Federal Reports

This healthcare inspection report is the second of three associated with implementation of the new electronic health record system (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington. It details OIG findings on a range of allegations regarding clinical care coordination challenges and potential patient safety issues.The OIG found that the new EHR implementation had created difficulties for users in eight areas:1. Patient record flags, including failures to transfer flags and information related to patients at high risk for suicide2. Data migration errors leading to inaccurate name, gender, and contact information3. Scheduling process issues, such as delays in primary care scheduling4. VA Video Connect problems, including inoperable and misdirected links5. Referral management deficiencies, including lost or unaddressed referrals6. Laboratory orders “disappearing” that affected workflow and tracking, and delayed results7. Patient portal and secure messaging being inaccessible8. Documentation processes, including creating additional work and limiting providers’ ability to correctly code patient diagnosesAlthough the OIG did not identify any associated patient deaths during this inspection, future deployment of the new EHR without resolving deficiencies can increase risks to patient safety. The OIG recommended the Deputy Secretary review and address the remaining unresolved deficiencies.Further discussion of allegations related to medication management issues after go-live, ticket process concerns identified by the OIG during evaluation of the allegations, and underlying factors related to all substantiated allegations can be found in the OIG’s companion reports.

This report details the OIG’s healthcare inspection to assess a range of allegations regarding medication management deficiencies and potential patient safety issues associated with implementation of the new electronic health record (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington.The OIG found that the new EHR implementation was deficient in numerous areas affecting medication management, including (1) data migration issues leading to inaccurate contact information and medication lists; (2) medication order processes erroneously discontinuing certain medications, permitting registered nurses to enter orders without authorization, and failing to notify providers of important prescribing information; and (3) medication reconciliation processes being impeded by incomplete medication lists that led to staff developing time-consuming workarounds, which increased risks of errors.Many of the medication management deficiencies remained unresolved during the OIG’s inspection from January to early June 2021. Although the OIG did not identify any associated patient deaths during this inspection, deployment of the new EHR without resolution of deficiencies may present risks to patient safety and affect providers’ treatment decisions.Findings can be found in two companion reports related to clinical care coordination issues after going live, concerns identified with the process for addressing “tickets” for resolving problems, and factors that contributed to deficiencies.The OIG made two recommendations to the Deputy Secretary: Ensure that substantiated and unresolved allegations are reviewed and addressed, and notify the OIG of any other medication management issues identified after the healthcare inspection. VA concurred with the first recommendation but not with the second, stating the recommendation creates a continuous reporting requirement to the OIG that prevents its closure. The OIG reminded the VA of its duty to provide this information and will close the recommendation when VA demonstrates an effective and sustainable process to identify and address patient safety issues.

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 problems2. Training deficits3. Interoperability challenges4. Post-go-live fixes and refinement needs5. Problem-resolution process challengesResolving 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.

RMA was engaged by the U.S. AbilityOne Commission Office of Inspector General (OIG) to conduct the performance audit and issue its report. The objectives of the audit were to assess 1) the completeness, accuracy, timeliness, and quality of the Q2 FY 2021 financial and award data submitted by the Commission for publication on USASpending.gov, and 2) the Commission’s implementation and use of the government-wide financial data standards established by the Office of Management and Budget (OMB) and the U.S. Treasury (Treasury). To answer the audit objectives, the RMA team obtained and identified information about applicable records from Commission and 3rd party data systems. RMA then sampled, reviewed, and reconciled Q2 FY 2021 financial and award data submitted by the Commission for publication on USASpending.gov. The team also assessed 1) controls in place for the extraction of data from source systems and for the reporting of data to the Treasury, 2) the completeness, accuracy, timeliness, quality of the financial as well as award data sampled, and 3) the Commission’s implementation and use of the 59 data elements and standards established by OMB and Treasury.

In this white paper, the OIG sought to identify opportunities and challenges in adopting electric delivery vehicles. We assessed the suitability of using electric vehicles as delivery vehicles and analyzed the potential long-term cost savings of a new electric delivery vehicle compared to a new gas-powered vehicle. We also benchmarked the electric vehicle experiences of other federal agencies, foreign posts, and companies in the logistics and shipping sector. We identified several clear benefits of adopting electric vehicles into the postal delivery fleet, including improved sustainability and environmental impacts. Our research confirms that electric vehicle technology is generally capable of meeting the Postal Service’s needs.