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‘Veterans here are tired of being guinea pigs’: After more than a year, new health record system still causing problems at Spokane VA hospital

Dec. 5, 2021 Updated Tue., Dec. 7, 2021 at 11:12 a.m.

Veteran Jason Ernsting poses with his service dog, Stormy, in front of the Mann-Grandstaff VA Medical Center in Spokane on Nov. 30. Ernsting has been having issues with the VA’s new health record system, which has also caused problems for other vets and providers alike.  (COLIN MULVANY/THE SPOKESMAN-REVIEW)
Veteran Jason Ernsting poses with his service dog, Stormy, in front of the Mann-Grandstaff VA Medical Center in Spokane on Nov. 30. Ernsting has been having issues with the VA’s new health record system, which has also caused problems for other vets and providers alike. (COLIN MULVANY/THE SPOKESMAN-REVIEW)
By Orion Donovan-Smith and Arielle Dreher The Spokesman-Review

Mike Tonkyn had to go to Mann-Grandstaff VA Medical Center three times to get his blood drawn.

Charlie Bourg’s cancer diagnosis was delayed several months, and now he needs surgery.

Heather Hill saw several of her patients suffer withdrawals after going weeks without medications to treat post-traumatic stress disorder.

Others went months without insulin, accidentally got a double-dose of remdesivir to treat COVID-19 or went through withdrawals after going without anti-seizure medication.

More than a year after the Department of Veterans Affairs began testing a new electronic health record system at Mann-Grandstaff VA Medical Center, veterans who rely on the Spokane hospital and the health care workers who count on the software to do their jobs say flaws in the system continue to threaten patients’ safety, even as VA last week announced plans to roll it out in Walla Walla and other cities early next year.

Some Mann-Grandstaff employees believe it’s only a matter of time before a death or serious harm occurs as a result of problems with the system, which they use to coordinate care and track patients’ medical histories, test results, medications and other information.

Monica McLaughlin and Gary Bilendy are both veterans and nurses at Mann-Grandstaff VA Medical Center in Spokane.   (DAN PELLE/THE SPOKESMAN-REVIEW)
Monica McLaughlin and Gary Bilendy are both veterans and nurses at Mann-Grandstaff VA Medical Center in Spokane. (DAN PELLE/THE SPOKESMAN-REVIEW)

“This is dangerous, and they’re going to inflict it on my fellow veterans if we just sit back and we’re silent,” Monica McLaughlin, a Navy veteran and nurse at Mann-Grandstaff, told The Spokesman-Review.

When VA announced in June 2017 it would award a $10 billion contract to Cerner Corp. to replace its existing electronic health record system, then-President Donald Trump promised it would mean “faster, better and far better quality care” for the 9 million veterans VA serves and called the move “one of the biggest wins for our veterans in decades.”

Instead, more than a year after the department started piloting the system at Mann-Grandstaff and its outpatient clinics in Coeur d’Alene, Sandpoint, Wenatchee and Libby, Montana, veterans and VA employees say it continues to cause safety risks and delays in care for 28,000 veterans and has left their roughly 1,700 employees exhausted and demoralized.

Despite deciding earlier this year the system was not ready to safely deploy at other VA facilities, which still use an older system, the department has continued to use the Inland Northwest as a testing ground to help other clinics and hospitals avoid the problems that have made about two-thirds of Mann-Grandstaff employees consider quitting, according to a recent internal survey.

VA Secretary Denis McDonough has said he remains committed to the program, which aims to improve coordination between VA and Defense Department medical facilities by adopting a similar system in both agencies. The program, far behind schedule, is now projected to cost at least $21 billion.

Meanwhile, two former senior VA officials who oversaw medical records say the project was misguided from the start and unlikely to improve on the system it was meant to replace.

In more than 40 interviews with The Spokesman-Review, veterans and current and former VA employees described a system that slows treatment and threatens patient safety more than a year after a transition VA officials described as “flawless.” While some declined to speak on the record, fearing retribution, others chose to come forward after months of warnings they said fell on deaf ears within VA, and because they believe the system’s flaws endanger veterans.

The problems described in those interviews have been corroborated by congressional oversight hearings, reports from government watchdog agencies and a “strategic review” VA conducted earlier this year.

“It’s got to be fixed,” said Bob Bossi, a 75-year-old Army veteran in Coeur d’Alene. “Veterans here are tired of being guinea pigs. Either give us back the old system or fix this one.”

