From a missed suicide attempt to an unnecessary visit to urgent care, tech glitches in the integration process of Oracle's Cerner software at U.S. Veterans Affairs hospitals led to serious health consequences, according to a new report published Thursday by the Veteran’s Office of Inspector General.
The new report follows another damning OIG report published a year ago citing problems with integrating electronic health records software from Cerner, which was acquired by Oracle in December for $28.3 billion. The company scored a $10 billion contract in 2018 to update the health and financial records system used by the VA to deliver care to millions of military vets.
Thursday's report provides detailed information on how the Cerner electronic records system deployed at the Mann-Grandstaff VA Medical Center in Spokane, Washington inadvertently sent orders for patient follow-up care into a memory hole. When order information was not recognized as a match by the software, it was sent into an “unknown queue.”
“From facility go-live in October 2020 through June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services,” the report reads.
The OIG provided examples showing the impact of this problem on patients. After an order for follow-up care for a homeless patient at risk for suicide landed in unknown queue limbo, the follow-up care never happened. The patient later contacted the VA crisis line saying he had a “razor in hand and a plan to kill himself.” Afterward, he was psychiatrically hospitalized.
Another patient did not receive a compression hose to help with lower leg swelling because the order went into the unknown queue. The patient ended up requiring urgent care for worsening of the edema.
"Of the numerous conclusions from the GAO and Inspector General, this latest report is the most worrisome. Delays and setbacks with government contracts on major IT projects is one thing; patient harm is another,” said Dr. Shravani Durbhakula, a pain physician and anesthesiologist at the Johns Hopkins School of Medicine, in a statement sent to Protocol.
Cerner did not respond to a request to comment for this story.
A report published a year ago by the VA’s OIG showed the main problems stemmed from Cerner’s approach to training VA hospital staff on using the system. It cited “significant gaps in training for business and clinical workflows” and a “lack of clinical knowledge” among Cerner trainers.
Climate TRACE's data show emissions at the facility-level.Image: Climate TRACE