A serious revelation that may derail the Cerner Millenium rollout. A draft report by the Department of Veterans Affairs (VA) Office of Inspector General (OIG) states that a flaw in Cerner’s software caused the system to lose 11,000 orders for specialty care, lab work, and other services – without alerting health care providers the orders (also known as referrals) had been lost. This created ‘cases of harm’ to at least 150 veterans in care. Moreover, the flaw was known prior to the Mann-Grandstaff VA Medical Center rollout in October 2020, and Cerner failed to either fix or inform the VA of it prior to the implementation.
The lost orders in the quaintly termed ‘unknown queue’ resulted in delayed care at minimum. The VA patient safety team classified dozens of cases of “moderate harm” and one case of “major harm.” The major harm cited affected a homeless veteran, aged in his 60s, who was identified as at risk for suicide and had seen a psychiatrist at Mann-Grandstaff in December 2020, after the implementation. After prescribing medication to treat depression, the psychiatrist ordered a follow-up appointment one month later. That order disappeared in the EHR and not scheduled. The consequences were that the veteran, weeks after the unscheduled appointment date, called the Veterans Crisis Line. He was going to kill himself with a razor. Fortunately, he was found in time by local first responders, taken to a non-VA mental health unit, and hospitalized.
The draft report implies that the ‘unknown queue’ problem has not been fixed and continues to put veterans at risk in the VA system.
There may be as many as 60 other safety problems. Other incidents cited in the draft report include one of “catastrophic harm” and another case the VA told the OIG may be reclassified as catastrophic. Catastrophic harm is defined by the VA as “death or permanent loss of function.”
The news broke in the Spokane Spokesman-Review today (20 June). Their reporters obtained the draft report from multiple sources. Mann-Grandstaff VA Medical Center is located in Spokane. The final report is expected to be released later this summer.
Those of us who have been following the migration from warhorse EHR VistA to Cerner Millenium recall that a year ago, OIG already had criticized the Mann-Grandstaff implementation for multiple “governance and management challenges” as well as patient safety concerns and system errors, resulting in a grilling of VA Secretary Denis McDonough and Cerner executives before the Senate Veterans Affairs Committee last July. A remark by the committee’s chair, Frank Mrvan, D-Indiana. that the three-month review at the time “raises more questions than it answers,” is proving to be remarkably prescient.
According to the article, “the department did not respond to questions about the draft report, but on Friday, after The Spokesman-Review sent the questions, VA officials told Military Times they would delay the system’s planned launch in Seattle, Portland and other large facilities until 2023″. Military Times noted that the congressional committees were not informed until Friday night. The delays are as follows: Puget Sound VA Health Care System (American Lake and Seattle VA Medical Centers) from August to March 2023 and VA Portland Health Care System (Portland and Portland-Vancouver VA Medical Centers) from November to April 2023. The Central Ohio Healthcare System implementation in May has gone as planned and the VA maintains that the two delays are not indicative of other problems.
Local Representative (R-5th Congressional District, eastern Washington state) Cathy McMorris Rodgers has already had at Cerner since last year. Her press release is illustrative of her activism around Mann-Grandstaff and further rollouts of the Cerner EHR, while Mann-Grandstaff continues to have problems and outages.
Oracle has a great deal riding on a smooth implementation of Cerner Millenium at the VA. More Congressional hearings are not a good look for Oracle and its ambitions of transforming healthcare. Damage control is snapping in place. This Editor noted that Oracle’s SVP for global corporate communications was quoted in the Spokesman-Review article, not a Cerner staffer. Also EHR Intelligence.
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