Like other veterans who spoke with The Spokesman-Review, Bossi has struggled to access and use a new online portal to contact his doctors, schedule appointments and reorder prescriptions. In interviews, veterans almost universally praised the efforts of Mann-Grandstaff employees, who collectively worked 61,000 hours of overtime in fiscal year 2020.

In written responses to questions from The Spokesman-Review, VA Press Secretary Terrence Hayes emphasized that VA prioritizes patient safety and is working with Cerner “to address the numerous issues identified by the staff and leadership” at Mann-Grandstaff.

“We have listened to our team at Mann-Grandstaff and will continue to provide support and resolutions for Mann-Grandstaff while applying their lessons learned to future site deployments,” said Hayes, declining to give a specific timeline for resolving the issues.

A spokesman for Cerner declined to answer detailed questions on the record, deferring to VA. But in a written statement, Brian Sandager, general manager and senior vice president of Cerner’s government services division, said the company “remains dedicated to VA and takes our responsibility to Veterans and providers seriously.”

“We continue to engage on-site at Mann-Grandstaff, working alongside providers and staff to gather lessons learned and implement changes as directed by VA,” Sandager said. “It’s important to get this right and we are committed to the mission.”

McDonough, who took the helm at VA in February, said Nov. 9 the department is “listening very closely to our personnel in Spokane” and thanked employees at Mann-Grandstaff for their “forbearance” and “dedication to testing out this new capability,” assuring them “the lessons that you’re providing us will be implemented before we deploy to any further sites.”

After initially planning to roll out the Cerner system at its much larger network of facilities in Western Washington shortly after Mann-Grandstaff, VA says it will deploy the system only when each facility has completed training in a simulated “sandbox” environment that doesn’t involve real patients.

Although the two former VA officials say Mann-Grandstaff could go back to the system other facilities still use – known as VistA – within a matter of days, Hayes confirmed Thursday that “VA does not plan for Mann-Grandstaff to revert back to VistA while the issues are being resolved.”

According to a schedule VA released Wednesday, which the department said is subject to change, the system is slated for deployment in March 2022 at facilities in Walla Walla and Columbus, Ohio, followed by others throughout Western Washington and in Idaho, Oregon, Alaska, Ohio and Michigan.

‘The Cerner system works’

On the morning of Nov. 2, VA Deputy Secretary Donald Remy, who was confirmed by the Senate in July to lead the health record program, told a House subcommittee charged with overseeing the effort that the department was on track and “learning from the implementation mistakes of the past.”

“The Cerner system works,” Remy said, “and I believe we’ve properly positioned it for success.”

An hour later in Spokane, the Cerner system went down.

Hayes confirmed that the outage, which lasted 80 minutes, followed 10 days in September and October where “parts of the Cerner system were inaccessible.”

In addition to four “full outages tied to the Cerner system” since it was implemented at Mann-Grandstaff on Oct. 24, 2020, Hayes said there have been “several downtime episodes where access to the Cerner system or part of the Cerner system was impacted,” either by a Cerner outage or a connectivity problem related to systems at VA or the Defense Department, which started transitioning its health care system to a similar Cerner platform in 2017.

When the system goes down, work grinds to a halt across the medical center and its clinics.

Gary Bilendy, a Marine Corps and Army veteran who has worked as a nurse for nearly 20 years and the past five at Mann-Grandstaff, said because staff members don’t know if the system will take minutes or hours to get restored, they have to write notes and enter information into a patient’s chart by hand, then enter it into the Cerner system or scan it in when it comes back online. That process takes extra time as the workers take special care to enter patients’ information correctly.

“I am a veteran, and I like taking care of veterans,” Bilendy said. “And I feel like we’re the last line of defense. If they get good health care, it’s the people doing it, not the VA.”

Mike Tonkyn served in the Marines in 1968-69 and goes to the VA for annual physicals. He’s one of dozens of vets who talked with The Spokesman-Review about their experiences with the new electronic health record system.  (COLIN MULVANY/THE SPOKESMAN-REVI)
Mike Tonkyn served in the Marines in 1968-69 and goes to the VA for annual physicals. He’s one of dozens of vets who talked with The Spokesman-Review about their experiences with the new electronic health record system. (COLIN MULVANY/THE SPOKESMAN-REVI)

Mike Tonkyn counts himself lucky to be “pretty darn healthy,” but the 71-year-old Spokane resident goes to Mann-Grandstaff for a yearly checkup, aware that he is at risk of diabetes, cancer and other health problems because he was exposed to the toxic herbicide Agent Orange during his time in the Marines.

