BREAKING: Veterans Affairs National Patient Safety Alert

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Veterans Affairs

Benjamin KrauseVeterans at risk may have been affected by a recent Department of Veterans Affairs health care alert showing a computer glitch was canceling doctors consults including consultations for anticoagulation assessments.

The alert states that a large number of appointments were auto-canceled both before and after October 1, 2015. The email alert sent to employees later leaked to DisabledVeterans.org explains the extent of the problem.

VIEW: Leaked National Patient Safety Alert Letter

VA claims a software glitch within its health care CPRS system rejected large numbers of veterans appointments. These appointments are called consult orders or procedure orders. VA became aware of the issue when facilities transitioned from ICD-9 to ICD-10 on October 1, 2015. An investigation of the problem revealed the cancelation problem existed prior to October 1.

The alert was not on VA’s web page for National Patient Safety Alerts and not in the press.

VA TRANSITION TO ICD-10

Here is the down low on the transition on VA.gov:

The U.S. Department of Health and Human Services has confirmed in a final rule that October 1, 2015, will be the deadline for the implementation of the International Classification of Diseases, 10th Revision (ICD-10). The final rule requires the use of ICD-9 through September 30, 2015. Visit the Centers for Medicare & Medicaid Services (CMS) industry resources for the ICD-10 transition page for information about ICD-10.

How to prepare for the ICD-10 transition

In an effort to keep community providers engaged during the transition to the new ICD-10 code sets, the Department of Veterans Affairs is actively seeking providers, facilities and clearinghouses to participate in ongoing ICD-10 discussion forums and end-to-end testing. Feedback received during the discussion forums will be integrated into end-to-end testing scenarios to ensure that on October 1, 2015, our ICD-10 remediated systems and processes successfully administer the new code sets and provide expected claim outcomes to our customers and Veterans. Information on how to participate in the discussion forums and end-to-end testing will be posted on this website.

VA obviously failed to adequately prepare for the transition and veterans were adversely affected. I wonder how long it will take for VA OIG to investigation why this was allowed to happen?

IMPACT OF NATIONAL PATIENT SAFETY ALERT

This is significant for veterans who received inpatient care where the consult may have been a matter of life or death. According to the alert, patients needing anticoagulation consults may have had the appointment or procedure canceled. It is likely that veterans seeking other consultations were also affected.

Anticoagulation can be a lifesaving treatment to protect against increased risk of stroke. Use of anticoagulation after atrial fibrillation and/or cardioversion is generally required by the medical standard of care according to the American Heart Association. The potential risks caused by this undetected glitch may be far reaching.

If you are suspicious you were affected, your normal VistA medical records may not contain the records since the order procedure was not completed. According to the agency, the patch permits VA to generate a detailed report of all consult and procedure orders that were rejected dating back to September 1, 2015.

What about the appointments before then? Think VA will dig back that far? Will they notify veterans’ families where the veteran died as a result of the error?

Here is the substance of the full national alert:

VETERANS AFFAIRS NATIONAL PATIENT SAFETY ALERT

Sending on Behalf of the Chief of Staff to All CPRS Users

VA Central Office recently issued a national patient safety alert that you need to know about.  Here are some key points for you to review.

Issue Concerning Rejected Consults

·         It was recently discovered that CPRS has rejected a large number of consult/procedure orders. 

·         This national problem became apparent when VHA facilities transitioned from ICD-9 to ICD-10 on October 1, 2015.

·         Further investigation revealed the issue occurred prior to October 1 as well, but to a lesser extent.

What Rejected Consults Looked Like in CPRS

According to the national VA alert, when orders were rejected, this CPRS error message would appear:

Error Saving Order CPRS 

Unfortunately, if an ordering provider clicked “OK” without reading the content of the error message, the provider may have unknowingly cancelled their consult order.

How This Issue Has Been Corrected Moving Forward

·         On December 29, 2015, VA Central Office installed a national CPRS patch that corrected this issue moving forward. 

·         Consult and procedural orders are no longer being inadvertently cancelled.

·         This patch also allows any provisional diagnosis codes to be accepted as valid.

