From a failed suicide attempt to an unnecessary emergency care visit, technical glitches in the process of integrating Oracle’s Cerner software into U.S. veterans hospitals have led to serious health consequences, according to a new report released Thursday by the Office of the Inspector General of Veterans Affairs.
The new report follows another damning OIG report published a year ago citing integration issues with Cerner’s electronic health records software, which was acquired by Oracle in December for $28.3 billion. dollars. The company signed a $10 billion contract in 2018 to update the medical and financial records system used by the VA to provide care to millions of military veterinarians.
Thursday’s report provides detailed information about how the Cerner electronic records system deployed at Mann-Grandstaff VA Medical Center in Spokane, Wash. inadvertently sent patient follow-up care orders down a memory hole. When order information was not recognized as a match by the software, it was sent to an “unknown queue”.
“From the facility’s go-live in October 2020 to June 2021, the new EHR failed to deliver over 11,000 orders for requested clinical services,” the report said.
The OIG provided examples showing the impact of this issue on patients. After an order for follow-up care for a homeless patient at risk of suicide landed in an unknown queue, follow-up care never happened. The patient then contacted the VA crisis line saying he had “a razor in his hand and a plan to kill himself”. Subsequently, he was hospitalized in psychiatry.
Another patient did not receive compression tubing to help with lower leg swelling because the order went to the unknown queue. The patient ended up requiring urgent care for worsening edema.
“Of the many findings of the GAO and the Inspector General, this latest report is the most disturbing. Delays and setbacks in government contracts on major IT projects are one thing; harm to patients is another.” , said Dr. Shravani Durbhakula, a pain physician and anesthesiologist at Johns Hopkins School of Medicine, in a statement sent to the protocol.
Cerner did not respond to a request for comment for this story.
A report released a year ago by the VA’s OIG showed that the main problems stemmed from Cerner’s approach to training VA hospital staff to use the system. He cited “significant gaps in training for commercial and clinical workflows” and a “lack of clinical knowledge” among Cerner trainers.