WASHINGTON – The Department of Veterans Affairs announced Thursday it will postpone the rollout of a troubled computer system it has been testing in Spokane for the past two years and will notify more than 40,000 veterans in the Inland Northwest, Oregon and Ohio that their treatment may have been delayed by problems with the system.
The new electronic health record system, developed by Oracle Cerner under a $10 billion contract to replace the VA’s existing system, had been scheduled to launch in the first quarter of 2023 at hospitals in Western Washington, Michigan and Ohio, but those and all other deployments have been pushed back to at least June , the department said in a news release.
“Right now, the Oracle Cerner electronic health record system is not delivering for Veterans or VA health care providers – and we are holding Oracle Cerner and ourselves accountable to get this right,” VA Deputy Secretary Donald Remy said in the release, adding that the system’s rollout would be delayed “while we fully assess performance and address every concern.”
The system, which VA employees rely on to track patient information and coordinate care, was first launched at Mann-Grandstaff VA Medical Center and its associated clinics across the Inland Northwest in October 2020. After multiple delays prompted by patient safety risks caused by the system, the department deployed it in March in Walla Walla; in April in Columbus, Ohio; and in June in Roseburg and White City, Oregon.
On Tuesday, in response to questions from The Spokesman-Review, the VA confirmed it was aware of the death in late September of a patient at the VA clinic in Columbus, Ohio. That incident is being treated as a potential “sentinel event,” a designation that prompts an investigation to prevent a similar occurrence in the future.
“Patient safety is VA’s top priority, and we are currently investigating to determine the root cause of this incident and get to the bottom of it,” VA spokesman John Santos said in a statement. “Our sincerest condolences go to the family and friends of this Veteran.”
In an email sent to all clinicians at Mann-Grandstaff on Oct. 7 and obtained by The Spokesman-Review, the hospital’s assistant chief of pharmacy, Sharon Oakland, attributed the sentinel event in Columbus to a patient not receiving a medication due to incorrect information in the Oracle Cerner system. “This is one more example,” she wrote in the email, of how the VA facilities using the new system are relying on “hypervigilance on everyone’s part to work within Cerner.”
After a leaked report by the VA Office of Inspector General in June revealed nearly 150 cases of harm linked to the Oracle Cerner system, VA Secretary Denis McDonough hit the brakes on deployments planned for last summer in Seattle, Tacoma and Boise while the department investigated safety risks reported by health care providers.
Shereef Elnahal, the VA’s under secretary for health, said in an interview with The Spokesman-Review on Wednesday that the department’s findings prompted it to send letters to veterans whose medications, appointments, referrals or test results may have been delayed due to problems with the new system.
“Unfortunately, we discovered that safety concerns were voluminous enough and prevalent enough throughout the system that we had to disclose to 41,500 veterans that their care may have been impacted as a result of the system’s deployment as it is currently configured,” Elnahal said.
The affected veterans were identified through a review by VA patient safety experts and data provided by Oracle Cerner on all patients enrolled at the hospitals and clinics where the system has been deployed in Washington, Idaho, Oregon, Montana and Ohio, Elnahal said. That group of roughly 41,500 patients represents a minority of the veterans enrolled for care at the facilities using the new system.
The VA began mailing the letters Wednesday and all of the affected veterans should receive them within about two weeks.
Soon after Elnahal started his job in July, becoming the first Senate-confirmed head of the Veterans Health Administration since 2017, he met with employees on Sept. 9 at the VA clinic in Columbus, Ohio, where the Oracle Cerner system was launched in April. The most concerning pattern he saw there, Elnahal said, was the highly complex system making it hard for clinicians to perform routine tasks, such as ordering a test or a follow-up appointment. The veterans who will receive letters were identified as potentially being affected by those problems.
“This is actually a list of veterans who at some point, we have evidence, got caught up in this phenomenon of commands not getting where they need to go,” Elnahal said. “That definitely went above the threshold for us to proactively contact those veterans, because that is far and away our first priority, the safety and quality of the care we provide to veterans.”
Delayed follow-ups due to orders in the system not reaching their intended recipient was the main cause of 149 cases of harm identified in a VA Office of Inspector General report released in July. Similar errors led to a roughly yearlong delay in treatment for a veteran in Chewelah, Washington, who was eventually diagnosed with terminal cancer.