What You Need to Know For Consults That Were Inadvertently Cancelled

·         The patch permits our facility to generate a detailed report of all consult and procedure orders that were rejected dating back to September 1, 2015.

·         This report is now under review, to ensure there are no rejected orders that are outstanding. 

·         As part of this review, individual providers may be contacted if they have a patient who was affected by this, to assess whether the cancelled consult/procedure order is still needed.  (All instances identified in the report will be reviewed through a collaborative effort between Continuous Improvement staff and Patient Service Line leaders).

If you have questions or concerns about this alert, please contact a clinical applications coordinator at pager 612-818-7202. 

KENT CROSSLEY, MD      

Chief of Staff

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namnibor
namnibor

What this article brings to mind is something from my youth and my grandparents in which most of the men in my family flew both for USAF and civilian recreational flying of planes and how my grandfather clearly explained how the early days of electric garage openers were subject to both Radio Frequency Interference FROM certain airplanes when they flew over, which would consequently open the garage door randomly and that garage also doubled as an office for my family’s manufacturing business and my grandfather happened to be sleeping in that garage one very warm humid Summer night and he found himself in his skivvies with the door opening from radio interference overhead and his solution was to simply disable even for his own use that very early remote door mechanism that consequently would randomly open from people with CB Radios (this was farm country and showing my age) driving by and even trying to prank people by this method.
Now, that was way before computers were out in the wild and microwave ovens were not even in wild yet either.

The VA and Technology is akin to placing Superman in a cave loaded with kryptonite…they just are like oil and water and do not easily mix.

Look in just the past decade to 15 years in how much $$$$$ has been funneled to the VA to FIX and bring their very mid-80’s tech up to date!?!!! No matter the contractor or how many millions/billions are thrown at it, that oil and water will not mix unless emulsified, which translates that metaphor to proper integration and implementation.

It would not surprise me one bit if a garage door opener remote would interfere with the VA’s very dated technology, which also brings to attention the very serious threat of ALL our personal info being easily hacked by terrorists and rogue nations, or someone with a radio controlled Toy Plane.
This is further compounded by the VA’s resistance to become properly networked with DOD and other miserably failed efforts to bring the VA up to date from their current mid-80’s stick in the mud they remain at.
Anyone ever really take notice to the VA’s computer screen pages at appointment desks? It LOOKS JUST LIKE the MS-DOS black screen with bright green font, which makes me wonder of the VA’s IT Dept. still has some huge room full of analog reel to reels and the very early ‘Floppy Discs’ that were larger than your largest dinner serving plate…and everything in that “VA Server Room” can now in 2016 be done on the cheapest ‘Netbook PC/MAC’ with minimum RAM/ROM, but then in other areas of VA and VBA the VA seems to have some more modern components in the mix, making it like trying to incorporate and network the parts of the VA IT that’s akin to communicating with two cups connected with strings in a child’s science class at school with modern servers…you need to bring the WHOLE SYSTEM collectively up to date, not just little bits here and there, esp. at the Tax Payer cost of all the past complete failures to bring this second largest Federal Agency up to date AND SECURE with rest of the world and where that tech sits.

It makes no sense. However, has anyone postulated that the VA may by design wish to keep things in the chaotic state their technology remains in order to further propagate and protect their state of absolutely NO accountability? I do. I think this simply makes it VERY EASY for the VA to state that this or that happened because of our out of date tech (even though we love it that way), which gives the VA an easy out anytime just like that still used excuse of “Your C-File was in the St. Louis VA Records Fire”, the modern equiv. of saying the dog or cat ate my homework.

VA and technology is like oil and water and it comes down to sort of a codependency on things remaining obscured because otherwise we would NOT have VA Construction Projects incredibly over-budget such as the Aurora, Colorado VAMC Black Hole Project.
This is as least my assessment of why the VA is still at the equiv. of early MS-DOS operating systems and then the higher tech is not protected much at all…all in the grand schema of avoiding that VA Kryptonite, “Accountability”.

