Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus

The VA Office of Inspector General (OIG) conducted an inspection at the VA Central Ohio Healthcare System (facility) in Columbus to review an allegation that implementation of the new electronic health record (EHR) led to a prescription backlog. While reviewing the allegation, the OIG determined facility leaders took timely and sustainable steps to manage the issue. However, the OIG identified other facility and national pharmacy-related patient safety issues. The OIG found implementation of the new EHR at the facility, despite known pharmacy-related patient safety and usability issues, contributed to ongoing patient safety risks and usability challenges at the facility. The new EHR contributed to pharmacy-related patient safety issues nationally as a software coding error resulted in inaccurate medication and allergy information transmission from new EHR sites to legacy EHR sites. Affected patients were not notified of their risk of harm and the OIG remains concerned for their safety. The OIG learned VHA communicated recommendations to providers to mitigate the risk of harm to affected patients; however, the recommendations were non-sustainable. Additionally, the new EHR's operational inefficiencies required increased clinical pharmacist staffing and development of workarounds and educational materials to complete pharmacy processes. The inefficiencies also led to pharmacy staff burnout, job dissatisfaction, and decreased morale. The OIG made three recommendations to the Deputy Secretary related to resolution of patient safety and usability issues. The OIG made six recommendations to the Under Secretary for Health. One recommendation focuses on accurate patient medication data and three recommendations address patient and provider awareness and evaluation of the risk of harm related to data transmission issues. Another recommendation is related to pharmacy staffing, and one focuses on the underlying technical and functional issues requiring workarounds and educational materials to perform pharmacy operations.