. The following month, officials at VA’s Office of Electronic Health Record Modernization told lawmakers that while the infrastructure would not be in place, it was not necessary to support going live in March 2020.

History would prove this to be false, since infrastructure delays were cited by VA in February 2020 as one of the reasons for pushing the go-live date until July. That date has since been delayed indefinitely due to the pandemic.

It’s also possible that VA expected more of the infrastructure to be complete by March—something that was further delayed by departmental infighting. According to the report, the responsibility for infrastructure upgrades was shared by OEHRM, VHA and the Office of Information Technology. Disagreements between OEHRM and VHA pushed the work back farther, with the requirements specification document—the document that lays out exactly what work needs to be done—not being signed until November 2019.

There was also no way at the national level for any of the departments overseeing infrastructure upgrades to track whether those upgrades were actually happening, the report stated. In addition, four of six staff positions on the infrastructure-readiness team were still unfilled as of November.

Even if the infrastructure had been in place for a go-live on March 28, the result would have been a system that caused a significant drop in efficiency of care, the IG’s second report states. When DoD transferred to a similar Cerner-designed system in 2017, facilities experienced a 30% drop in productivity in the 18 months following the transition.

For example, the EHR that went live on March 28 would be lacking some key capabilities at first, including online prescription refills. Online prescriptions are the most popular method of refilling medications among veterans and Mann-Grandstaff handled more than 10,000 a month.

A photo of improper cable management in the Coeur d’Alene CBOC telecommunications room. Source: VA OIG, Spokane, Washington; 8:30 a.m. and 1:51p.m.; October 9, 2019

VA had taken this into account, and the facility had mapped out mitigation efforts—ways to counteract that decrease in productivity—that would last between 12 and 24 months after the go-live date. This included plans to hire more staff, change clinic processes, and rely more on community care.

However, the facility encountered roadblocks at the VISN level when it came to hiring new staff. And as of January 2020, the Mann-Grandstaff had a community care backlog of 21,055 requests, meaning an increased reliance on that system would lead to further delays.

Three months from the initial go-live date, the mitigation efforts remained incomplete. Facility leaders told IG investigators of “robust and frequent discussion” between the facility and VA leaders about the expected drop in access, but those discussions did not include actions the facility could take to counteract that drop.

“OIG found that facility leaders were planning to go live in March 2020 with an incomplete set of system capabilities,” the report states. “The OIG was unable to determine all patient safety risks associated with the new EHR system; however, the work-arounds for the electronic prescription refill process alone constitute an example of a significant, potential patient safety risk.”

The reports include a number of recommendations, not least of which is for VA to establish a more realistic schedule, one that incorporates lessons that should have been learned from DoD’s EHR experience.