U.S. Department of Veteran Affairs’ EHR raises patient safety concerns

WASHINGTON, UNITED STATES—Reports show that the Department of Veteran Affairs (VA) Oracle Health electronic health record (EHR) platform has encountered scheduling errors and pharmacy-related coding mistakes, which have negatively affected healthcare delivery.

The VA’s Office of Inspector General (OIG) found that a system error in the Oracle Health EHR software installed at the Columbus-based VA Central Ohio Healthcare System was a critical element in the unintentional overdose and death of a patient, who had a history of substance abuse and suicidal thoughts, in 2022. 

The OIG report stated a “system error resulted in a scheduler failing to reschedule a missed mental health appointment, which may have contributed to the patient’s disengagement from their mental health treatment and, ultimately, the patient’s substance use relapse and death.”

In another report, the OIG stated that the five VA medical facilities equipped with the Oracle Health EHR system have spotted EHR scheduling problems. The appointment queue wasn’t operating as planned, which could lead to patient bookings not being automatically rescheduled. 

Employees using the system also noted that it is difficult to share information between providers and schedulers. 

“Before the EHR is deployed at a facility, Oracle Health provides facility staff with general training on how to use the system,” the report reads. 

“However, many schedulers indicated the training was not sufficient to prepare them to use the EHR scheduling system for their daily duties.”

This comes as the VA looks to resume the Oracle Health deployment at more VA medical centers. The rollout was paused in April 2023 due to ongoing malfunctions.