In September, Tonkyn headed to the lab at Mann-Grandstaff after his doctor ordered some blood work, but when he sat down and rolled up his sleeve, the phlebotomist told him they couldn’t do a blood draw because the order was missing, apparently lost in the new health record system.

When he returned several days later to try again, the waiting area was packed. After a while, an employee came out and explained that the Cerner system had gone down and anyone who wasn’t there for an urgent blood draw would have to come back another day.

“They were just as frustrated as us,” said Tonkyn, who finally got his blood drawn on his third trip to the lab. “Of course, there were some noncognizant people in the waiting room yelling at them. I could see why their morale would go down.”

VA’s Office of Inspector General, an independent watchdog agency within the department, warned in an April 2020 report that “critical physical and information technology infrastructure upgrades had not been completed at Mann-Grandstaff” and its associated clinics.

Current and former VA employees say the outages are just one example of a system that was brought to the Inland Northwest without being proven safe and before VA facilities had even the basic IT infrastructure – like computers and reliable high-speed internet connections – they needed to use it.

Despite VA twice delaying the rollout in Spokane – originally scheduled for March 2020, just as COVID-19 arrived in Spokane County – Carolyn Clancy, who served as VA’s acting deputy secretary until Remy’s confirmation, acknowledged to lawmakers in July that Mann-Grandstaff “probably was not ready to go live.”

While D.C. officials debated and delayed the Cerner rollout, staff at Mann-Grandstaff were treating veterans sick with COVID-19 from the Spokane Veterans Home, which in April 2020 was in the midst of a large outbreak that claimed 10 lives and sent many residents to the medical center for hospitalization. The virus would find its way back to the care home just a few months later.

Oversight agencies, lawmakers and VA employees raised numerous red flags in the months ahead of the Oct. 24, 2020, “go-live” date at Mann-Grandstaff, but the department forged ahead even as the staff faced the additional strain of providing care during a pandemic.

“Despite the uncertainties of COVID-19, we have endeavored to move forward with no stoppage in work, no pause, no delay, and without safety issues to VA facilities and trainers,” John Windom, executive director of VA’s Office of Electronic Health Record Modernization, told lawmakers Sept. 30, 2020, three weeks before the Cerner launch at Mann-Grandstaff.

In that same congressional hearing, Travis Dalton, then president of Cerner’s government services division, said the company was “pleased with our accomplishments to date” and would “continue our march forward to the deployment of the electronic health record solution next month at Mann-Grandstaff.”

“Many lessons have been learned and incorporated,” Dalton told lawmakers. “We are ready.”

In a July hearing, Clancy suggested Windom’s office, which led the Cerner rollout until a reorganization VA announced Wednesday, had expected a rocky transition and figured problems were inevitable.

“I think they believed that it was important not to keep delaying the initial deployment, that we would learn a great deal, and they didn’t expect it to go well,” she said. “I would have to surmise that they believed that we should get on with it and learn more, because this is how we actually deploy systems like this on the ground.”

Ed Meagher, who served as VA’s deputy chief information officer and chief technology officer between 2001 and 2006, said the department could have foreseen the problems by building a model based on what it knew about VA and Cerner’s IT infrastructure and the expected workload.

“From a technology point of view, it’s absolutely malpractice that you haven’t modeled this,” Meagher said in an interview. “If you don’t have that, you’re working off of Cerner marketing material, and you’re putting the future of the VA at stake.”

‘They are so lucky no one died’

For veterans enrolled at Mann-Grandstaff, the most immediate change with the advent of the Cerner system was a new online portal to schedule appointments, order prescription refills and send secure messages to their doctors.

To inform veterans of the change, VA hosted virtual “town hall” meetings on three consecutive Wednesdays in October 2020. Joe Harmer, a 76-year-old Army veteran who lives in Greenacres, was on all three calls and said VA and Cerner representatives spent more time extolling the virtues of the new system than explaining how to use it.

“You couldn’t believe how much they glad-handed each other,” Harmer said. “I mean, ‘This is the greatest program, and I want to introduce so-and-so, they’re with that company and, wow, this is gonna be dynamite.’ And they’d come on and just romance the hell out of it.”

Harmer relies on several prescriptions to treat post-traumatic stress disorder related to his time in Vietnam and peripheral neuropathy, a nerve condition linked to Agent Orange exposure he describes as feeling like walking barefoot on broken glass. When he struggled to log into the new portal to reorder his medications, he drove to Mann-Grandstaff with his computer and asked for help, but even the VA employee there couldn’t figure out how to log in.

