A Quarter of a Million VA Patients May Get the Wrong Meds Due to Errors in New Electronic Health Records System

During a congressional hearing on Thursday, February 15th, a federal oversight authority sounded the alarm to legislators, indicating that approximately 250,000 former service members might face the risk of receiving medication prescriptions that clash with their allergies or could negatively interact with their ongoing treatments. This concern stems from glitches within the Department of Veterans Affairs (VA) newly implemented electronic health records platform.

So, fellow VA patients, I implore you to carefully check your meds from here on out.  I once received a bottle of a topical medication to be used for a skin condition, and marked on the label were the words “for heart and blood pressure.” I checked with my VA pharmacist, and they confirmed that it was an error due to the med I was taking being so close in spelling to a heart and blood pressure medication.

No Documented Harm…Yet

A VA representative, speaking at the same session, emphasized that there have been no confirmed instances of patient harm directly attributable to these data mishaps. None yet.

However, it was reported that a veteran did not receive essential prescribed medication due to inaccuracies in their medical records. Furthermore, the oversight body criticized the VA for not proactively informing patients about potential inaccuracies in their prescription data.
David Case, the VA’s deputy inspector general, voiced his concerns on technology modernization at the House Veterans Affairs Committee’s subcommittee:

“We are troubled by the fact that patients have not been made aware of their personal risk, effectively leaving them out of the loop in their own healthcare.” 

Communications Glitches Between Computer Systems

This episode is the most recent setback in deploying the Oracle Cerner Millennium system. The system’s challenges have been significant enough to prompt the VA to halt its further implementation while seeking resolutions for the network issues.
The crux of the problem lies in how the Oracle system transmits data to a central medical records database, the Health Data Repository, which maintains details on patients’ medication and allergy records. The glitch arises when this data, coded incorrectly by the Oracle system, is accessed through the older Vista electronic health records system, leading to potential inaccuracies.

Case highlighted that about 250,000 veterans could be impacted by this flaw, according to data from the Veterans Health Administration. He shared an incident where a patient suffering from PTSD and traumatic brain injury was denied necessary medication due to the rehab facility’s reliance on the Vista system, which did not display the prescription obtained through a facility using the Oracle system.

The patient’s condition deteriorated over five days, ultimately requiring emergency intervention, as detailed in Case’s testimony.

Congress Orders a Pause on Further Implementation

Case also pointed out the VA’s insufficient efforts in alerting legacy electronic health record (EHR) providers about this issue and the steps needed to ensure safe care for patients transitioning to the new EHR sites.

Mike Sicilia, Oracle Corp.’s executive vice president, informed lawmakers of multiple attempts to rectify data transmission errors to the Health Data Repository. Despite these efforts, a recent software update was retracted due to similar data issues discovered during the final testing phases.

Sicilia defended Oracle’s role, suggesting the challenges weren’t solely their responsibility. “This situation is complex, involving multiple systems, versions, and interfaces. While we take full responsibility for rectifying system defects, it’s a collective issue,” he remarked.
The Oracle system, part of a $10 billion initiative with limited deployment in the Pacific Northwest and Ohio, has faced increasing scrutiny from lawmakers as patient safety concerns have emerged.

Amid congressional pressure, the VA announced a pause in April on further implementations of the new system to address these issues. Yet, legislative frustration continues to mount.

Subcommittee chairman Rep. Matt Rosendale, R-Mont., expressed his exasperation, likening the continued attempts to refine the Oracle Cerner pharmacy software to an exercise in futility. “Persisting in the same approach, expecting different outcomes, is sheer madness,” he concluded.