This also seems to be a very easy out for the VA to defer future accusations of “wait lists’ or “canceled appointments”, et al, by using the excuse “we were hacked” or “we need X Amount of Billions to try to bring systems up to date”, at least that’s how I see it because there’s absolutely no excuse for the second largest Federal Agency, The VA, to NOT be standardized and all data highly protected…other than it being a very easy out to not take any responsibility for lost data and even use the stone age IT as an excuse to prevent any blame (accountability) on the VA…so easy to just state “all the data was lost, so sorry, start over and DO NOT collect $200.”

THIS must be Sloan Gibson’s and the VA’s “redefined term” for “accountability”…just blame it on computer systems…meanwhile in reality land, most people know that a computer system is reliant on whatever the humans inputted or did not into the system. This is just a way to defer accountability and personify the computer system, never mind the idiot that cancelled your consult and sis not bother to notify you…not my fault…it’s the computer’s fault….we need more $$$$$ to “fix it”, repeat/rinse.

Meanwhile the VA builds brand new VAMC’s with color changing digital walls…WTF?
ALL OBSCURED BY DESIGN. All leading up to a grand begging for more ca$h from Congress….wait for it, it’s inevitable as that old garage door being interfered by CB radios and planes overhead.

CorpsmanuP! (@Tang1967)
CorpsmanuP! (@Tang1967)

Obviously they forgot to add “Accountability” to the classification of diseases as well. This might explain the SES auto- cancellation of demotions when they revised their so- called tracking of discipline system.

It would be interesting to find out how many other “critical lab value” software” have been affected by this debacle. You have other critical lab values that may affect patients that they are required to notify patients if there is even a suspicion of something that may affect patients. This disclosure directly affects “Shulkin Man” (Spoken like the commercial “Trojan Man” emphasis added)

They are the biggest DWEEBS ever recorded on paper!

Hondo
Hondo

This is like putting a new high pressure pump in an old warter system, as soon as it’s turned on there are leaks everywhere. Just thinking out loud……………..

Daniel Gray
Daniel Gray

happened to me at the Ft Wayne Indiana VAMC. The worker was inputting me into the computer for an appointment and she clicked on something and she stated that her whole computer rebooted so she had to do this two or three times to get me into the system for an appointment to see my own PCP (primary care physician)

Maybe they should have done a test run of the system BEFORE they started making changes? I mean that’s what a normal person would have done, but then again nobody has ever accused the VA of being normal.

91Veteran
91Veteran

You are correct. Can you imagine what a disaster Amazon would be if they made changes without testing those changes first?
Either the VA does not have a test bed for these changes, or they were never realistically tested if they do.
I doubt they have a test bed given how widespread this disaster is. Which brings the question, why did it take so long for the VA to notice this? How many reports of failure did their ITs get before someone investigated?

91Veteran
91Veteran

It would be interesting to hear why they never bothered to post this to their National Patient Safety Alert system. It would be also interesting to know the final number of consults that were canceled.
I bet fewer than 100 affected will ever be contacted.

Don
Don

Almost everything that surfaces about the VA is a malfunction, dysfunction or crime! Veterans and the taxpayers deserve far better than what they are getting.

Gary R. Finley
Gary R. Finley

So, what do I think? I think that your sentences are incoherent, And I wonder if you have REALLY passed any BAR exams.

Regardless, I also think that you are a fear monger try to make a buck from veterans who don’t know their way in the “system”. You give nor real, clear, direction to the “system”, you only allude that you have some “secret knowledge”, (at a damn good price), which after purchase is in real life useless and the monies spent, essentially, unrecoverable.

What do I think? I think you have a nice little scam going, and hurt more VETERANS than the VA ever has. THAT’S what I think!!!

91Veteran
91Veteran

Does your VA supervisor know you are commenting on blogs on company time?

namnibor
namnibor

I definitely, unmistakably, smell VA TROLL! We are on an active VA Troll Alert. Under no circumstance should you feed the troll should they multiply like Gremlins after midnight or a water-splashed Gremlin: same result.

Walt
Walt

Keep up the good work Ben!!

ronald
ronald

The endless river …

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