Sarah Simonson, 41, served in the Air Force and works as the sole veterans service officer in mostly rural Douglas County in central Washington, where the more limited services of the Wenatchee clinic make the online portal a vital tool for veterans to access care.

While it’s not part of her official scope of work, Simonson said she’s frequently had to help veterans log into the portal over the past year, as VA – like other health care providers – has scaled back in-person treatment and encouraged patients to use online services.

“That transition has been extremely difficult, and I don’t consider myself technologically inept,” she said. “It was difficult enough for me.”

In interviews, more than a dozen veterans described struggling to navigate a confusing series of login screens. Those who successfully logged in experienced repeated freezing and a messaging system that worked only intermittently.

One of the most common problems after the Cerner transition was that medical records and prescriptions failed to transfer to the new system, forcing employees to enter that information manually. Many veterans count on VA to send their prescription refills by mail, and in some cases incorrect information resulted in medication being mailed to the wrong addresses.

Elizabeth Parker waited as long as she could to log into the new patient portal, knowing it might have some kinks. When she finally logged in for the first time, the 63-year-old Army veteran realized none of her prescriptions had transferred to the new system.

Running low on important medications, she frantically called her doctor, the pharmacy at Mann-Grandstaff and finally the office of U.S. Rep. Cathy McMorris Rodgers, a Spokane Republican. It took a week before a VA doctor manually entered her prescriptions into the system.

In a hearing Nov. 2, McMorris Rodgers said her office had by then received 138 complaints from veterans directly related to the Cerner system.

The prospect of not having her medications was immensely stressful for Parker, who has post-traumatic stress disorder and diabetes and is a breast cancer survivor. It took a week of crying and advocating for herself on countless phone calls to get her medications. The fighting took a toll, she said, and left her contemplating suicide.

Earlier this fall, Parker had to go through the same process again to get supplies to treat her diabetes, which were also not listed in her patient portal.

“When I am trying to stick up for myself, I am pretty feisty,” Parker said. “But what about the people that can’t do that, who are really sick and old?”

Heather Hill is a psychotherapist and the owner of Central Washington Veteran’s Counseling in Wenatchee. Here she poses for a photo in her office on Wednesday in Wenatchee, Wash.  (Tyler Tjomsland/The Spokesman-Review)
Heather Hill is a psychotherapist and the owner of Central Washington Veteran’s Counseling in Wenatchee. Here she poses for a photo in her office on Wednesday in Wenatchee, Wash. (Tyler Tjomsland/The Spokesman-Review)

Heather Hill, a psychotherapist in Wenatchee, said many of her patients went for months without important psychiatric drugs and other medications after the Cerner transition.

“At the very beginning, all of them got screwed,” Hill said. “Things that were preserving people’s lives now were just falling through the cracks.”

Hill, who owns Central Washington Veterans Counseling and works with VA patients through a program that lets veterans see private providers, said the scariest case was a veteran of the wars in Iraq and Afghanistan with post-traumatic stress disorder, nerve damage and a traumatic brain injury from being hit by an improvised explosive device.

Hill said that veteran, a Bronze Star recipient, called her two months after he stopped receiving his prescriptions from VA, suffering severe withdrawals from multiple psychiatric and nerve pain medications and confused about how to get refills through the new system.

“My fear was that somebody was going to die.” Hill said. “They are so lucky no one died.”

In response to a question from The Spokesman-Review in February, Laura Kroupa, then chief medical officer for VA’s Office of Electronic Health Record Modernization, said approximately 24,000 veterans received medications through the Spokane VA when the Cerner system launched in October 2020. As of Feb. 9, more than three months later, Kroupa said Mann-Grandstaff reported providing pharmacy services to roughly two-thirds of those veterans.

When veterans had trouble ordering prescriptions or messaging their providers through the online portal, they often turned to calling VA, but the influx of calls left the phone lines overwhelmed. Out of options, many wound up going to Mann-Grandstaff or its clinics for help.

Jerry Ring, a 77-year-old Army veteran who lives in Spokane, gave up on the new patient portal after seeking help from a patient advocate at Mann-Grandstaff and has taken to walking into the pharmacy with a bag full of pill bottles when he needs refills.

Dick Edwards, an 88-year-old “atomic veteran” with cancer linked to radiation exposure from his Army service during nuclear bomb tests in the Marshall Islands, was used to sending his doctor secure messages through the old patient portal. After making several calls that were routed to other VA facilities, apparently because phone lines in Spokane were overwhelmed, he gave up on the new web portal and now drives from his South Hill home whenever he needs help.

