WASHINGTON (Tribune News Service) — A computer system at Spokane’s VA hospital has caused harm to at least 148 veterans in the Inland Northwest, a draft report by a federal watchdog agency reveals.
The draft report also claims that Cerner Corp., which is being paid at least $10 billion for the electronic health records system, knew about a flaw that caused the harm but failed to fix it or inform the Department of Veterans Affairs before the system launched at Mann-Grandstaff VA Medical Center in October 2020.
VA Secretary Denis McDonough said this spring he was not aware of any harm caused by the system and he would halt its rollout if safety experts determined it increased risk to veterans, yet the draft report shows a VA patient safety team briefed the department’s deputy secretary in October 2021 about the harm and ongoing risks. Despite those warnings, the VA has since launched the system at more facilities in Washington, Idaho, Oregon and Ohio.
The draft report by the VA’s Office of Inspector General, or OIG, found the electronic health record system developed by Cerner failed to deliver more than 11,000 orders for specialty care, lab work and other services — without alerting health care providers the orders had been lost. Those lost orders, often called referrals, resulted in delayed care and what a VA patient safety team classified as dozens of cases of “moderate harm” and one case of “major harm.”
The content of the draft, obtained by The Spokesman-Review from multiple sources, may change by the time it is published. The final report will include responses from VA leadership that are not included in the draft.
The department did not respond to questions about the draft report, but on Friday, after The Spokesman-Review sent the questions, VA officials told Military Times they would delay the system’s planned launch in Seattle, Portland and other large facilities until 2023.
The case identified as major harm occurred after a homeless veteran in his 60s, who had been identified as at risk for suicide, saw a psychiatrist at Mann-Grandstaff in December 2020. After prescribing medication to treat the veteran’s depression, the doctor ordered a follow-up appointment one month later, but the order disappeared in the computer system and the appointment was not scheduled.
Weeks after the follow-up appointment was supposed to occur, according to the report, the patient called the Veterans Crisis Line saying he had a razor and planned to kill himself. First responders reached the man in time to take him to a local, non-VA hospital’s mental health unit, where he was hospitalized.
While the draft OIG report notes that the VA and Cerner have taken steps to limit the number of orders that get lost in what users describe as the “unknown queue,” it calls those mitigation efforts “inadequate” and warns the flaw will continue to put veterans’ safety at risk when the system is deployed in other hospitals and clinics.
Previous OIG reports and reporting by The Spokesman-Review have identified an array of problems with the Cerner system, but the draft report shows the scale of its impact and concludes for the first time that it caused harm to veterans.
“To protect the integrity of our work, the VA Office of Inspector General does not publicly disclose the findings from any of its projects until the publication of a final report,” OIG spokesman Fred Baker said in a statement.
The OIG is…
Read More: Watchdog reveals flaw in Cerner computer system caused nearly 150 cases of harm