WASHINGTON – Washington lawmakers reacted with outrage after a report published by an internal Department of Veterans Affairs watchdog Friday confirmed a computer system at Spokane’s VA hospital has caused nearly 150 cases of harm, while another report found VA leaders in charge of training users on the new system misled investigators.
The Spokesman-Review previously reported the cases of patient harm based on a draft report by the VA Office of Inspector General, an independent oversight body charged with investigating the department, that found a flaw in the system caused delays in patient care when referral orders for follow-up care effectively went missing. The report alleges Cerner Corp., which is developing the system under a $10 billion contract, knew about the issue but did not fix it nor warn VA of the risks it created.
The second report found two senior VA officials gave the Office of Inspector General inaccurate information during a previous investigation into problems with training employees to use the new system. In one case, the officials provided data claiming 89% of employees had passed a proficiency test, when in reality fewer than half that many – just 44% – had shown they could use the Cerner system. The report concluded that while the officials didn’t intentionally mislead investigators, their “lack of diligence” hampered oversight.
Tech giant Oracle acquired Cerner, now known as Oracle Cerner, in a $28.3 billion deal that closed in June. The company faces the task of addressing a wide range of problems with the electronic health record system that have reduced access to care and left VA employees exhausted and demoralized since the system was launched in Spokane in October 2020.
Lawmakers who represent the Inland Northwest cities where the system has been deployed – including Spokane, Wenatchee and Walla Walla – were quick to respond to the reports’ findings on Friday, with Rep. Cathy McMorris Rodgers, R-Spokane, calling them “even worse than I suspected.”
“I am appalled by all parties involved in this disaster,” she said in a statement, calling Cerner’s failure to brief VA leaders and train health care providers on the feature that caused referrals to go missing “reprehensible.”
“As for VA leadership, their manipulation of training and system proficiency data to save face has put veteran safety at risk and is morally bankrupt,” McMorris Rodgers said. “This agency has completely lost sight of its mission and done irreparable damage to my trust in their ability to deliver results for Eastern Washington veterans.”
Most of the 149 cases of harm were classified as “minor,” but there were 52 incidents of “moderate” harm – requiring a longer hospital stay or more care – and two cases of “major” harm, defined by the VA as “permanent decrease in the body’s functioning or disfigurement” that “requires surgery or inpatient care.” The draft report included only one case of major harm, in which a veteran known to be at risk of suicide was not scheduled for a follow-up appointment because of the flaw in the system and later called the Veterans Crisis Line threatening to kill himself.
The findings of the second report, including the VA training officials manipulating proficiency test results, were disclosed during a Senate VA Committee hearing in July 2021. VA Press Secretary Terrence Hayes declined to say whether the two officials were still employed by the department, saying in an email, “VA does not share personnel-related details about its employees with the public or press.”
Sen. Patty Murray, a Washington Democrat who sits on the Senate VA Committee, said the Cerner system should not be deployed at other sites “until its glaring errors are resolved.” After The Spokesman-Review gave the VA an opportunity to respond to the draft report revealing harm and ongoing risk to veterans caused by lost referrals, the…
Read More: Washington lawmakers outraged after watchdog reports find computer system harmed