WASHINGTON-Washington lawmakers are outraged after a report published by internal Department of Veterans Affairs watchdog Friday confirmed that the computer system at Spokane’s VA hospital has caused nearly 150 injury cases, while another report found VA leaders overseeing the training of users in the system recently misled investigators.
Spokesman-Review previously reported patient injury cases based on a draft report by the VA Office of Inspector General, an independent oversight body accused of investigating the department, which found a system defect causing the delay. patient care when the referral order for The follow-up care is effectively lost. The report says Cerner Corp., which is developing the system under a $ 10 billion contract, knew about the issue but did not fix it or warn the VA of the risks it posed.
The second report found that two senior VA officials had provided the Office of Inspector General with inaccurate information during a previous investigation into problems with employees training to use the new system. In one case, officials provided data claiming that 89% of employees passed a proficiency test, when in fact less than half of the majority – only 44% – indicated they could use the system. Cerner. The report concludes that while officers inadvertently misled investigators, their “lack of diligence” hampered management.
Tech giant Oracle acquired Cerner, now known as Oracle Cerner, in a $ 28.3 billion deal that closed in June. The company faces the task of solving a wide range of problems with the electronic health record system that reduces access to care and leaves VA employees tired and demoralized since the system. launched in Spokane in October 2020.
Lawmakers representing the Inland Northwest towns where the system is deployed – including Spokane, Wenatchee and Walla Walla – were quick to respond to findings in reports Friday, with Rep. Cathy McMorris Rodgers, R-Spokane, calling them “worse. Than I suspected.”
“I am shocked by all the parties involved in this disaster,” he said in a statement, calling Cerner’s failure to notify VA leaders and train health care providers on the part. cause lost referrals that are “bad.”
“As for the VA leadership, their manipulation of training and system expertise data to save the face puts the veteran’s safety at risk and moral bankruptcy,” McMorris Rodgers said. “This agency has completely lost sight of its mission and has done irreparable damage to my confidence in their ability to deliver results for Eastern Washington veterans.”
Most of the 149 injury cases were classified as “minor,” but there were 52 incidents of “moderate” injury – requiring a longer hospital stay or additional care – and two cases of ” major injury, defined by the VA as “permanent reduction in function or physical injury” that “requires surgery or inpatient care.” The draft report included only one case of serious injury, in which a veteran known to be at risk of suicide was not scheduled for a follow-up appointment due to a system error and was later called the Veterans Crisis Line. threatened to kill himself.
The findings of the second report, including VA training officials manipulating the results of the proficiency test, were revealed during a Senate VA Committee hearing in July 2021. VA Press Secretary Terrence Hayes declined to comment. say whether the two officers are still working in the department, saying in an email, “The VA has not shared staff-related details about its employees with the public or the press.”
Si Sen. Patty Murray, a Washington Democrat who sits on the Senate VA Committee, said the Cerner system doesn’t need to be deployed to other sites “until its flaws are resolved.” After The Spokesman-Review gave the VA and opportunity to respond to the draft report revealing the injury and ongoing risk to veterans due to lost referrals, the department announced to delay the launch of the Puget Sound regional system from in August to March 2023.
“My number one priority here is patient safety and, as reports are clear, the EHR system is endangering patient safety in the tone of hundreds of orders,” Murray said in a statement.
According to the Office of the Inspector General, Cerner’s system failed to deliver more than 11,000 orders for requested clinical services between October 2020 and June 2021. not fully resolved.
“As I said before, officers need to be completely transparent and not prevent or slow down the flow of any information to the Inspector General’s office,” Murray said. “That’s why I’m going to take a closer look at these reports and continue to hold VA and Oracle Cerner accountable. Our veterans and hard-working land donors, in Spokane and Walla Walla, trust us to get it right, so I won’t stop pushing for solutions until they are resolved.
Rep. Dan Newhouse, R-Sunnyside, represents a Central Washington district that includes clinics in Yakima and Richland that began using the Cerner system in March, when it was launched at Walla Walla VA Medical Center where they partnered.
“The details found in these reports are very disturbing,” Newhouse said in a statement. “These reports underscore that the VA, and this administration, deliberately ignored reports that showed their system was putting the lives of our veterans at risk.”
The VA signed a $ 10 billion contract with Cerner under the Trump administration in 2018, bypassing the usual competitive bidding process with the justification that the VA should use the same system as the Department of Defense, which began launching a Cerner system at its facilities earlier that year, starting at Fairchild Air Force Base outside Spokane. Although the Biden administration repeated other decisions during the Trump era, VA Secretary Denis McDonough chose to continue the Cerner project, which is planned to spend at least $ 21 billion over more than a decade if the necessary infrastructure upgrades.
Leading members from both the House and Senate VA committees also released statements about the watchdog reports on Friday, along with Rep. Mark Takano of California, the leading Democrat on the House panel, said he was “very disappointed” with the VA’s lack of transparency.
“We have been concerned about patient safety and the possibility of harm to the patient since the beginning of this project,” Takano said. “We have been repeatedly assured at the highest level in the VA and the program office that no veterans have been harmed by the Oracle Cerner Millennium product transfer. Today’s report by the VA Office of the Inspector General shows that we have not yet give the whole story.
Rep. Mike Bost of Illinois, the committee’s leading Republican, visited VA facilities in Richland and Walla Walla with Newhouse in early July.
“Instead of fixing system issues, VA and Cerner seem more interested in hiding it,” Bost said. “We expect honesty, at the very least, and a plan to resolve training and referral issues so they don’t happen again.”
Si Sen. Jon Tester of Montana, the top Democrat on the Senate VA Committee, called the reports “unacceptable” and said Oracle Cerner “needs to improve its game and provide a functioning, quality system that taxpayers can do. . “
Kansas Senator Jerry Moran – who was less vocal than other lawmakers in his criticism of Kansas City, Missouri -based Cerner – did not mention the company in a statement focusing on blaming the VA.
“The lack of care provided by the department to veterans affected by the new system is unacceptable,” Moran said. “Reports now illustrate patient safety issues that can be traced directly to failures at the highest levels of the VA, including the department’s failure to ensure personnel are straightforward and open to OIG investigators. working to identify system problems. “
The Senate VA Committee will hold a hearing Wednesday to ask VA officials and an Oracle executive about the status of the launch of the Cerner system. Despite claims by VA leaders that the system does not appear “reliable enough” to be used in Seattle and Portland, the department plans to launch it in Boise on Saturday.