Draft OIG Report Finds VA EHR Patient Safety Issues Have Harmed 100+ Veterans

The VA continued to roll out the EHR at additional facilities despite warnings from a patient safety team, according to a draft OIG report.

A draft report from the Department of Veterans Affairs (VA) Office of Inspector General (OIG) revealed that the Cerner EHR system at Spokane’s VA hospital has put patient safety at risk, causing harm to at least 148 veterans, according to reporting from The Spokesman-Review.

The draft report also claims that EHR vendor Cerner knew about a flaw that caused the harm but failed to fix it or inform the VA before the system went live at Mann-Grandstaff VA Medical Center in October 2020.

VA Secretary Denis McDonough said this spring that he was not aware of any harm caused by the EHR and he would halt its rollout if safety experts determined it increased risk to veterans.

However, the draft report revealed a VA patient safety team briefed the VA’s deputy secretary in October 2021 about the harm and ongoing risks. Despite those warnings, the VA has brought the system live at more facilities in Washington, Idaho, Oregon, and Ohio.

The EHR failed to deliver over 11,000 orders for specialty care, lab work, and other services without alerting providers the orders had been lost, the draft report found.

Those lost referrals resulted in care delays and what a VA patient safety team categorized as dozens of cases of “moderate harm” and one case of “major harm.”

The content of the draft, obtained by The Spokesman-Review from multiple sources, may change by its publishing date. The final report will include responses from VA leadership not included in the draft.

The VA did not respond to questions from the news outlet about the draft report. However, after The Spokesman-Review sent the questions, VA officials told Military Times they would delay the EHR’s planned launch in Seattle, Portland, and other large facilities until 2023.

While the draft OIG report notes that the VA and Cerner have taken steps to limit the number of orders that get lost in what users describe as the “unknown queue,” it calls those mitigation efforts “inadequate.”

Previous OIG reports have identified a variety of problems with the Cerner system, but the draft report shows the scale of its impact and concludes for the first time that it caused harm to veterans.

“To protect the integrity of our work, the VA Office of Inspector General does not publicly disclose the findings from any of its projects until the publication of a final report,” OIG spokesman Fred Baker said in a statement to the news outlet.

The final OIG report is expected to be released later this summer.

“I’m outraged by the reports of veterans being harmed by the Cerner electronic health record system,” Congresswoman Cathy McMorris Rodgers (WA-05) wrote in a press release. “For more than a year, Cerner and VA leadership have avoided accountability, withheld key findings and information, and put the lives of our nation’s heroes at risk.”

McMorris Rodgers noted that the lack of transparency has led to a breakdown in trust between veterans and the VA.  

“I’ve had numerous conversations with both VA and Cerner leadership, in which I repeatedly raised concerns about ongoing problems with the system,” she said. “Time and time again, my concerns—and the valid concerns raised by veterans and providers—were dismissed.”

“It’s now clear the VA and Cerner both knew about major systematic flaws, yet they blatantly disregarded patient safety by rolling out the system to other facilities,” McMorris Rodgers continued. “These actions are reprehensible and entirely unacceptable for this agency, which has clearly lost sight of its sole mission of serving veterans.” 

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