“It’s just utter chaos,” Edwards said. “They really fouled things up when they changed that. It’s not good at all.”

‘I feel so sorry for the employees’

This summer, a patient in the Mann-Grandstaff urgent care went into a fatal heart rhythm, and the team jumped into action to save their life.

McLaughlin, a nurse there, was caring for additional patients, providing backup and looking on while the team worked to save the veteran’s life.

The prepared medication was ready to go, rolled out on a cart. The team had practiced for these moments.

The physician set up the medication drip and tried to scan it into the patient’s health record. It wouldn’t scan. More staff came down to help. In the meantime, the experienced team began administering the medication they knew would save the patient’s life, all while trying to make sure the proper dose got recorded in the patient’s record.

The Cerner system has created an added stress when it comes to transferring patients out of the hospital. Mann-Grandstaff does not have a 24-hour emergency department, and some patients have to be transferred to other local hospitals for care if it exceeds the service capacity at VA.

When the patients are transferred, it’s vital that their records are accurate, so they don’t receive a double-dose of certain medications when they arrive at the new hospital, McLaughlin said.

This has meant, at times, that VA staffers have had to write the dose information, manually enter it into a patient’s record after the fact and send details via fax after the patient has left in the ambulance. It also has meant a stressful phone call to an already busy nurse at the transfer hospital to communicate what the Cerner system will not.

“Time is of the essence with these meds, with the right dosage and time,” McLaughlin said. “Something as simple as an antibiotic, if they get a double dose, they could have consequences.”

The urgent care clinic at Mann-Grandstaff has become a repository for patients who can’t reach their primary care doctor, especially when they can’t get refills for important prescriptions for things like insulin, antidepressants and medicine to treat heart conditions or prevent seizures. And while patients coming to urgent care for medication refills is something that happened pre-Cerner, the new system has exacerbated the issue, McLaughlin said.

Pharmacy staff sometimes send veterans home with a short-term supply of their medications while they sort out errors in the Cerner system. When that doesn’t happen in time, hospital employees often must deal with the results, caring for patients suffering withdrawals or other effects of missing medications.

Staff who spoke to The Spokesman-Review said that the full impact of the new electronic health record system is likely not fully known due to the rural nature of the Inland Northwest VA region. Many veterans who use the Spokane VA live counties away.

“We don’t know the effect this has had on veterans in rural areas with limited means of communication and limited means of travel,” McLaughlin said.

McLaughlin recalled one veteran who hadn’t received their regular insulin supplies for half a year, who arrived in urgent care looking for treatment. When this happens, staff file patient safety reports.

In an email sent to staff Oct. 8, Mann-Grandstaff Director Robert Fischer said employees had filed 576 patient safety reports related to the Cerner system in the fiscal year that ended Sept. 30. Some of those reports are likely duplicates warning about the same issue, but despite repeated requests from Congress, VA has yet to release the details of those reports.

In that same email, Fischer emphasized to staff that patient safety is a top priority and “care delivery moves at the speed of safety at Mann-Grandstaff.”

As a result of that cautious pace, doctors and nurses have seen fewer patients. In a hearing just before the Cerner launch, Fischer told lawmakers Mann-Grandstaff had “an initial marching order that will put us at 25% of productivity at least for the first week.”

A July report by VA’s Office of Inspector General said while the department had failed to provide reliable data to show just how sharply productivity had fallen, Mann-Grandstaff leaders estimated providers were seeing half as many patients as they did before the facility made the switch to the Cerner system. An analysis of available data in the report noted that although some of the drop-off was due to the pandemic, the new system had caused a “significant decrease” in productivity.

VA spokesman Hayes declined to provide details on how productivity has changed since the Cerner launch, citing “intrinsic differences between the two platforms and how appointments and encounters are counted,” but said trends show an “increase in provider appointments and capacity compared to the first three months following initial implementation.”

While Fischer told lawmakers in September 2020 that Mann-Grandstaff had hired more than 100 additional staff to offset that lost productivity, veterans described having to wait longer than usual for appointments.

The failure of VA facilities to accurately report wait times was the subject of a national scandal in 2014, yet Mann-Grandstaff has been removed from the VA wait time website since the Cerner launch.

When The Spokesman-Review asked why that information was not publicly available, Hayes said the facility was “exempted” from reporting wait times as a result of the transition to the Cerner system. He added the Veterans Health Administration is “exploring the different functionality” of the Cerner system to determine how to measure wait times.

