WASHINGTON — Responding to a draft surveillance report that found a computer system at the VA Hospital in Spokane harmed dozens of veterans, Veterans Affairs Secretary Denis McDonough said Wednesday his confidence in the system had been shaken.
The Spokesperson’s Review reported On Sunday, a draft report from the VA’s Office of Inspector General found 148 cases of harm resulting from a flaw in the electronic health record system developed by Cerner Corp. since its launch at Mann-Grandstaff VA Medical Center in October 2020. It also revealed that VA security experts informed McDonough’s deputy of the harm and warned him of the continuing risks in October 2021, months before the secretary told lawmakers in April that he would not continue to roll out the system if those experts determined it posed risks to veterans.
“If I had known what I know today, when I appear before Congress, I would have answered these questions differently,” McDonough said Wednesday in response to a question from The Spokesman-Review. He added that he had been in contact with the Office of Inspector General and said, “I’ve definitely gotten smarter on these reports over the past two months.”
After The Spokesman-Review informed the VA that it had obtained the draft report, the department told the Military Times On Friday, it would postpone the planned launch of the Cerner system in the Puget Sound area from August 27 to March 2023. On Tuesday, the VA announced that it would delay the planned Saturday deployment in Boise by about a month, until August 23. July.
In a statement Wednesday, Sen. Jim Risch, R-Idaho, called on the VA to suspend the launch of the system at Boise VA Medical Center and its affiliated clinics in eastern Oregon and Idaho until all problems are solved.
“The issues with the Cerner electronic health record system that my colleagues and I described in our April letter to Secretary McDonough, in addition to new issues that arose this week, have still not been resolved,” Risch said. , adding that Cerner’s system “should not be implemented in Boise VA, or any other VA location, until the VA can assure us that it will not harm our veterans.
In his monthly briefing with reporters on Wednesday, McDonough called patient safety “our No. 1 concern at all levels at VA.”
“I now know there are instances of patient harm and there could be a range of contributing factors,” he said, adding that the team of safety experts that he deployed to Spokane “at least can’t rule out.” that the Cerner system played a part in the evil.
The draft report focuses on a single issue with the system, identified by the VA security team as a top priority, which prevented orders sent by doctors and nurses from reaching their recipients, without alerting the sender. of the error. This resulted in the loss of thousands of orders in what clinicians call “the unknown queue,” leading to delays in care that worsened health issues and, in one case, left a veteran on the brink of suicide.
The draft report also mentions that the VA’s safety team identified at least one case of “catastrophic” harm, defined by the VA as “death or permanent loss of function”, related to a separate issue not detailed. in the report. McDonough said he was not aware of any patient deaths linked to the Cerner system, but declined to address specific instances of harm.
McDonough called communication between the patient safety team and the VA office responsible for implementing the Cerner system “the cornerstone of how we ensure patient safety” and said he believes that he better communication was occurring since the VA implemented weekly meetings between the two offices earlier this year. . The secretary also encouraged clinicians at Mann-Grandstaff and other institutions using the Cerner system to share their feedback with VA leaders, even inviting them to contact him directly.
When asked what the department would do if the Cerner system didn’t meet the needs of the VA, McDonough said he was “not ready to answer guesswork,” but pledged to conduct to complete the project – begun by the Trump administration – with as much diligence and transparency as possible.
“We would obviously make decisions on that,” he said, “but we’re currently doing our best to make the Cerner option work.”
While the new system won’t be rolled out until 2023 at sites in Seattle, Portland and elsewhere west of the Cascades, healthcare providers will continue to use it while Cerner — acquired June 8 as part of a agreement worth $28.3 billion – works with the VA to address issues that healthcare providers believe make their jobs less efficient and increase the risk of harm to patients.
At facilities in Idaho and Oregon slated to adopt the system on July 23, McDonough said employees would go through “a whole series of pre-deployment training” that uses “really significant cutting-edge work done by the ‘Spokane team’.
Northwest lawmakers continued to criticize the VA and Cerner.
“The details of this draft report are deeply troubling and have serious implications for our nation’s veterans,” Rep. Dan Newhouse, R-Sunnyside, said in a statement Tuesday, pledging to work with the House committee. VA and Rep. Cathy McMorris Rodgers, a Republican from Spokane who slammed the VA and Cerner during the weekend.
Newhouse developed in a column published on Wednesday in The Star at Grand Coulee, calling on the VA to provide additional resources to Spokane and Walla Walla hospitals that will continue to use the Cerner system while the issues are resolved.
Rep. Kim Schrier, a Democrat whose district includes a clinic in Wenatchee that implemented the Cerner system in October 2020 with Mann-Grandstaff, said in a statement that it was unacceptable for any system to cause harm.
“Cerner and the VA need to make sure veterans receive excellent, timely care,” she said. “And must also ensure that staff are not burdened with workarounds to a knowingly faulty system. The VA should absolutely suspend the rollout of this system nationwide until this issue can be resolved.
Schrier, who used a Cerner system as a pediatrician before entering Congress in 2019, said the issues reported by VA clinicians go beyond “a few issues” you might expect during the adoption of a new computer system.
“The VA, the Biden administration and Cerner all share guilt for not informing the VA of this flaw,” she said. “I will continue to do everything I can to ensure Wenatchee CBOC veterans receive the care they need and I will hold this administration accountable until it is fixed.”
The top Democrats on the House VA committee and subcommittee overseeing Cerner’s deployment, Representatives Mark Takano of California and Frank Mrvan of Indiana, also released a statement Wednesday.
“While we are still waiting for the VA Office of Inspector General to release its report regarding an ‘unknown queue’ in the Cerner Millennium electronic health record, preliminary findings raised in media coverage over the weekend end are seriously troubling and contradict what we have heard from VA officials in public testimony,” the lawmakers said.
“We have already entered into discussions with VA about Cerner’s performance and requested an official briefing on the upcoming report. Once published, we will carefully review the findings to determine if there are any contractual or legal implications of these preliminary findings.