WASHINGTON – Charlie Bourg and Charlie Monroe first met in 2016 when the two veterans started a marathon protest outside Mann-Grandstaff VA Medical Center that evolved from demanding access to exercise equipment into a catch-all demonstration calling for better treatment for patients and staff.
Since then, “the Charlies” have been a fixture at the Spokane hospital, serving as de facto patient advocates and a sounding board for frustrated employees. So when reports of missing medications and myriad other errors emerged soon after the Department of Veterans Affairs launched a new computer system at the hospital in October 2020, they worried veterans could wind up dead, victims of a system critics say is being effectively beta-tested on live patients in the Inland Northwest.
“We were out hunting to find out who it was being injured,” Bourg said, “and one day I had to call Charlie and tell him, ‘Hey, I found the first guy.’ ”
When Monroe asked who it was, Bourg delivered the news he had just received from his doctor.
“It’s me,” Bourg told his friend. “I’m dying.”
Bourg, 68, said doctors told him cancer had spread from his prostate to other parts of his body during a roughly yearlong delay in treatment, which he attributes to problems caused by the electronic health record system VA employees rely on to track patient data and coordinate care.
“At first, I didn’t believe him, and then it just took all the wind out of my sails,” said Monroe, 74, a Navy veteran. “I’m losing a brother. What else can I tell you? We’ve been together through thick or thin for the last seven years. It’s like taking my right arm off, that’s how close we’ve been going through all of this.”
Had the cancer been caught earlier, Bourg said an oncologist told him in the spring, it could have been treated before it metastasized to his abdomen and pelvis.
Instead, Bourg said, the cancer specialist could only guarantee he will live until Christmas, with his life expectancy after that dependent on the treatment he chooses. He takes pills to slow the cancer’s progress but opted against chemotherapy and other options after the doctor advised him he had no chance of beating the disease.
“They told me up front that, because it metastasized, anything they do is just going to make my quality of life go down,” Bourg said. “I’ll live a little longer, but my quality of life is going to go to hell.”
According to a letter from Mann-Grandstaff Director Robert Fischer to Sen. Patty Murray, Bourg’s primary care provider notified him Dec. 7, 2020, that a routine screening known as a prostate-specific antigen test indicated he may have prostate cancer, adding that the urology clinic was being alerted. The next day, a urology provider at Mann-Grandstaff opened the message and placed a “return-to-clinic order” in the new computer system – then barely a month old – to schedule a follow-up appointment.
The Spokesman-Review obtained the letter after Fischer sent it June 16, in response to an inquiry by the Washington Democrat’s office on Bourg’s behalf.
Since the message had been sent to the urology clinic by a primary care provider, the system automatically routed the order back to a “scheduling queue” in primary care, Fischer wrote. Because the urology provider didn’t work in primary care, the “ordering provider” field was left blank, and as a result no appointment was scheduled.
On April 9, 2021 – four months after the initial referral – Bourg had another appointment with his primary care provider, who noticed that he hadn’t seen a urologist and sent another message to the urology clinic. By then, Fischer wrote, the “system defect” had been corrected and the order was routed correctly, requesting an appointment to be scheduled May 5, 2021.
Bourg said he didn’t follow up sooner because he was told the urology clinic would review the test results and let him know if they needed to see him. Previous tests had found high PSA levels, he said, before they declined again.
On Aug. 8, 2021, Bourg realized he had never heard from the urology clinic and asked his primary care provider what had happened. According to Fischer’s letter, the urology clinic’s scheduler had correctly used the order for a May 5 appointment but the system “automatically modified the appointment date” to Sept. 21, 2021.
When Bourg finally saw the urologist on Sept. 21, a biopsy was scheduled for Oct. 14, 2021. A week after the biopsy, Bourg was told he had cancer. He had surgery to remove his prostate in January 2022 – more than a year after his referral to see a specialist – and follow-up testing in May revealed the cancer had spread. It was too late.
Ross Koppel, a professor of biomedical informatics at the University of Pennsylvania School of Medicine, said what happened to Bourg is “a classic case” of the mistakes that can occur when a hospital adopts a new electronic health record system, or EHR.
“This is not unusual in conversions from one EHR to another, or when things go awry because the system is not fully integrated,” said Koppel, a sociologist who has written extensively about the perils of transitioning between the highly complex computer systems.
But Koppel said what has happened at VA facilities using the system – which now include sites in Washington, Idaho, Oregon and Ohio – goes beyond the usual challenges that come with such a transition. In part, he said, that’s because the VA is replacing a highly specialized, homegrown system known as VistA with a commercial system designed for hospitals that rely on billing insurance.
