VA Admits Oracle Cerner EHRM Issues Contributed to 4 Veteran Deaths

In a recent briefing on March 15, 2023, the Department of Veterans Affairs (VA) officials informed the Senate committee staff of six "catastrophic harm" incidents, including veteran deaths, linked to patient safety issues with the Oracle Cerner VA EHR Modernization (EHRM) project.

Specifically, the use of the Oracle Cerner EHR led to four veteran deaths, said Senator Richard Blumenthal, (D-Conn), according to The Spokesman-Review. Blumenthal also revealed that a patient at Spokane's Mann-Grandstaff VA Medical Center was one of the deceased veterans, and three veterans died in central Ohio after the launch of the Oracle Cerner system in April 2022.

While the root causes of the deaths were not provided, the Oracle Cerner EHR system has been linked to patient safety problems, including prescription processing, medication management, clinical referrals, and identifying patients at risk of suicide.

This is not the first time the Oracle Cerner VA EHR has experienced challenges. A 2021 OIG report found that medical record mistakes had harmed at least 148 veterans after the VA implemented the system at initial sites in Washington. Additionally, researchers discovered that the system had yet to deliver more than 11,000 orders for specialty care, lab work, and other services without alerting healthcare providers that the system had lost the order.

Around 10,000 VA employees use the Oracle-Cerner EHR system across five medical centers, and it has yet to undergo full deployment. However, there have been reports of delays, disruptions, and rising costs, according to Committee Ranking Member Senator Jerry Moran, (R-Kan), as reported by FedScoop. He posited that the VA and Oracle Cerner must work together more effectively to address issues with the system.

During the same hearing, several other lawmakers expressed frustration with the VA EHRM program. Patty Murray, the chair of the Senate Appropriations Committee, called the risks to patient safety caused by flaws in the system "totally unacceptable" and threatened to withhold funding for the project unless the issues are resolved. Until Murray sees proof that the system is working safely, she is “not sure it makes sense...to continue to fully fund the budget request for this system.”

When asked about the recent deaths, Neil Evans, MD, chief officer for the Office of Connected Care within the VHA, said while testifying at the hearing, “We take every episode where there is harm, and we evaluate it carefully to try and understand why. It’s never good, we are never satisfied when it happens.”

However, Evans mentioned that the alternative, using the VA’s legacy system, VistA, is also not without faults.

“Yes, there have been cases that have found that frankly with both our EHR on the VistA side as well as with the Oracle Cerner EHR, that the EHR has been a potential contributor to that harm,” he said.

In between discussing the ongoing EHR patient safety issues, the VA also mentioned renegotiating a five-year option period for Oracle Cerner's Millennium EHR platform aiming to incorporate new penalty provisions, according to separate FedScoop reporting.

“One of the key items we’re looking at is improving the frustration…around the limited enforcement mechanisms of the May 2018 contract. It’s very restrictive,” Michael Parrish, VA’s chief acquisition officer, said. “What we are renegotiating with the Oracle team is to strengthen and add more enforcement mechanisms, especially around service level agreement.”

Sen. Jon Tester, D-Mt., the chairman of the Senate Veterans Affairs Committee, criticized Oracle Cerner, and called for “tougher” terms in the renegotiated VA EHR contract, including “severe penalties for poor performance.” Tester also suggested that “if Oracle won’t agree to those terms, then the VA should be prepared to…renegotiate an entirely new contract or find a different team of partners.”