A survey of 833 Mann-Grandstaff employees, whose results were shared internally in October and obtained by The Spokesman-Review, shows the Cerner system has had a devastating effect on employee morale: 83% of staff said their morale had worsened as a result of the Cerner system, 81% said it had increased burnout and nearly two-thirds said it had made them consider quitting.

Jason Ernsting, a Navy veteran who lives in Nine Mile Falls, sees that impact each time he goes to Mann-Grandstaff.

Ernsting, 53, relies on VA to treat post-traumatic stress disorder and debilitating pain from a back injury from his time in the Navy. After living in several parts of the country, he raved about the care he’s received in Spokane and called Mann-Grandstaff “the best VA out of all of them.”

“I feel so sorry for the employees,” Ernsting said. “I don’t see them smiling anymore. They’re beaten up, because they spend too much time having to reboot their system, wait for that to get up, or something that used to take two to three clicks now takes four times more.”

When care is delayed

Along with Cerner’s electronic health record system, Mann-Grandstaff also adopted a new scheduling system developed by Cerner, which was piloted at a facility in Columbus, Ohio, before the rollout in Spokane.

“We should all be proud of the (Cerner scheduling system) deployment,” Windom told lawmakers in September 2020, adding it “makes the scheduling experience and appointment management seamless for our veterans, increases scheduler productivity and tracks provider utilization to ensure efficient use of VA resources.”

The reality was just the opposite, according to a November report from VA’s Office of Inspector General that found the department “knew of but did not fully resolve significant limitations before and after implementing the system at the Columbus and Spokane facilities, leading to reduced effectiveness and increased risk of patient care delays.”

The VA’s new electronic health record has led to late diagnoses, missed medications and severe impacts for veterans. For Charlie Bourg, at left, this meant his cancer referral and diagnosis was delayed several months.  (DAN PELLE/THE SPOKESMAN-REVIEW)
The VA’s new electronic health record has led to late diagnoses, missed medications and severe impacts for veterans. For Charlie Bourg, at left, this meant his cancer referral and diagnosis was delayed several months. (DAN PELLE/THE SPOKESMAN-REVIEW)

Charlie Bourg knows he’s been a thorn in the side of Mann-Grandstaff administrators since he and other veterans staged a protest outside the building in 2017 to demand more transparency from the administration and better care, but the 67-year-old Army veteran from Chewelah, Washington, has nothing but good things to say about the VA health care workers he has counted on for more than a decade.

During a routine checkup in December 2020, Bourg’s primary care doctor at Mann-Grandstaff put in a referral for him to see a urologist in the same building after noticing the results of a blood test for prostate health.

It wasn’t the first time this had happened, and in the past the specialist’s office had reached out to Bourg to schedule an appointment. But that never happened, and when he saw his doctor for a different issue nine months later, she realized the referral had never reached the urology clinic.

Within a week, Bourg finally saw the urologist. Soon after, a biopsy found that he had an aggressive form of prostate cancer. He’s scheduled for surgery in January and hopes an upcoming test will find the cancer hasn’t spread, but he’s preparing for the prospect of radiation.

After seeing the biopsy results, Bourg said, his doctor told him the cancer likely could have been caught months earlier had the test been done when she first ordered the referral.

The Spokesman-Review could not confirm the cause of the lost referral, but in a July report VA’s Office of Inspector General quoted an official in the Office of Electronic Health Record Modernization saying that the version of the Cerner system employees were trained on was missing the “referral management” component, an issue the official admitted was “the biggest gap” in the training program.

“We’ve seen Cerner do so much damage to veterans where they’re not getting the care they need,” Bourg said, before quickly pivoting to the impact on health care workers. “They’re understaffed, they’re being run ragged and they don’t have any faith in the system anymore.”

Current and former Mann-Grandstaff employees reported a growing number of their colleagues quitting or reducing their hours in response to burnout and concerns about the Cerner system.

Hayes confirmed there has been “a recent trend of increasing staff departures from Mann-Grandstaff VAMC for a number of possible reasons, including but not limited to retirements, transfers to other VA facilities and resignations,” noting that burnout and resignations due to the pandemic are a problem throughout the U.S. health care sector.

In his Oct. 8 email, Fischer thanked his employees for helping to make the electronic health system “safer and more efficient” for all VA patients, but acknowledged that the Cerner transition has been difficult, testing “our collective resilience.”

‘We are the beta test’

According to VA officials, Congress and federal watchdog agencies, a major cause of all these problems has been inadequate training for VA staff and a lack of outreach to veterans to explain the perks of the Cerner system.

