The Veterans Health Administration’s VistA clinical information technology system and its key Computerized Patient Record System, or CPRS, went on a historic fritz Aug. 31 at the VA’s Northern California Healthcare System—an integrated healthcare delivery network serving 377,000 veterans with close to 2,000 patient visits a day—disrupting service for more than eight hours, a pair of VA physician IT leaders told a congressional oversight panel last week.
In the opinion of one VA physician-informaticist who testified before the House Veterans Affairs Committee on Wednesday, part of the failure can be attributed to changes in the management structure of information technology services at the VA that were designed to improve system security and strengthen IT project oversight. The House committee held a hearing on the status of the IT restructuring program.
The overhaul of IT management at the VA came in the wake of the 2004 fiasco involving an unusable computer system for materials and financial management. The Core Financial and Logistics System, or CoreFLS, was developed under contract with consultant BearingPoint. VA officials scrapped the failed system after five years of development and a cost of nearly $250 million.
A blow-by-blow account of the VistA system failure in Northern California detailed a cascade of events, including two backup system failures and a lack of communication that exacerbated the problem. The report was given by physician Bryan Volpp, associate chief of staff, clinical informatics, for the Northern California system. The system is composed of 17 patient-care sites, including a 50-bed acute- and critical-care hospital in Sacramento and a 115-bed inpatient nursing home and subacute-care facility in Martinez, Calif. A copy of Volpp’s written
testimony is posted on the House committee's Web site. Volpp described a “major disruption” that began as a log-on failure at 7:30 a.m., as physicians and clinicians prepared for their day of patient visits scheduled to begin at 8 a.m. Volpp said the problem was traced to the Sacramento Regional Data Processing Center, which provides a centralized database for the 17 Northern California care sites. The sites tried to implement their backup procedures, but two of those—a transfer to the database at the Denver data center and use of a system that affords read-only access to existing data—both failed. Timely reporting of the cause of the failure and estimates of the projected downtime, typical of previous outages, also did not occur, Volpp said.
One saving grace was a third and final backup procedure—a switch to printing out care-record summaries hosted on local personal computers—that was activated successfully, albeit not quickly enough that morning to prevent some clinicians from seeing patients scheduled for the earliest appointments without having access to any of their medical records.
A host of other problems ensued, including:
The medical staff was forced to write discharge instructions and notes on paper.
The electronic lists of instructions and of medications were not available for the patients being discharged.
Patients being discharged could not be given follow-up appointments at the time of discharge. The appointments had to be made later and the patient notified by phone.
There were delays in obtaining discharge medications and patients remained on the wards longer than would normally be required.
The nurses administered medications to the patients and used the paper Medication Administration Record, or MAR, to record the administration events. Initial medication passes were interrupted and delayed until the paper copies of the (MAR) could be printed.
In fact, it took VA staff almost a week to get medication administration records in the restored computerized system fully up to date, Volpp said. The total effects of the system outage will last much longer, according to Volpp.
“Administrative staff worked for over two weeks to complete the checkouts on all the patients who were seen that day,” he said. “However, entering checkout data on all these patients many days after the fact is potentially inaccurate,” he said. “Many providers have gone back into CPRS and tried to reconstruct notes that summarize the paper notes that they wrote in order to mitigate the risk of missing information. This work to recover the integrity of the medical record will continue for many months since so much information was recorded on paper that day. When you consider that hundreds of screening exams for PTSD, depression, alcohol use and smoking, and entry of educational interventions, records of outside results, discharge instructions and assessments are all now on paper and are not in a format that is easily found in the electronic record, the burden of this one failure will persist for a long time.”
J. Ben Davoren, the physician director of clinical informatics at the San Francisco VA Medical Center, said the broader VA management realignment is causing its own problems, and the Aug. 31 system failure is but one serious example.
Davoren called the Northern California system failure, “the most significant technological threat to patient safety VA has ever had.”
Some of these potential problems with the management realignment were foreseen and communicated to top VA officials as far back as 2005, Davoren said. Disconnecting local facility officials from control over needed IT projects has caused delays in development and implementation, according to Davoren. Local innovation and multiple iterations of software development facilitated by the close proximity of clinicians and programmers has been a hallmark of the VA’s clinical system development effort over the years.
According to his written testimony, Davoren said that in response to then-VA Secretary Anthony Principi’s proposals for IT realignment, “I believe that employees at some medical centers expressed a number of concerns about the details of the plan. In particular, I believe they felt that the regionalization of IT resources would create new points of failure that could not be controlled by the sites experiencing the impact, and that the system redundancy required to prevent this was never listed as a prerequisite to centralization of critical patient-care IT resources. From my point of view as the director of clinical informatics, it was clear to me that the focus of reorganization/realignment was on technical relationships and not on how the missions of VHA would be communicated to the new (Office of Information and Technology) structure. For example, realignment success metrics were focused on (regional data processing center) deliverables rather than facility needs. Finally, key facility-based IT staff had been tightly integrated into local committees and planning groups as subject matter experts, but could no longer be tasked directly by the facility director to participate, and had no clear OI&T-driven incentive to continue. Ultimately, the concern was that in trying to create a new structure in the name of ‘standardization,’ support would wane to a ‘lowest common denominator’ for all facilities, no matter how diverse their actual needs were.”
“In my view, there remains a tremendous uncertainty about how to work with our long-standing IT colleagues to address local or regional clinical care, research or educational needs,” Davoren said. As a result, he said, “There is a sense of great inertia that overrides the anticipation of great opportunities in the new OI&T structure.”
Davoren said there has been a welcome consciousness-raising within the VA about privacy and security issues, but heightened security measures also have had drawbacks, including difficulty scheduling teleconferences and other snafus. “For example, to fully comply with security requirements on our examination-room PCs, we must log out of both a clinical application such as our Computerized Patient Record System and the Microsoft Windows operating system each time we leave the room even for a moment, yet it may take as long as 12 minutes to log back on when we return. Given a 20- or 30-minute visit with their veteran patient, the clinician is thus forced to choose to “do the right thing” for either the patient or the system, but cannot do both, “the bad news is that centralization of physical IT resources to the (regional approach) has directly led to more system downtime for individual medical centers than they have ever had before, resulting in hundreds of simultaneous threats to the safety of our veteran patients.”
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