Shawn Vestal: Failures of leadership compound VA records debacle

They call it the “unknown queue.”

This queue, a part of Cerner Corp.’s beleaguered new electronics records system at Mann-Grandstaff VA Medical Center, is a computerized dead-letter office where requests for treatment were mistakenly routed, never to be seen again.

Between October 2020 and June 2021, more than 11,000 requests for clinical care at the VA vanished into this black hole instead of going to the provider who could deliver the care.

Referrals to specialists never arrived. Requests for diagnostic scans didn’t show up. Follow-up treatment was never scheduled.

In 149 instances, according to the VA’s Office of Inspector General, patients suffered harm as a result. Most of those cases were considered minor or moderate, but two incidents were classified as major.

In one of them, a suicidal homeless veteran was referred for psychiatric treatment that he never received. He later called the suicide hotline, razor in hand – and was only then hospitalized.

Also, in a separate case not included in that tally, there was a case of “catastrophic” harm – defined as either death or permanent loss of function – resulting from problems with the system.

Meanwhile, as the problem dragged on month after month, and as attempted solutions didn’t take, Cerner and VA officials minimized, dismissed, shifted blame, and either lied or were outrageously uninformed about the documented impact on veterans’ health.

In one egregious example, the head of the office overseeing the modernized record system, Terry Adirim, told a congressional panel in April, “I don’t believe that this system, that there’s any evidence that it has harmed any patients, or that it will, going forward.”

At the same time, VA Secretary Denis McDonough told lawmakers he would not be continuing to roll out the Cerner system if it he thought it was causing harm to patients.

But Adirim, McDonough and other top VA officials had received reports about patient harm months earlier, the OIG says.

The butt-covering and denial is just one of many damning revelations in the OIG investigation into the Cerner debacle and the dogged, excellent reporting by the S-R’s Orion Donovan-Smith, who brought this issue to public light.

More recently, his reporting revealed that the VA has vastly understated the frequency that the system was affected by outages requiring staffers to resort to paper record-keeping. Naturally, the multibillion-dollar costs of the project are also exploding.

People who serve in the military have an acronym suitable for all this – one that cannot be spelled out in a family newspaper.

Politicians have begun holding hearings, issuing news releases, and demanding answers. Perhaps this pressure will produce solutions. But the truth – as related by the OIG, at least – is that there is no reason in the world things should have gotten this far.

In fact, the unknown queue problem existed before Cerner ever brought its system to the VA.

The company, now known as Oracle Cerner after Oracle bought it, was given a $10 billion no-bid contract by the Trump administration to implement a modernized electronic record system at VA hospitals.

At that point, though, the problems with the “unknown queue” were already well-known within the company. Investigators found examples of Cerner customers using the system in other capacities complaining about the problem dating back to 2014.

No one in the company shared this with the VA, the OIG concluded. Hospital officials were left to discover – and work around – the problem themselves starting days after the system went online in October 2020.

As one doctor said, the unknown queue problems “were well known but Oracle Cerner seemingly waited until we stumbled upon them. Really inexcusable and indefensible in the case of patient harm.”

The unknown queue was a dusty corner of the system where requests for treatment went to die. If a doctor asked for an X-ray or wrote a prescription, and the request was somehow mismatched with the provider, the request went into this queue, and no one was aware of it.

One VA leader described this as comparable to a mail deliverer throwing undeliverable letters behind a bush instead of returning them to sender.

This happened over and over again. Hundreds of times. And it kept happening, even as VA staffers began taking on the extra burden of trying to make sure things were working right. And it keeps happening today, as the VA holds off on implementing the system we have in Spokane in other veterans hospitals.

The obliviousness among leaders has often been stunning. This week, a spokeswoman for Oracle said the company is “confident that the VA system will be the standard bearer for the industry.”

Let’s hope not.

No large, complicated system, in business or government, can succeed if its leaders are not forthright and serious when things go wrong. The failures of the Cerner system have been compounded at every turn by failures of leadership.

And these failures continue.

A footnote in the OIG report details a meeting last month among investigators, Adirim and other top officials. Adirim told the OIG that efforts to fix the “unknown queue” problem were complete, and that there were now just 28 orders in that queue on average.

“Contrary to (Adirim’s) assertion,” the report states, “the OIG checked the unknown queue on the morning of the meeting and found 522 orders.”