WASHINGTON – Washington lawmakers reacted with outrage after a report published by an internal Department of Veterans Affairs watchdog Friday confirmed a computer system at Spokane’s VA hospital has caused nearly 150 cases of harm, while another report found VA leaders in charge of training users on the new system misled investigators.
The Spokesman-Review previously reported the cases of patient harm based on a draft report by the VA Office of Inspector General, an independent oversight body charged with investigating the department, that found a flaw in the system caused delays in patient care when referral orders for follow-up care effectively went missing. The report alleges Cerner Corp., which is developing the system under a $10 billion contract, knew about the issue but did not fix it nor warn VA of the risks it created.
The second report found two senior VA officials gave the Office of Inspector General inaccurate information during a previous investigation into problems with training employees to use the new system. In one case, the officials provided data claiming 89% of employees had passed a proficiency test, when in reality fewer than half that many – just 44% – had shown they could use the Cerner system. The report concluded that while the officials didn’t intentionally mislead investigators, their “lack of diligence” hampered oversight.
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 addressing a wide range of problems with the electronic health record system that have reduced access to care and left VA employees exhausted and demoralized since the system was launched in Spokane in October 2020.
Lawmakers who represent the Inland Northwest cities where the system has been deployed – including Spokane, Wenatchee and Walla Walla – were quick to respond to the reports’ findings on Friday, with Rep. Cathy McMorris Rodgers, R-Spokane, calling them “even worse than I suspected.”
“I am appalled by all parties involved in this disaster,” she said in a statement, calling Cerner’s failure to brief VA leaders and train health care providers on the feature that caused referrals to go missing “reprehensible.”
“As for VA leadership, their manipulation of training and system proficiency data to save face has put veteran safety at risk and is morally bankrupt,” McMorris Rodgers said. “This agency has completely lost sight of its mission and done irreparable damage to my trust in their ability to deliver results for Eastern Washington veterans.”
Most of the 149 cases of harm were classified as “minor,” but there were 52 incidents of “moderate” harm – requiring a longer hospital stay or more care – and two cases of “major” harm, defined by the VA as “permanent decrease in the body’s functioning or disfigurement” that “requires surgery or inpatient care.” The draft report included only one case of major harm, in which a veteran known to be at risk of suicide was not scheduled for a follow-up appointment because of the flaw in the system and later called the Veterans Crisis Line threatening to kill himself.
The findings of the second report, including the VA training officials manipulating proficiency test results, were disclosed during a Senate VA Committee hearing in July 2021. VA Press Secretary Terrence Hayes declined to say whether the two officials were still employed by the department, saying in an email, “VA does not share personnel-related details about its employees with the public or press.”
Sen. Patty Murray, a Washington Democrat who sits on the Senate VA Committee, said the Cerner system should not be deployed at other sites “until its glaring errors are resolved.” After The Spokesman-Review gave the VA an opportunity to respond to the draft report revealing harm and ongoing risk to veterans caused by lost referrals, the department announced it would delay the system’s launch in the Puget Sound region from August to March 2023.
“My number one priority here is patient safety and, as the reports make plain, the EHR system is jeopardizing patient safety to the tune of hundreds of orders,” Murray said in a statement.
According to the Office of Inspector General, the Cerner system failed to deliver more than 11,000 orders for requested clinical services between October 2020 and June 2021. While the VA and Oracle Cerner have since taken steps to mitigate the problem, the watchdog office says it has not been fully resolved.
“As I’ve said in the past, officials need to be completely transparent and cannot withhold or slow walk any information to the Inspector General’s office,” Murray said. “So I’m going to carefully review these reports and continue to hold both VA and Oracle Cerner accountable. Our veterans and the hardworking providers on the ground, in Spokane and Walla Walla, are counting on us to get this right, so I won’t stop pressing for solutions until this is fixed.”
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 launched at the Walla Walla VA Medical Center with which they are affiliated.
“The details found in these reports are deeply disturbing,” Newhouse said in a statement. “These reports highlight that the VA, and this administration, intentionally ignored reports showing that their system was putting our veterans’ lives at risk.”
The VA signed a $10 billion contract with Cerner under the Trump administration in 2018, skipping the usual competitive bidding process with the justification that the VA needed to use the same system as the Department of Defense, which had begun rolling out a Cerner system in its facilities earlier that year, beginning at Fairchild Air Force Base outside Spokane. Despite the Biden administration reversing other Trump-era decisions, VA Secretary Denis McDonough has chosen to continue the Cerner project, which is projected to cost at least $21 billion over more than a decade when accounting for necessary infrastructure upgrades.
The top members from both parties on the House and Senate VA committees also released statements about the watchdog reports on Friday, with Rep. Mark Takano of California, the top Democrat on the House panel, saying he was “extremely disappointed” by the VA’s lack of transparency.
“We have been concerned about patient safety and the possibility of patient harm from the very beginning of this project,” Takano said. “We have repeatedly been assured by the highest levels of VA and the program office that no veterans had been harmed by the transition to the Oracle Cerner Millennium product. Today’s report by the VA Office of the Inspector General shows that we had not been given the whole story.”
Rep. Mike Bost of Illinois, the top Republican on the committee, visited VA facilities in Richland and Walla Walla with Newhouse in early July.
“Instead of fixing the issues with the system, VA and Cerner seem much more interested in hiding them,” Bost said. “We expect honesty, at the very least, and a plan to resolve the training and referral issues so they never happen again.”
Sen. Jon Tester of Montana, the top Democrat on the Senate VA Committee, called the reports “unacceptable” and said Oracle Cerner “needs to step up its game and deliver a functioning, quality system that’ll do right by taxpayers.”
Sen. Jerry Moran of Kansas – who has been less vocal than other lawmakers in his criticism of Kansas City, Missouri-based Cerner – didn’t mention the company in a statement that pointed blame at the VA.
“The lack of care the department has provided to veterans impacted by the new system is unacceptable,” Moran said. “Today’s reports illustrate patient safety issues that can be traced directly to failures at the highest levels at VA, including the department’s failure to ensure that personnel are candid and open with OIG investigators working to uncover problems in the system.”
The Senate VA Committee will hold a hearing Wednesday to question VA officials and an Oracle executive about the status of the Cerner system’s rollout. Despite VA leaders admitting the system had not shown “adequate reliability” to be used in Seattle and Portland, the department plans to launch it in Boise on Saturday.