In a survey conducted by the Office of Inspector General after staff had used the new system for two or three months, just 5% of employees said they were able to use all four core functions of the system: finding relevant patient information, sharing that information, navigating the system’s different applications and documenting patient care.

The July report also noted VA officials had altered the results of a Cerner proficiency test to show 89% of employees had passed in their first three attempts. In reality, only half that amount – 44% – had passed in three tries or fewer.

In his Oct. 8 email to staff, Fischer said Mann-Grandstaff employees had attended 44,238 staff hours of training on the new system, or an average of about 26 hours for each of the roughly 1,700 employees.

But some employees at Mann-Grandstaff and a doctor who was involved in testing the Cerner system starting in 2017 say the real problem is the system they are being trained to use was never designed to meet VA’s needs.

In a lecture to the Association of VA Anesthesiologists in October, Art Wallace, the chief of anesthesiology at the San Francisco VA Medical Center, said the problems with the Cerner system start with the contract. The Spokesman-Review obtained slides and the text of Wallace’s lecture after they were shared among current and former VA employees.

In his presentation, Wallace explained that while most commercial electronic health record systems are essentially accounting software “with a text editor tacked on,” VistA – the system replaced by Cerner in Spokane – was written by clinicians with the goal of providing the best care possible, “with some accounting tacked on.”

“Cerner is providing an accounting system,” Wallace said. “The VA is trying to buy an electronic health care record system to provide clinical care. If the two parties have fundamentally different ideas of the purpose of a system, the customer will not get what they want.”

Cerner’s system is used in some 27,000 facilities around the world, but like other commercial health record systems, it is designed to bill insurance companies to pay for patients’ care.

Meanwhile, VA is essentially a single-payer health system akin to the United Kingdom’s National Health Service.

That difference, Meagher said, is at the crux of the problems Mann-Grandstaff employees are having with the Cerner system, which requires far more steps for each process than VistA does.

“What Cerner does best is capture billable events via exhaustive questions and back-and-forth as you input things,” said Meagher, the former VA deputy chief information officer. “That’s what ties them up. They’re answering questions that are meaningless to them. They’re very meaningful to a commercial organization, because that’s how they get paid, but they’re meaningless to the VA.”

Wallace said in the lecture he was one of some 500 VA employees who made 10 weeklong trips to Cerner headquarters in Kansas City, Missouri, starting in 2018 to provide feedback on the system. Over the course of those sessions, Wallace said, he and other doctors made requests to improve the system that were repeatedly denied.

“When we examined forms and asked Cerner how long they took to fill out, on one form there were thousands of questions and Cerner estimated it would take 90 minutes,” Wallace said in the lecture. “We indicated the nurse had under five minutes to examine the patient, educate them, and fill out the form. Cerner indicated we should hire more staff.

“Rather than make the software compatible with people,” he said, “Cerner expects the VA to make the people compatible with their software.”

Other requests that were denied, according to Wallace’s lecture, included adding a field to specify a patient’s diagnosis when booking a surgical procedure – “essential in planning a case” – using consistent terms throughout the system and removing a “birth weight” field to make room for more relevant information.

Wallace told his colleagues he was concerned enough about the new system’s effect on anesthesiology, in which “loss of situational awareness from computer problems is dangerous,” that he pushed to visit Mann-Grandstaff and was eventually allowed to test the system for two days in Spokane.

“Testing at the Spokane VA identified more than 80 problems that made the system unusable and unsafe for clinical care,” he said, citing the example that 80% of common anesthesia medications were missing from the system. “None of the configuration changes we had agreed on were made.”

The Cerner system that launched at Mann-Grandstaff in October 2020 was what VA officials called “capability set 1.1,” an unfinished version of the software that did not include functions needed in larger hospitals. Months after go-live, VA officials said the parts of the system deployed in Spokane were working well.

“In the areas of the hospital that are very similar to the commercial system – for example, urgent care and inpatient care – it’s going very smoothly,” Kroupa told lawmakers in April.

But McLaughlin and Bilendy told The Spokesman-Review the system still crashes and glitches regularly, still won’t allow providers to scan some medications and takes much longer to use than VistA.

Kroupa retired in September and declined to comment for this story.

Current and former employees described training exercises that couldn’t be completed in the months leading up to October 2020 because the system wasn’t fully functional, while they were assured things would be ready by the go-live date.

