Federal Reports

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.