Washington lawmakers outraged after surveillance reports found computer system harmed nearly 150 Spokane veterans and VA leaders misled investigators
WASHINGTON — Washington lawmakers reacted with outrage after a report released Friday by an internal Veterans Affairs watchdog confirmed that a computer system at the VA Hospital in Spokane caused nearly 150 cases of harm. , while another report found that VA executives were tasked with training users on the new system misled investigators.
The spokesperson-review previously flagged the cases of patient harm based on a draft report from the VA’s Office of Inspector General, an independent oversight body charged with investigating the department, which has discovered that a flaw in the system led to delays in patient care when referral orders for follow-up care effectively disappeared. The report alleges that Cerner Corp., which is developing the system under a $10 billion contract, was aware of the problem but did not fix it or warn VA of the risks it created.
The second report found that two senior VA officials had provided the Office of Inspector General with inaccurate information during a previous investigation into issues training employees to use the new system. In one case, officials provided data claiming that 89% of employees had passed a proficiency test, when in fact less than half of that number – just 44% – had shown they could use the Cerner system. . The report concluded that while officials did not 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 resolving a wide range of issues with the electronic health record system that have reduced access to care and left VA employees exhausted and demoralized since the system launched in Spokane in October 2020. .
Lawmakers who represent towns in the Northwest Interior where the system has been deployed — including Spokane, Wenatchee and Walla Walla — were quick to respond to the reports’ findings on Friday, 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 educate healthcare providers about “reprehensible.” the feature that caused the references to disappear.
“As far as VA leaders are concerned, their manipulation of system training and skill data to save face has endangered veterans’ safety and is morally bankrupt,” McMorris Rodgers said. “This agency has completely lost sight of its mission and has done irreparable damage to my confidence in its ability to deliver results to veterans in Eastern Washington.”
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”. decreased function or disfigurement of the body” which “requires surgery or hospital care”. The draft report included only one major harm case, in which a veteran known to be at risk of suicide was not scheduled for a follow-up appointment due to a flaw in the system and was then called the suicide threat veterans hotline.
The findings of the second report, including VA training officials manipulating proficiency test results, were disclosed during a VA Senate Committee hearing in July 2021. VA press secretary Terrence Hayes declined to say though the two officials were still employed by the department, stating in an email, “VA does not share personnel details about its employees with the public or the press.”
Sen. Patty Murray, a Washington Democrat who sits on the Senate VA committee, said the Cerner system should not be rolled out to other sites “until its egregious errors are resolved.” After The Spokesman-Review gave the VA the opportunity to respond to the draft report revealing the continued harm and risk to veterans caused by the loss of removals, the department announced it would delay the launch of the system. in the Puget Sound area from August to March 2023.
“My number one priority here is patient safety and, as the reports clearly show, the EHR system puts patient safety at risk on 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 clinical service orders requested between October 2020 and June 2021. While the VA and Oracle Cerner have since taken steps to mitigate the problem, the monitoring office says it has not been fully resolved.
“As I’ve said in the past, officials must be completely transparent and cannot withhold or slow down the flow of information to the inspector general’s office,” Murray said. “I will therefore carefully review these reports and continue to hold VA and Oracle Cerner accountable. Our veterans and hard-working vendors on the ground in Spokane and Walla Walla are counting on us to get it right, so I won’t stop pushing for solutions until this is 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 the Walla Walla VA Medical Center with which they are affiliated.
“The details found in these reports are deeply troubling,” Newhouse said in a statement. “These reports underscore that the VA and this administration intentionally ignored reports that 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, skipping the usual bidding process with the rationale that the VA had to use the same system as the Department of Defense, which had begun deploying a Cerner system at its facilities earlier that year, beginning with Fairchild Air Force Base outside Spokane. Although the Biden administration reversed other Trump-era decisions, VA Secretary Denis McDonough opted to continue the Cerner project, which is expected to cost at least $21 billion over more than a decade taking into account the necessary infrastructure upgrades.
Top members of both parties on the House and Senate VA committees also released statements on the oversight reports on Friday, with Rep. Mark Takano of California, the top Democrat on the House panel, saying he was “extremely disappointed “by the lack of VA. of transparency.
“We were concerned about patient safety and the possibility of patient harm from the start of this project,” Takano said. “We have been repeatedly assured by the highest levels of VA and the program office that no veteran has been harmed by the transition to the Oracle Cerner Millennium product. Today’s report from the VA’s office of the inspector general shows we didn’t get the full story.
Rep. Mike Bost of Illinois, the committee’s top Republican, toured VA facilities in Richland and Walla Walla with Newhouse in early July.
“Instead of solving problems with the system, VA and Cerner seem much more interested in hiding them,” Bost said. “We expect at least some honesty and a plan to fix the training and orientation issues so they never happen again.”
Senator Jon Tester of Montana, the top Democrat on the VA Senate Committee, called the reports “unacceptable” and said Oracle Cerner “needs to step up its game and deliver a quality, functional system that will make the taxpayers’ business.
Kansas Sen. Jerry Moran — who was less vocal than other lawmakers in his criticism of Kansas City, Mo.-based Cerner — did not mention the company in a statement blaming the VA.
“The lack of care the department has provided to veterans affected by the new system is unacceptable,” Moran said. “Today’s reports illustrate patient safety issues that can be directly attributed to failures at the highest levels of VA, including the department’s failure to ensure staff are candid and open with OIG investigators working to uncover problems in the system.”
The Senate VA committee will hold a hearing on Wednesday to question VA officials and an Oracle executive about the status of the Cerner system deployment. Although VA executives admit the system hasn’t shown “adequate reliability” for use in Seattle and Portland, the department plans to launch it in Boise on Saturday.