‘We are going to test it here in Spokane’
When then-President Donald Trump announced in June 2017 the VA would give a $10 billion contract to Cerner Corp. to adopt the company’s electronic health record system, he promised it would mean “faster, better and far better quality care” for the more than 9 million veterans who rely on the VA’s 171 medical centers and more than 1,100 clinics.
The official rationale for the contract, which was awarded directly to Cerner without the usual competitive bidding process, was to align the VA with the Department of Defense, which had entered into its own contract to adopt a Cerner system under the Obama administration.
Speaking at an event at Fairchild Air Force Base in October 2018, then-VA Secretary Robert Wilkie said the department had chosen the Inland Northwest as the pilot site for the system because the region had “the perfect mix of active duty, technical infrastructure, rural components and a large number of veterans.”
As of November 2021, roughly 47,000 veterans were enrolled at Mann-Grandstaff and its affiliated clinics in Wenatchee, Coeur d’Alene, Sandpoint and Libby, Montana, according to Mann-Grandstaff spokesman Bret Bowers. About 28,000 of those veterans had visited one of the facilities within two years.
“So what we are doing here in Washington, we are testing out the medical health records, which is the largest program the VA has ever undertaken,” Wilkie said at the time. “We are going to test it here in Spokane.”
Since the Biden administration took over in January 2021, VA officials have denied that what is taking place in the Inland Northwest is a “test,” preferring to talk about “harvesting” information to aid the system’s adoption in other locations and maintaining that subsequent “go-lives” have gone better than Spokane’s.
Bourg, who lives in Chewelah, is one of scores of veterans who have been harmed by delayed care and other problems related to the system, according to a July report by the VA Office of Inspector General.
That report revealed that an internal VA safety review ordered by VA Secretary Denis McDonough found 149 cases of harm due to a single problem that caused delays in care. It also mentioned an unspecified number of veterans harmed by different problems with the system, including one case of “catastrophic harm,” defined as either death or permanent disability.
The VA declined to answer questions from The Spokesman-Review about the patient safety review’s findings, including how many total cases of harm the team identified and whether any of them had resulted in a veteran’s death. In a statement, Press Secretary Terrence Hayes said the department can’t comment on individual cases but investigates every alleged case of harm, adding that patient safety is the VA’s highest priority.
McDonough has expressed concern over the reported problems but has chosen to continue rolling out the Cerner system. After the secretary delayed the system’s launch at other facilities in March 2021 and ordered a “strategic review” of risks to patient safety, deployment went ahead a year later in Walla Walla on March 26; Columbus, Ohio, on April 30; and Roseburg and White City, Oregon, on June 11.
After The Spokesman-Review reported in June about the then-forthcoming Office of Inspector General report on patient harm, the department postponed the system’s planned launch in Western Washington from August 2022 until March 2023. Days before it was set to deploy in Boise in July, that launch was also delayed until next year. In the wake of reports that the system has been plagued by outages and glitches – FedScoop revealed in August the system has seen a total of 498 “major incidents” since it launched in Spokane – McDonough has made assurances that the system will be fixed before it comes to bigger, more complex facilities next year.
The tech giant Oracle acquired Cerner in a $28.3 billion deal that closed in June and Oracle executives have promised to rapidly improve the system, now called Oracle Cerner.
In a statement, an Oracle spokesman called Bourg’s situation “tragic” and said the company had looked into the causes of what happened, concluding that its system was not responsible for his condition.
“Our findings show that nothing related to the EHR’s functionality or performance had anything to do with the care this veteran received and was unrelated to their diagnosis or treatment,” said Michael Egbert, vice president for corporate communications at Oracle. “The Oracle Cerner EHR is successfully in use at many thousands of health care facilities across the United States without incident. We remain a committed partner to VA to ensure its EHR system, and everyone who uses it, is able to provide the best possible care that our veterans deserve.”
‘A failed EHR experiment’
Scot Silverstein, a physician in Philadelphia who works as an independent legal expert in electronic health record forensics, said it isn’t reasonable to point blame at health care providers for mistakes caused by poorly designed systems.
“You don’t assume that, due to some computer mis-design, your order is going to go into limbo somewhere or the date you select is going to be rescheduled without you being informed,” Silverstein said. “It would presume that doctors are omniscient.”
