Routing gap in VA healthcare software resulted in patient harm, says Watchdog

Oracle Cerner software, which is being installed by the Department of Veterans Affairs as part of a $21 billion technology refresh, has flaws that directly result in patient harm, according to a report by the agency’s Office of Inspector General.

The OIG report focuses on the “unknown queue” used by the Oracle Cerner Health Record System to capture clinical orders with incomplete routing information. The report covers events at the Mann-Grandstaff VA Medical Center, the first go-live site for the new software.

According to the report, patient records software failed to alert clinicians that orders were not reaching their intended destination. Since the software went live in October 2020 to June 2021, more than 11.00 clinical orders have been routed to the unknown queue. According to the report, 8,500 were radiological orders and 2,500 were other clinical services.

The OIG report concluded that the unfamiliar queue “ultimately resulted in thousands of medical supplies orders not being delivered to the requested service, putting patients at risk for incomplete care and causing multiple cases of patient harm.” The report also noted that “Oracle Cerner failed to notify VA end users of the existence of the unknown queue and put the onus on VA to identify and fix the problem.”

In response comments, VA Assistant Secretary Donald Remy said the queue was “awkwardly named” but had the function of holding misaddressed orders for review. “Accordingly, the existence of the queue is not an indication of negligence or negligence,” he wrote in his comments.

Remy and OIG investigators disagreed on a few factual details. For example, in his response comments, Remy said that as of June 23, 2022 — the date of a call between VA and OIG staff about the report — there were five orders in the unknown queue. OIG wrote that more than 500 orders were queued that day.

The report cited two incidents of greater harm related to orders languishing in the unknown queue, including one involving a homeless veteran who was referred to a psychiatric ward. The order never reached its destination, and the patient was eventually hospitalized after threatening suicide when he called a crisis hotline. The second incident of greater harm surfaced while the report was being prepared and no details were included on this claim.

A VA doctor cited in the report said the unfamiliar queuing system represented “a programming flaw,” adding that queued orders “require a lot of staff time to research and reroute to the right place.”

In his response comments, Remy acknowledged the staff’s time commitment, but noted that a VA Functional Support Team reviewed the unknown orders and developed remedial actions, including a daily review of the unknown queue.

Rep. Cathy McMorris Rodgers (R-Wash.), representing Spokane, commented on the report.

“The results of the VA Inspector General’s investigation are even worse than I suspected. Not only were 149 veterans in eastern Washington injured by the broken electronic medical record system, VA and Oracle Cerner leadership downplayed the seriousness of the unknown queue issue, failing to adequately train on-site providers, and manipulating data to provide an unfactual representation via general system training and user skills,” said Rodgers.

A draft version of the report was obtained by reporters and was the subject of an article in the Spokesman-Review, a Spokane, Washington newspaper, on June 19.

This is an evolving story and will be updated with new information and comments.

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