A glitch in the Department of Veterans Affairs' new electronic medical records system caused harm to at least 149 patients at the VA's Spokane, Washington, hospital, including a suicidal veteran forced to call the VA's crisis line in desperation after his psychiatry referral was lost.
A report published Thursday by the VA's Office of Inspector General found that the Oracle Cerner Millennium electronic health records system used at the facility contained an overflow bucket for orders or referrals that didn't match up with the system's drop-down menu of file destinations.
But physicians and hospital staff weren't aware of the folder, referred to as the "unknown queue," so when they ordered any follow-on appointments, specialty care or lab work that didn't match a destination, the orders effectively disappeared from their view.
According to the VA's top watchdog, the engineers at Oracle Cerner built the queue but never told hospital staff about it. And physicians placing the orders never received any warnings that their requests failed to reach their intended recipients.
The flaw resulted in the loss of more than 11,000 requests from October 2020 through June 2021, including two that caused patients "major harm," 52 cases of moderate harm and 95 of minor harm, according to the OIG.
The VA defines major harm as requiring surgery or inpatient care or resulting in disfigurement or permanent disability; moderate harm as needing an increased level of care or extended hospitalization; and minor harm as no injuries but causing unnecessary delays in care.
A VA briefing slide obtained by the OIG likened the problem to sending holiday cards to family and friends, but those labeled with wrong addresses being "stuffed … behind a bush instead of being returned to the sender."
"End result: Your family doesn't know you made the effort and you don't know your effort failed," the slide noted.
According to the report, the problem would not have been discovered had VA employees not filed a trouble ticket regarding the lost orders just four days after the system went live at the Mann-Grandstaff VA Medical Center in Spokane, Washington.
Once it was found, the hospital established a process for canceling and reentering each order in the queue, but staff was still constrained because the queue was visible only to Cerner employees.
"Absent [Veterans Health Administration] actions, the existence of the unknown queue and the unfulfilled clinical orders may not have been identified, and many patient care orders may not have been complete," the VA watchdog wrote.
The VA signed a deal worth up to $16 billion in 2018 with Cerner, purchased by Oracle earlier this year, for an electronic health records system that would be completely compatible with the Department of Defense's medical records system, built by the same contractor.
But the program has been plagued by delays and problems from the start. The initial rollout was delayed twice, first in February 2020 to ensure that users were adequately trained to use the system and then in April 2020 as a result of the COVID-19 pandemic.
In March of this year, the system crashed at Mann-Grandstaff, leading the facility to halt intakes and suspend appointments. That failure was followed by at least six more shutdowns, prompting lawmakers to ask the VA to suspend further implementation until the system worked.
The VA pursued the rollout, taking the system live in Walla Walla, Washington, in March and the Central Ohio Healthcare System in May before announcing another delay to all other locations until at least April 2023.
Prior to the release of the OIG report, VA Secretary Denis McDonough told reporters he had been in "close communication with the inspector general" over the investigation into Mann- Grandstaff and said he was "aware of instances of patient harm."
But he did not say when he learned of the problems and declined to discuss the report, a draft of which was leaked to the Spokane Spokesman-Review. McDonough said that the "back and forth" discussions with the IG over any issues it finds before a report is released are "really really important to us getting better at what we do."
"Our number one concern across the board and VA in VHA, is patient safety," McDonough said during a press conference at VA Headquarters on June 22.
One of the cases of "major harm" caused to a patient involved a homeless veteran at risk for suicide who saw a psychiatrist at Mann-Grandstaff in December 2020 for mental health issues. The patient was prescribed medication and a follow-up appointment, but the appointment request went to the "unknown queue" and the visit never was scheduled.
Weeks after the follow-up visit was to have taken place, the veteran called the Veterans Crisis Line while in possession of the means to take their own life. Veterans Crisis Line employees were able to contact first responders, who saved the veteran.
In a case of minor harm, a veteran with diabetes was referred for education and treatment for his condition, categorized as "uncontrolled." But the appointment never was scheduled. The veteran finally received care 14 months later after another appointment was placed.
The OIG made several recommendations to the VA to address the problems, including that VA Deputy Secretary Donald Remy review Oracle Cerner's failure to inform the VA about the unknown queue, evaluate the technology and fix it.
Remy agreed with the recommendations but pushed back against the watchdog's characterization of the queue, which he said was purposefully created to capture undeliverable orders and was not "indicative of carelessness or negligence."
Remy added that saying 11,000 orders were not filled also was not accurate, noting that many were for X-rays or other radiological orders that aren't made by physicians.
"Electronic Health Record leadership at the time did alert VHA stakeholders of the existence of the queue; the need to manually resolve the issue; and the opportunity to automate an order's confirmation of connection," Remy wrote in a response to the report.
The Department of Defense appears to have had fewer issues with the rollout of its Oracle Cerner system, dubbed MHS Genesis. As of June 11, more than half of the DoD's medical commands employed the system, which officials said was on budget and on schedule for completion by the end of 2023.
Still, the rollout has not been error free. Providers have complained that the information contained in the records isn’t always accurate or complete. According to a DoD Inspector General report released earlier this year, nearly 58% of doctors surveyed said they had concerns about the system.
During the first week of July, the system was blamed for a temporary shutdown of the pharmacy at the Eisenhower Army Medical Center at Fort Gordon, Georgia, and elsewhere within the DoD. During the outage, caused by a system slowdown, pharmacists and technicians filled emergency prescriptions manually, while other prescriptions were deferred, hospital spokesman Scott Speaks said in an email.
"The pharmacy software latency issues did involve the MHS GENESIS system, but we have an ongoing support dialog with their support team to identify and remedy issues as they arise," Speaks said.
Speaks added that the problem was resolved within hours.
Some members of Congress have pressed the VA for answers on the troubled program and moved swiftly last week to condemn the department and Oracle Cerner for their failure to be transparent about the threat to patient safety.
"Yesterday's report by the VA Office of Inspector General shows that we had not been given the whole story," said House Veterans Affairs Committee Chairman Mark Takano, D-Calif., in a press release. "I am extremely disappointed by the lack of transparency and expect better from VA."
"Instead of fixing the issues with the system, VA and Cerner seem much more interested in hiding them. We expect honesty, at the very least, and a plan to resolve the training and referral issues so they never happen again," Illinois Rep. Mike Bost, the committee's ranking Republican, said in another press release.
The Senate Veterans Affairs Committee will hold a hearing Wednesday to examine the problems, calling the VA's program executive director for electronic health record modernization, the VA's deputy inspector general and an executive vice president from Oracle to testify.
"These reports are unacceptable," said Chairman Sen. Jon Tester, D-Mont., in a press release. "They demonstrate a clear failure by the federal government to uphold its commitment to our nation's veterans, and speak to the fact that Oracle Cerner needs to step up its game and deliver a functioning, quality system that'll do right by taxpayers."
– Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime