Review of Defects in VA’s Computerized Patient Record System Version 27 and Associated Quality of Care Issues

At the request of the former Secretary of Veterans Affairs, this review evaluated testing and deployment of Computerized Patient Record System (CPRS) version 27 (v27). The purposes of this review were to identify the processes supporting the planning, testing, authorization, and implementation of CPRS v27; identify system development control deficiencies; and determine whether Veterans Health Administration (VHA) developed appropriate action plans in response to CPRS v27 defects. Additionally, we assessed the associated risk to patients and VHA actions in response. We recommended that OI&T and VHA: Develop a process to ensure that the selection of Alpha/Beta test sites adequately represents how different VA medical facilities utilize CPRS, while considering the depth and complexity of software changes associated with major releases of CPRS. Establish fully dedicated CPRS testing teams, comprised of system end users and programmers, to augment Alpha/Beta testing of CPRS and to improve the quality and depth of field testing. Implement full system functionality and integration testing of CPRS during the Alpha testing to reduce the risk that CPRS functionality defects will adversely effect patient safety during production (Beta) testing. Adopt a phased implementation approach for installing major releases of CPRS to more effectively mitigate patient safety risks associated with software development defects. We also recommended that VHA establish explicit criteria for determining how soon safety advisories are issued after CPRS problems have been judged to be significant threats to patient safety.