Review Uncovers VA EHR Scheduling System Patient Safety Concerns

The deployment of the Department of Veterans Affairs (VA) patient scheduling system at two pilot sites has delayed veteran healthcare access, according to an OIG review that raises additional patient safety concerns regarding the agency’s Cerner EHR implementation.

The Veterans Health Administration (VHA) and the Office of EHR Modernization (OEHRM) implemented the new scheduling component separate from the full EHR system at the Chalmers P. Wylie VA Ambulatory Care Center in Columbus, Ohio, in August 2020.

In October 2020, VHA and OEHRM implemented the full EHR suite, which included the new scheduling system, at the Mann–Grandstaff VA Medical Center in Spokane, Washington.

While OEHRM, VHA, and Cerner identified and resolved several potential performance issues with the new system during pre-implementation testing and workshops at Columbus and Spokane, the OIG review team determined that OEHRM was aware of additional system issues but did not fully address them before implementation in Columbus.

These unresolved pre-implementation issues included the system’s inability to mail appointment letter reminders automatically. The review also found that OEHRM did not address concerns related to changing modality of care within the system (in-person or telehealth) before implementation.

Additionally, OEHRM did not address the system’s lack of oversight report functionality for tracking patient scheduling accuracy, the report noted.

The review also revealed that OEHRM leaders did not provide employees with adequate opportunities to give feedback on the new scheduling system before implementation.

An OIG survey found that of 213 schedulers that had used the new system, only 123 schedulers (about 58 percent) reported being able to provide feedback on the system pre-implementation. Of those, only 9 percent reported that their stated concerns resulted in scheduling system changes.

The EHR vendor for the project, Cerner, began training Columbus and some Spokane schedulers and providers in February 2020 and January 2020, respectively. However, the vendor paused training shortly after due to COVID-19.

As Columbus prepared to implement the system in August 2020, an OEHRM released an internal document that summarized training-related survey feedback revealed schedulers’ concerns.

According to the document, schedulers did not feel ready to handle real, complex scheduling scenarios. Schedulers noted that their training was not tailored to their roles and that they did not have enough time to practice using the system.

Cerner resumed training, and VHA and OEHRM moved forward with implementation in the summer of 2020.

Additional issues arose once VA implemented the scheduling system at the Columbus facility in August 2020, the OIG review team found.

For instance, the scheduling system did not include certain clinics, appointment types, or providers. Some schedulers also lacked the permissions needed to schedule appointments. Facility staff noted that it generally took over a week for Cerner to close help tickets, which delayed some patients’ care.

The OIG review team also found that data from VHA’s legacy system were not accurately or completely transferred to the new scheduling system when deployed at Columbus and Spokane. Schedulers had to manually search provider schedules and veteran data to ensure accuracy.

Additionally, the review revealed issues with the system’s appointment reminder feature. Staff had to turn off reminder calls for telehealth appointments because of confusing information, such as stating those patients should check in at a front desk when in-person care was not available or advised.

According to the OIG review, VHA and OEHRM did not address the post-implementation issues that came up at the Columbus site before implementing the new system at Spokane in October 2020.

Schedulers developed workarounds due to a lack of guidance and inadequate training on how to respond to system limitations, the report noted.

VHA employees also began working with Cerner in efforts to correct the most pressing patient safety issues using a ticketing process. However, schedulers told the OIG review team that they experienced long delays in resolving tickets without status updates.

Additionally, the OIG team learned that OEHRM lacked a protocol to assess whether Cerner was complying with its contract’s timeliness requirements.

"Cerner takes our responsibility to Veterans and VA providers seriously," Brian Sandager, general manager and senior vice president of Cerner Government Services wrote in a statement to EHRIntelligence. "The new system should aid VA staff to improve access to care for Veterans. The report noted schedulers praised the system for being more user friendly and highlighted the ease of scheduling video visits. We remain engaged on-site in Spokane and Columbus gathering feedback and implementing changes as directed by VA. It’s important to get this right and we remain committed to this mission."

VHA and OEHRM were planning to implement the scheduling system at all 20 Veterans Integrated Service Network (VISN) facilities by December 2021. However, OEHRM paused future deployment in March 2021 while VA conducts a strategic review of the full EHR program.

The OIG issued eight recommendations to help VHA and OEHRM address issues with the system: improve training for schedulers; engage schedulers more fully in testing and improvements; issue guidance on measuring patient wait times; track help tickets, consistent with Cerner contract terms; develop a strategy to promptly resolve identified issues; develop mechanisms to assess schedulers’ accuracy; evaluate patient care timeliness; and provide guidance to schedulers to address system limitations until problems are resolved.