Electronic health record glitch put VA patients at risk

House veterans affairs panel chairman ties poor management to problems with latest upgrade of department’s EHR system

Glitches in Veterans Affairs Department electronic medical records software led to problems in the treatment of nine patients in three facilities in October and November 2008, drawing the ire of a key congressional overseer.

The software problems came about after VA distributed version 27 of its Computerized Patient Record System (CPRS) to medical facilities in late August. The software was to be installed by Oct. 6.

Clinicians noticed that when switching from one patient record to another, a new record was not loading under the second patient’s name, Josephine Schuda, a VA spokeswoman, said. Forty-one of 153 VA facilities reported experiencing this problem.

“This problem was occurring intermittently,” she added.

The problem occurred when a patient’s record remained set in the system after CPRS was trying to shut itself down because of inactivity, Schuda explained.

Facilities were notified of the problem in a VA memo dated Oct. 10, 2008. The VA issued a patch to fix the software Nov. 6. No problems have been reported since then, Schuda said.

Rep. Bob Filner (D-Calif.), chairman of the House Veterans' Affairs Committee, released a statement Jan. 15, expressing disappointment over “troubling new revelations…regarding operating problems with the most recent upgrade to the [VA’s] electronic medical records system…. Oversight of this incident will continue."

“The VA has been plagued by poor leadership and management,” Filner continued, alleging that VA operates in an environment of secrecy and lack of transparency.

The software problems first came to light through a posting on a Web site called vawatchdog.org Jan.7 and was later picked up in a story by the Associated Press Jan. 14.

The nine incidents of faulty patient treatment involved continuation of intravenous infusions of a drug, most often heparin, beyond the time specified in doctors’ orders.

“There were no reports of harm to any patients,” Schuda said. “We have followed up by checking adverse events reports and nothing matched up with these incidents.”

Schuda denied the AP report which said that some patients treatments were delayed due to the software glitch. She also contradicted Filner’s allegations of secrecy, saying that “we notified members of Congress and veterans services organizations in email messages on November 6.”


About the Author

Peter Buxbaum is a special contributor to Defense Systems.

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