The text of the letter, which the VA provided to The Spokesman-Review, explains that the department is transitioning to the new system “to ensure that you have the modernized, integrated, and world-class care that you deserve” and encourages the affected veterans to make sure their prescriptions are correct, appointments are scheduled and test results are delivered to them. Veterans who believe their care may have been impacted are directed to call a dedicated call center at (800) 319-9446.
“We purposefully made a separate call center so that our clinicians in the field, seeing veterans, don’t take a huge volume of calls that forces them to disrupt veteran care that’s happening over the next couple of weeks,” Elnahal said.
Staff at the call center, he said, will take information from veterans who believe their care has been affected by the Oracle Cerner system and a VA health care team will follow up within five days.
The letters, which will be signed by Elnahal and local VA leaders in each region, conclude by saying, “We apologize for any inconvenience or concern this may cause you and your family. Our staff care deeply about your health, and we want to continue to partner with you for your health and wellbeing. Thank you for your understanding as we work quickly to ensure that you receive the best possible medical care.”
The system’s launch in Spokane was delayed twice by the Trump administration before going ahead just days before the 2020 election, during a local surge in COVID-19 cases and despite warnings that it was not ready to safely use. Thursday’s announcement marks the third time the rollout has been delayed under the Biden administration, but Elnahal’s focus on the system’s poor design represents a notable departure from VA leaders’ past remarks, which have often downplayed problems and pointed blame at health care workers themselves.
Elnahal said that while the VA is sending more technical assistance and additional clinicians to support the sites already using the Oracle Cerner system – which has decreased the number of patients each provider can see in a day – the biggest need is simply to make the system work better.
“The most definitive thing that will help us address clinicians’ stress as they interface with Cerner is reconfiguring the systems to solve what they worry about the most, which is any safety issue that could befall veterans,” he said. “We’re trying to be proactive and get ahead of that issue with the letter, but at the same time we are starting now in solving that piece of the system’s configuration, which is what I worry about the most, because our clinicians on the front line worry about that the most.”
Elnahal is the first permanent leader of the Veterans Health Administration – the nation’s largest health care system, serving more than 9 million veterans – since former President Donald Trump named Elnahal’s predecessor, David Shulkin, as VA secretary in early 2017. As under secretary for health, Elnahal said his role in the Oracle Cerner rollout is “to be the voice of our clinicians” and to make tough decisions about how the system should be configured.
While the VA estimates that delaying the system’s rollout until mid-2023 will provide enough time to work with Oracle Cerner to fix the problems, Elnahal emphasized that the department won’t bring the system to new facilities until the “top-level safety issues are resolved,” even if that means further delays.
“Those specific patient safety risks have a lot to do with the way the system is configured right now,” he said. “It’s not as intuitive as it should be and there’s a lot of room for improvement.”
Problems related to transitioning between electronic health record systems have been widely documented and are not unique to the VA, but the rest of the U.S. health care system doesn’t have the same level of transparency as the VA, which is subject to oversight by Congress and the Office of Inspector General, an internal watchdog agency. The VA also has a confidential reporting system that encourages clinicians to report patient safety risks and incidents of harm, which improves safety but can give the impression that the VA has a poor safety record in comparison to private hospitals, which often don’t have similar reporting mechanisms.
“Not many other health systems would have been able to surface, so swiftly and effectively, these safety concerns,” Elnahal said, crediting VA clinicians and patient safety experts. Because the VA had “robust systems in place” to detect safety threats, he said, the department raised the problems quicker than any other health care system would have.
The system being replaced by Oracle Cerner, known as VistA, is still used in nearly all VA facilities and has been credited with pioneering the electronic health record field. Elnahal, who used VistA during his medical training, said the existing system “represents a really amazing part of VA history, but it is just too old and simply cannot meet the future needs of veteran health care.”
While Elnahal said all commercial electronic health record systems are “not optimal,” he called the Oracle Cerner system “a workable product” that can be configured to meet the VA’s needs.
Asked whether the sites currently using the Oracle Cerner system could revert to VistA until problems with the new system are fixed, he said doing that “would actually introduce more risk than benefit at this point in the process.”
“Sometimes, you’re not presented with options to immediately resolve the safety concerns that are in front of you,” he said. “It is simply the case that the best option in front of us to resolve these patient safety concerns is to work with Oracle Cerner over the next several months to resolve the Cerner system issues at the sites where it exists. We know that this is possible, because other health systems have gone through this journey before, and I think we can do it.”