McMorris Rodgers Outraged By Patient Harm, VA Leadership’s Attempted Training And Proficiency Cover-Ups

Investigation Finds 149 Veterans Harmed and Exposes Leadership Failures

Jul 14, 2022
Press
Veterans

Washington, D.C. –  Eastern Washington Congresswoman Cathy McMorris Rodgers (WA-05) today released the following statement in response to two reports released by the VA’s Office of Inspector General (OIG) that found 149 veterans have been harmed by the Oracle Cerner Electronic Health Record (EHR) system, as well as that VA leadership manipulated data concerning training proficiency on the new system:

“The findings from the VA Inspector General’s investigation are even worse than I suspected. Not only were 149 veterans in Eastern Washington harmed by the broken electronic health record system, VA and Oracle Cerner leadership downplayed the severity of the issue of the unknown queue, failed to adequately train providers on site, and manipulated data to support a non-factual narrative about general system training and user proficiency,” said Rodgers.

“I am appalled by all parties involved in this disaster,” she continued. “Oracle Cerner’s failure to brief VA leadership and train the providers on the unknown queue–a feature they intentionally designed–is reprehensible. As for VA leadership, their manipulation of training and system proficiency data to save face has put veteran safety at risk and is morally bankrupt. This agency has completely lost sight of its mission and done irreparable damage to my trust in their ability to deliver results for Eastern Washington veterans.”

Report 1: The New EHR’s Unknown Queue Caused Multiple Events of Patient Harm

According to the report, the new EHR failed to deliver more than 11,000 orders to the correct service locations from facility go-live from October 2020 through June 2021. Instead, these orders were delivered to an unknown queue, which Oracle Cerner designed to capture orders entered by providers that the new EHR cannot deliver to the intended location. 

However, the new EHR failed to alert providers that the orders were sent to the unknown queue.

Shortly after VA’s go-live with the new EHR, facility staff identified missing orders, and they could not see orders sent to the unknown queue. Oracle Cerner was aware of the EHR’s unknown queue prior to VA’s go-live with the new EHR, but they did not inform VA end-users of the unknown queue or provide guidance to address the unknown queue in advance of go-live with the new EHR.

As a result, the new EHR’s delivery of orders to the unknown queue created a patient safety risk, which the Veterans Health Administration (VHA) assessed as major severity, frequently occurring, and very difficult to detect. In total, 149 cases of patient harm took place, including 2 major harm, 52 moderate harm, and 95 minor harm events.

Click here to view the full report.

Report 2: Senior Staff Gave Inaccurate Information to OIG Reviewers of EHR Training

According to the report, two of the VA Office of Electronic Health Record Modernization (OEHRM) Change Management leaders failed to provide timely, complete, and accurate information and data to the OIG, which impeded oversight efforts.

Specifically, Change Management’s executive director and the director for training strategy:

  • Presented documentation to OIG staff that described a training evaluation plan without disclosing that the action items had not been fully implemented and that no training evaluation plan had actually been reviewed or approved;
  • Provided data with significant errors that resulted in doubling the reported proficiency check pass rate from 44 percent to 89 percent; and
  • Failed to recognize red flags and confirm accuracy prior to reporting the revised results, which likely would have revealed the removal of all failing proficiency check scores from the calculations.

Click here to view the full report.

TIMELINE OF CATHY’S ACTIONS:

  • In March 2021, Cathy called for a review of the Cerner electronic health record (EHR) system at the Mann-Grandstaff VA Medical Center. Her request was immediately agreed to by Department of VA Secretary Denis McDonough. 
  • In June 2021, the review was completed and revealed problems at Mann-Grandstaff that must be resolved before the system is deployed at additional VA sites.
  • In July 2021, Cathy called for increased transparency around the 90-day strategic review of the Cerner EHRM at Mann-Grandstaff and urged Secretary McDonough to address concerns around the real improvements that have yet to be made to the system.
  • In November 2021, Cathy testified before the House Veterans Affairs Committee and encouraged Deputy Secretary Remy to join her on a visit to the Mann-Grandstaff. The deputy secretary later canceled the visit.
  • In February, Cathy called for the immediate delay of the EHR to the Walla Walla VA Medical Center until the issues with the system were resolved.
  • In March, Cathy released a statement following the crash of the Cerner EHR at Mann-Grandstaff that resulted in the system being offline for a full day.
  • In May, Cathy called for transparency from VA leadership amid a growing number of outages and rumors at the facility.
  • In June, Cathy blasted the VA and Cerner for reports of patient harm at the Spokane VA.

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