Wallace said in his lecture VA and Cerner management did not allow testing of the software used at launch in Spokane, “violating multiple best practices in clinical informatics.” While he and other doctors in the rest of the nation’s VA facilities are still using VistA, Mann-Grandstaff employees continue to fight the erratic new system, coming up with workarounds and sharing them with each other.

“We are the beta test,” Bilendy said. “That’s what we’re doing now, and it’s not going well.”

McLaughlin likened the rollout of the Cerner system to the military’s development of the V-22 Osprey aircraft, which killed 30 people in training exercises between 1991 and 2000 and cost billions of federal dollars.

Despite the 576 Cerner-related patient safety reports, many requests to change the system have apparently been ignored or denied. One reason is that changes aren’t entirely up to VA.

“Changes are something that we are usually negotiating with the Department of Defense,” Clancy said in a July hearing. “We have to notify them because, again, we’re trying to create this seamless experience for the servicemember who then becomes a veteran and so forth, so we don’t want to have two unique, customized systems.”

More than a year after the Cerner launch, VA officials have continued to chalk up the problems to inadequate training.

“We’re trying to make sure that we provide them with the information that they need,” Remy said in a November hearing, “so that they can understand how the system can actually make their jobs easier.”

For experienced health care professionals, some of them veterans themselves, this feels like gaslighting.

“These are people used to plugging bullet holes or doing their jobs under fire before they were medical professionals,” McLaughlin said. “When they tell us we don’t understand – or it’s a lack of comprehension and if we would just learn – we’re talking about people who worked with advanced weapons systems in the military.”

U.S. Rep. Kim Schrier, a Democrat who represents Wenatchee, used a Cerner system in her work as a pediatrician at Virginia Mason Medical Center before entering Congress in 2019.

After meeting with doctors and nurses at the Wenatchee VA clinic Nov. 9, Schrier said the problems they described were not a matter of user error.

“I don’t think this is a lack of training,” Schrier said. “I think this is a Cerner problem. It is the system that has a problem.”

Roger Baker, who served as VA’s chief information officer from 2009 to 2013, said the main mistake VA leaders have made is failing to understand why health care workers have not embraced the new system.

“It’s because they will not compromise one -tenth of 1% of care quality for veterans in order to roll out a new system,” Baker said. “The medical people just will not do that, and you can look at that as resistance to change, but I think it’s resistance to any reduction in care quality for the veterans they care for.”

On Wednesday, VA announced it would eliminate the Office of Electronic Health Record Modernization in favor of a new “program executive director” and three other new management positions.

In a progress report that accompanied the reorganization move, Remy acknowledged deploying a new health record system can be “highly disruptive” and restated that “VA remains committed to the Mann-Grandstaff implementation.”

According to an updated schedule included in the progress report, VA will deploy the Cerner system in Columbus, Ohio, on March 5, followed on March 26 by the Walla Walla VA Medical Center, including its clinics in Lewiston, Richland, Yakima and three more in northeastern Oregon.

The next rollouts are slated for Roseburg and White City, Oregon, on June 11, Boise on June 25 and Anchorage, Alaska, on July 16.

VA’s Puget Sound facilities, including its Seattle and American Lake hospitals and eight other facilities that serve about 120,000 veterans, are scheduled to make the switch Aug. 27. The final planned launches of 2022 are in Battle Creek, Saginaw and Ann Arbor, Michigan, on Oct. 8 and in Portland on Nov. 5.

Later on Wednesday, McDonough testified before the Senate VA Committee for an end-of-year update on the department.

“Our mission at VA is very simple,” he said in his opening remarks. “We must serve veterans, their families, caregivers and survivors as well as they have served us. That’s the promise we make at VA.”

Like other veterans who rely on Mann-Grandstaff, Joe Harmer, the Army veteran from Greenacres, said he’s worried the Cerner system could jeopardize that mission as VA expands its use around the country.

“The VA’s telling them they have to take on this system, but they’re just gonna punish these other veterans in these other areas if they do it, because it’s just not working,” Harmer said. “I really feel that the VA is giving us a second chance to die for our country.”

Orion Donovan-Smith's reporting for The Spokesman-Review is funded in part by Report for America and by members of the Spokane community. This story can be republished by other organizations for free under a Creative Commons license. For more information on this, please contact our newspaper’s managing editor.

Arielle Dreher's reporting for The Spokesman-Review is primarily funded by the Smith-Barbieri Progressive Fund, with additional support from Report for America and members of the Spokane community. These stories can be republished by other organizations for free under a Creative Commons license. For more information on this, please contact our newspaper’s managing editor.

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