WASHINGTON – In response to a draft watchdog report’s claim that a computer system at Spokane’s VA hospital harmed scores of veterans, Secretary of Veterans Affairs Denis McDonough said Wednesday his confidence in the system has been shaken.
The Spokesman-Review reported Sunday that a draft report from the VA Office of Inspector General found 148 cases of harm that resulted from a flaw in the electronic health record system developed by Cerner Corp. since it launched at Mann-Grandstaff VA Medical Center in October 2020. It also revealed that VA safety experts briefed McDonough’s deputy about the harm and warned of ongoing risks in October 2021, months before the secretary told lawmakers in April he wouldn’t continue rolling out the system if those experts determined it presented risks to veterans.
“If I had known what I know today, when I was appearing before Congress, I would have answered those questions differently,” McDonough said Wednesday in response to a question from The Spokesman-Review. He added that he had been in contact with the Office of Inspector General and said, “I’ve definitely gotten smarter on these reports over the course of the last couple of months.”
After The Spokesman-Review notified the VA it had obtained the draft report, the department told the Military Times on Friday it would postpone the Cerner system’s planned launch in the Puget Sound region from Aug. 27 to March 2023. On Tuesday, the VA announced it would delay a planned Saturday rollout in Boise by about a month, until July 23.
In a statement Wednesday, Sen. Jim Risch, R-Idaho, called on the VA to halt the system’s launch at the Boise VA Medical Center and its affiliated clinics in Eastern Oregon and Idaho until all problems are fixed.
“The problems with the Cerner Electronic Health Record system my colleagues and I outlined in our April letter to Secretary McDonough, in addition to new issues that arose this week, still have yet to be resolved,” Risch said, adding that Cerner’s system “should not be implemented at the Boise VA, or any VA location, until the VA can assure us that doing so will not harm our veterans.”
In his monthly briefing with reporters Wednesday, McDonough called patient safety “our No. 1 concern across the board at VA.”
“I do now know that there are instances of patient harm and that there could be a range of factors that contribute to that,” he said, adding that the team of safety experts he deployed to Spokane “at least can’t rule out” that the Cerner system played a role in the harm.
The draft report focuses on a single problem with the system, identified by the VA safety team as a top priority, that prevented orders sent by doctors and nurses from reaching their intended recipients, without alerting the sender to the error. That resulted in thousands of orders getting lost in what clinicians call “the unknown queue,” causing delays in care that worsened health problems and in one case left a veteran on the brink of suicide.
The draft report also mentions that the VA safety team identified at least one case of “catastrophic” harm, defined by the VA as “death or permanent loss of function,” related to a separate problem not detailed in the report. McDonough said he was not aware of any patient dying in connection to the Cerner system, but he declined to address specific cases of harm.
McDonough called communication between the patient safety team and the VA office in charge of implementing the Cerner system “the lifeblood of how we ensure patient safety” and said he believes better communication is occurring since the VA implemented weekly meetings between the two offices earlier this year. The secretary also encouraged clinicians at Mann-Grandstaff and other facilities using the Cerner system to share their feedback with VA leaders, even inviting them to contact him directly.
When asked what the department would do if the Cerner system fails to meet the VA’s needs, McDonough said he was “not ready to answer hypotheticals” but pledged to carry out the project – begun by the Trump administration – as diligently and transparently as possible.
“We’d obviously make decisions about that,” he said, “but we’re right now trying our darnedest to make the Cerner option work.”
While the new system will not be deployed until 2023 at sites in Seattle, Portland and elsewhere west of the Cascades, health care providers will continue using it while Cerner – acquired June 8 in a deal worth $28.3 billion – works with the VA to solve problems that health care providers say make their work less efficient and raise the risk of patient harm.
At the facilities in Idaho and Oregon scheduled to adopt the system July 23, McDonough said employees would go through “a whole series of predeployment trainings” that make use of “really important, cutting-edge work done by the team in Spokane.”
Northwest lawmakers have continued to criticize the VA and Cerner.
“The details from this draft report are deeply disturbing and have serious implications for our nation’s veterans,” Rep. Dan Newhouse, R-Sunnyside, said in a statement Tuesday, pledging to work with the House VA Committee and Rep. Cathy McMorris Rodgers, a Spokane Republican who slammed the VA and Cerner over the weekend.
Newhouse elaborated in an op-ed published Wednesday in The Star in Grand Coulee, calling on the VA to provide extra resources to the hospitals in Spokane and Walla Walla that will continue to use the Cerner system while problems are addressed.
Rep. Kim Schrier, a Democrat whose district includes a clinic in Wenatchee that implemented the Cerner system in October 2020 along with Mann-Grandstaff, said in a statement it is unacceptable for a system to cause harm.
“Cerner and the VA must ensure Veterans are receiving excellent care in a timely manner,” she said. “And must also make sure that staff aren’t being burdened by workarounds to a knowingly flawed system. The VA should absolutely pause the rollout of this system around the country until this problem can be resolved.”
Schrier, who used a Cerner system as a pediatrician before she entered Congress in 2019, said the problems reported by VA clinicians go beyond “a few kinks” that can be expected when adopting a new computer system.
“The VA, the Biden Administration, and Cerner all share culpability for not notifying the VA of this flaw,” she said. “I will continue to do all I can to make sure that Veterans at the Wenatchee CBOC are receiving the care they need and will hold this Administration accountable until it is fixed.”
The top Democrats on the House VA Committee and the subcommittee charged with oversight of the Cerner rollout, Reps. Mark Takano of California and Frank Mrvan of Indiana, also issued a statement Wednesday.
“Although we are still waiting for the VA’s Office of Inspector General to release its report related to an ‘Unknown Queue’ within the Cerner Millennium Electronic Health Record, the draft findings raised in media coverage over the weekend are seriously troubling and contradict what we have heard from VA officials during public testimony,” the lawmakers said.
“We have already begun discussions with VA on the performance of Cerner and requested an official briefing on the forthcoming report. Once released, we will be reviewing the findings closely in order to determine if there are any contractual or legal repercussions of these draft findings.”
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