The Office of the Inspector General (OIG) report on the troubled rollout of Cerner Millenium at the VA continues to reverberate. The final report, revealed last month in draft [TTA 21 June], detailed a flaw in Cerner’s software that caused the system to lose 11,000 orders for specialty care, lab work, and other services – without alerting health care providers that the orders (also known as referrals) had been lost. This was the infamous ‘unknown queue’. The final report identified 149 adverse events related to the lost orders, including a homeless veteran at risk of suicide whose follow up appointment was lost, threatened to kill himself, but fortunately was helped (and hospitalized) outside the VA system. None of these problems surfaced before the go-live at Mann-Grandstaff VA Medical Center, but did four days later–and apparently other end users weren’t informed of the problem until a year later.
In FierceHealthcare’s update published today, “The OIG called it “troubling” that the deputy secretary [Donald Remy] “appears to absolve Oracle Cerner for its failure to inform VA of the unknown queue while placing the blame for outcomes from the unknown queue on VHA end-users.”” and “In a second report (PDF) released last week, the federal watch agency says VA project executives misrepresented its EHR training program” starting with Mann-Grandstaff. Two VA senior staffers responsible for training employees there gave inaccurate data to inspectors.
Cerner Millenium and the VA implementation (and other problems around the DOD implementation) are now Oracle’s headache. Executive Vice President Mike Sicilia was scheduled to testify Wednesday afternoon at a Senate hearing this afternoon to answer the many questions raised about the EHR rollout and safety problems.