Hayes, the VA press secretary, emphasized that the system’s rollout is on pause at least until January 2023, when it is scheduled to launch in Battle Creek, Saginaw and Ann Arbor, Michigan.
“The goal of the new system is, and always has been, to provide better health outcomes for Veterans and a better experience for providers,” he said in a statement. “Right now, the system is not meeting those goals and needs major improvement. We at VA could not be more frustrated on behalf of Veterans and providers, and we’re holding Oracle Cerner and ourselves accountable to get this right.”
In a July 27 hearing of the House VA Committee, Rep. Cathy McMorris Rodgers asked the head of the VA office in charge of the Cerner rollout, Terry Adirim, about Bourg’s case, without identifying him.
“I want to tell you about another of my constituents who’s a victim of what, unfortunately, is looking like a failed EHR experiment,” said McMorris Rodgers, R-Spokane, calling Bourg’s experience “absolutely inexcusable.”
Adirim said she was sad to hear about what happened and added, “Certainly, nobody should suffer the consequences of a failed process and communication that occurred at the initial deployment of our new EHR.”
Fischer, who appeared before the committee virtually, said he was “awfully sorry” for what happened to Bourg. When McMorris Rodgers asked the Mann-Grandstaff director if he was getting the support he needed from VA headquarters to ensure veterans’ safety, Fischer said the Cerner system needs to be improved so that staff don’t have to rely on time-intensive workarounds to avoid errors.
“Until that’s done,” he said, “our employees and our veterans will be involved in these patient safety issues.”
Bourg was born in Seattle and enlisted in the Army in 1972, the year before the ceasefire that officially ended the Vietnam War. That didn’t stop him from deploying to Vietnam on temporary duty in 1973 to support the U.S. withdrawal, working for a few months to recover armored vehicles.
Back in the United States, he spent time at Fort Ord in California, Aberdeen Proving Ground in Maryland and Fort Lewis near Tacoma. At each of those bases, as in Vietnam, the military used the herbicide known as Agent Orange and other chemicals linked to increased risk of prostate cancer.
After Bourg met his wife Debi, 64, they moved to her family’s land in Chewelah, where they live next door to his son Steven, 45.
“It’s hard to watch you,” Debi Bourg said to her husband at home in July. “You know, the weight loss and things. It’s really hard, because it’s – every day it’s noticeable.”
The medications he takes to slow the effects of the cancer have sapped his energy, Bourg said, but he still tries to stay active and spend time with his family, determined to make the most of the time he has left.
“The only time I really get upset about it is when I start thinking about my wife and my grandkids and my kids,” Bourg said. “I’ve got two little 7-year-old granddaughters. I know I’m not living forever, but I would have liked to see them graduate from high school.”
“Same way with these three,” he added, gesturing to his youngest grandchildren, whom he and Debi help care for: 6-year-old Terry, 5-year-old Ava and 3-year-old Zooey.
His daughter Mary Bourg, who lives in Tacoma, said she doesn’t know how to tell her 7-year-old twin daughters about their grandfather’s illness.
“It’s just really upsetting that somebody can actually delay his medical care and now his grandchildren will not grow up truly knowing their grandfather,” she said.
After he received his prognosis earlier this year, Bourg said, Fischer called him and encouraged him to file a tort claim with the VA. Bourg declined, opting to find a lawyer instead.
The nature of electronic health records makes it hard to assign blame entirely to a dysfunctional system, its users or patients themselves, a fact Silverstein said companies like Cerner have used to evade liability.
For his part, Bourg said he thinks highly of his VA health care providers. “The ones I blame are VA and Cerner,” he said. “VA for putting an untested system in place and Cerner for having a system that they knew was faulty and unleashing it on the veterans.”
After The Spokesman-Review reported in April that a veteran had been hospitalized at Mann-Grandstaff with heart failure after the Cerner system contributed to a vital medication being accidentally discontinued, Adirim told a House VA subcommittee on April 26 the problem was due to doctors not understanding “a usual thing that happens” in the system.
“To say that is basically to deny obligation of the system for its own functioning,” Koppel said, referring to Adirim’s response. “I have the highest regard for the VA and the people who work there are magnificent, but that was beneath them.”
Mary Bourg, 43, said she suspects the VA is rushing the rollout of the Cerner system because delaying it would cost more money.
“You shouldn’t put money before people’s lives,” she said. “And if you put a system into place that’s not fully functioning correctly, I mean, there’s going to be more lives lost. And that’s just unacceptable, especially for people who fought for this country. … It shouldn’t be OK for anybody else’s families to go through this.”
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