Lawmakers Call for Further Delay of VA EHR Implementations for Patient Safety

The Department of Veterans Affairs (VA) has postponed several EHR implementations after a draft OIG report found that the Cerner EHR system has negatively impacted patient safety at Spokane’s VA hospital, according to reporting from The Spokesman-Review.

The draft report revealed that a flaw in the Cerner EHR caused 148 cases of harm at Mann-Grandstaff VA Medical Center since its implementation in October 2020.

Additionally, the draft report claims that VA safety experts briefed McDonough’s deputy about the harm and warned of ongoing risks in October 2021, months before the secretary told lawmakers he would halt system deployment if experts found it presented risks to veterans.

“If I had known what I know today when I was appearing before Congress, I would have answered those questions differently,” McDonough said Wednesday in response to a question from The Spokesman-Review.

He noted that he had been in contact with the OIG and said, “I’ve definitely gotten smarter on these reports over the course of the last couple of months.”

After The Spokesman-Review notified the department that it had obtained the draft report, VA told the Military Times on Friday it would delay the Cerner system’s planned launch in the Puget Sound region from August 27 to March 2023.

On Tuesday, the department announced it would postpone a planned Saturday implementation in Boise until July 23.

Sen. Jim Risch, R-Idaho, urged VA to halt the system’s launch at the Boise VA Medical Center and its affiliated clinics until Cerner and VA address system deficiencies.

“The problems with the Cerner electronic health record system my colleagues and I outlined in our April letter to Secretary McDonough, in addition to new issues that arose this week, still have yet to be resolved,” Risch said in a statement released Wednesday.

In his monthly briefing with reporters Wednesday, McDonough called patient safety “our number one concern across the board at VA.”

“I do now know that there are instances of patient harm and that there could be a range of factors that contribute to that,” he said, adding that the patient safety team he deployed to Spokane “at least can’t rule out” that the Cerner system played a role in the harm.

The draft report found that 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.

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 draft report also mentioned that the VA safety team found at least one case of “catastrophic” harm —indicating “death or permanent loss of function”—related to a separate problem not detailed in the report.

McDonough said he was unaware of any patient dying in connection to the Cerner EHR implementation but declined to address specific cases of harm.

He noted that communication between the patient safety team and the VA EHR implementation office is “the lifeblood of how we ensure patient safety.”

The secretary also said that he believes better communication is occurring between the groups after VA implemented weekly meetings between the two offices earlier this year.

McDonough encouraged clinicians at Mann-Grandstaff and other facilities using the Cerner EHR to share their feedback with VA leaders, even inviting them to reach out to him directly.

When asked what VA would do if the Cerner system fails to meet the department’s needs, McDonough said he was “not ready to answer hypotheticals.” Still, he pledged to carry out the project as diligently and transparently as possible.

“We’d obviously make decisions about that,” he said, “but we’re right now trying our darnedest to make the Cerner option work.”

Reps. Mark Takano of California and Frank Mrvan of Indiana, the top Democrats on the House VA Committee and the subcommittee charged with oversight of the Cerner rollout, issued a statement Wednesday.

“Although we are still waiting for the VA’s Office of Inspector General to release its report related to an ‘Unknown Queue’ within the Cerner Millennium electronic health record, the draft findings raised in media coverage over the weekend are seriously troubling and contradict what we have heard from VA officials during public testimony,” the lawmakers said.

“We have already begun discussions with VA on the performance of Cerner and requested an official briefing on the forthcoming report,” they continued. “Once released, we will be reviewing the findings closely in order to determine if there are any contractual or legal repercussions of these draft findings.”