Federal Reports

Enhanced Planning, Performance Measurement and Evaluation, and Information Can Improve Oversight of Broker-Dealer Examinations report No. 583

The VA Office of Inspector General (OIG) issued a management advisory memorandum to inform the Veterans Health Administration (VHA) Under Secretary for Health of concerns facility leaders and staff expressed to OIG staff regarding VA’s new electronic health record (EHR) during Healthcare Facility Inspections. The OIG conducted Healthcare Facility Inspections of the VA Southern Oregon Healthcare System and the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington, during the weeks of March 4 and June 3, 2024, respectively. VA deployed the new EHR at the Jonathan M. Wainwright Memorial VA Medical Center and the VA Southern Oregon Healthcare System in March 2022 and June 2022, respectively.Leaders at the VA Southern Oregon Healthcare System described the implementation of the new EHR as “the single largest challenge that we have here,” noting that the new EHR has impacted “every system” and resulted in “rewriting the way VA does business.” The director at the Jonathan M. Wainwright Memorial VA Medical Center described multiple challenges, including timing of deployment, which overlapped with dealing with the effects of the pandemic; limited training; and enterprise-wide communication deficiencies. Additionally, leaders and staff at both medical facilities described notable concerns related to (1) efficiency and loss of productivity, (2) staffing, (3) financial impacts, and (4) patient safety.Since 2020, the OIG has reported on various issues with the new EHR. Interviews of leaders and staff during Healthcare Facility Inspections of the VA Southern Oregon Healthcare System and the Jonathan M. Wainwright Memorial VA Medical Center demonstrate that new and previously-identified issues persist in 2024.The OIG requested the Under Secretary for Health evaluate whether the issues cited in the memorandum warrant process reviews and/or contract enhancements to improve efficiency, user experiences, and patient safety.

The VA Office of Inspector General (OIG) conducted this audit to determine whether VA and its contractor had sufficient controls to prevent, respond to, and mitigate the impact of major performance incidents affecting the electronic health record (EHR) system.In May 2018, VA awarded a 10-year contract to Cerner (now Oracle Health) to implement the system. Since then, it has experienced hundreds of major performance incidents affecting the five VA medical centers where the system was initially deployed.The OIG found VA and Oracle Health did not have adequate controls to prevent system changes from causing major incidents, to respond to those incidents uniformly and thoroughly, or to mitigate their impact by providing standard procedures and interoperable downtime equipment. Further, although major performance incidents can delay care to veterans, VA had no formal process to link reports of these delays to specific major performance incidents. Ultimately, the inadequate controls for handling major incidents stemmed from the May 2018 contract. In May 2023, VA modified the contract to strengthen some requirements for addressing major incidents but could do more.The EHR system’s estimated cost has grown. It was originally $16 billion. If VA does not improve controls, major performance incidents will continue, leading to further costly delays in system implementation and posing an ongoing risk to patient safety.The OIG made nine recommendations, including real-time data sharing to give VA greater awareness of potential problems in system operations, prioritizing major performance incident response in a clear and consistent manner, developing and enforcing response and other performance metrics to hold the contractor accountable, requiring sufficient detail in post-resolution reports, raising staff awareness of procedures and acquiring appropriate backup systems for downtime, and better identifying and addressing major performance incidents linked to negative patient outcomes.

Our audit determined that while the Peace Corps does have an established framework to oversee and monitor domestic awarded contracts, it can improve its management of the following: • Contract oversight including contract modifications, documentation, and guidance for Contract Officer Representatives and Technical Points of Contact; and • Contract completion, including performance assessments and closeout.

The EPA does not have a national process in place to track or verify the status of land-use controls at Resource Conservation and Recovery Act corrective action facilities. The EPA has not identified standard methods for long-term oversight of land-use controls at corrective action facilities. Additionally, the EPA regions vary in their progress toward attainment of Resource Conservation and Recovery Act Corrective Action Program Goal 4. Further, EPA information systems that can be used to access program information contain data issues, and the EPA is not using its information systems to track the status of land-use controls.