Washington, D.C. – Eastern Washington Congresswoman Cathy McMorris Rodgers (WA-05) today questioned VA leadership over their handling of the new electronic health record (EHR) system, ongoing concerns with patient care, and reports about services being reduced at Mann-Grandstaff. This comes just one day after Cathy sent a letter to VA Deputy Secretary Donald Remy calling on the department to plan for long-term staffing needs as medical centers in Eastern Washington manage the additional workload created by the failed implementation of the EHR.

This was Cathy’s first opportunity to demand answers from leadership since the VA Office of Inspector General (VAOIG) released two reports that found 149 veterans have been harmed by the EHR system, as well as that VA leadership manipulated data concerning training proficiency on the new system.

During today’s House Veterans’ Affairs Committee hearing on patient safety and the EHR modernization program, Cathy demanded answers from Mann-Grandstaff Medical Director Dr. Robert Fischer, Program Executive Director of VA’s Electronic Health Record Modernization Integration Office Dr. Terry Adirim, and Deputy Inspector General of the VA David Case. 

Below are highlights and excerpts from their exchange:

VETERANS FALLING THROUGH THE CRACKS

CMR: “Mr. Case, not only has the Cerner EHR turned Mann-Grandstaff upside down, but it has been a constant battle to uncover the truth from the VA. It is frustrating for me and veterans in my community to hear VA executives brush aside the concerns we have been raising since go-live. 

“Your recent report on the unknown order queue mentions one incident of catastrophic patient harm … in which a homeless veteran’s follow-up appointment with a psychiatrist got lost in the unknown queue. 

“He nearly attempted suicide, but fortunately he called the veterans’ crisis line and they got him to a local hospital. [T]his should never have been allowed to happen.

“Mr. Case, when did this incident take place? What safeguards were in place with respect to the unknown order queue then, as opposed to now?”

Case: “Yes, this was an incident that occurred very early in the process starting in December 2020 moving into January 2021. At that point, none of the mediating factors had been put in place at the time. In fact, there was a complete dependence by the VA on Oracle Cerner of what was in the unknown field.”

A CASE OF CATASTROPHIC HARM 

CMR: “Dr. Adirim and Dr. Fischer, let me tell you about another one of my constituents who is a victim of what is unfortunately looking like a failed EHR experiment right now. It took almost a year for one of my constituents to get a biopsy at Mann-Grandstaff, and he has aggressive cancer now. He finally had surgery early this year. His prospects are not good. [H]is experience at Mann-Grandstaff with the Cerner EHR has been absolutely inexcusable.

“Dr. Adirim and Dr. Fischer, without revealing any names, are you familiar with this veteran? Why did he fall through the cracks, and what have you done to make sure it never happens to another veteran?”

Adirim: “First, I want to say that I am really sad to hear that about this veteran. Certainly, no one should suffer the consequences of a process of communication that occurred at the initial deployment of our new EHR, so I’m sorry to hear that. But, without more details about the veteran and the circumstances I can’t answer that question.”

Fischer: “That resulted from a misdirected follow up order where the individual was supposed to be seen by urology and thankfully, but unfortunately as well, he came back and asked what ever happened to that urology referral. And then we discovered that it had went into a queue and we had not yet reviewed that case in order to intervene. I know this veteran pretty well, and I’m awfully sorry that this occurred to him.” 

ADDRESSING SAFETY AT MANN-GRANDSTAFF

CMR: “Dr. Fischer, do you have the tools you need from the VA central office to ensure safety is not compromised, and that all services are available in a timely fashion at Mann-Grandstaff?”

Fischer: “My personal opinion is that the Cerner health record needs to be improved so that all of these various mitigation strategies, which are people dependent and generally of low reliability, can be removed and we will have a fully functioning, high performing health record. Until that’s done, our employees and our veterans will be involved in these patient safety issues.”

CMR: “Dr. Fischer, as you know, there have been reports that in-patient services at Mann-Grandstaff may close. Can you commit today that in-patient services are not in jeopardy at Mann-Grandstaff?”

Fischer: “Well, I can tell you from my perspective, they are not. But I’m not the decider in issues related to services – whether they’re continued, restricted, expanded. But I believe that, like our employees do, it’s important to maintain inpatient services and – if possible – to expand those services in Eastern Washington.” 

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