From missed suicide attempts to unnecessary urgent care visits, tech glitches in the process of integrating Oracle’s Cerner software into U.S. Veterans Affairs hospitals have led to serious health consequences, according to a new report published on Thursday by the Veteran’s Office of Inspector General.
The new report follows another malicious OIG report published last year citing problems with the integration of electronic health records software from Cerner, which Oracle acquired in December for $ 28.3 billion. The company won a $ 10 billion contract in 2018 to update the system of health and financial records used by the VA to deliver care to millions of military veterinarians.
Thursday’s report provides detailed information on how the Cerner electronic records system was deployed at Mann-Grandstaff VA Medical Center in Spokane, Washington without inadvertently sending orders for follow-up patient care into a memory hole . When order information is not identified as a software match, it is sent to an “unknown queue.”
“From the facility’s go-live in October 2020 to June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services,” the report said.
The OIG provided examples showing the impact of this problem on patients. After an order for follow-up care for a homeless patient at risk for suicide went into unknown queue limbo, follow-up care never occurred. The patient later contacted the crisis line in the VA and said he had a “razor in hand and had a suicide plan.” Then, he was hospitalized psychiatrically.
Another patient did not receive a compression hose to help with lower leg swelling because the order went to an unknown queue. The patient requires immediate care for exacerbation of edema.
“Of the many conclusions from the GAO and Inspector General, this latest report is the most worrying. Delays and setbacks in government contracts on major IT projects are one thing; patient damage is another,” he said. said Dr. Shravani Durbhakula, a pain physician and anesthesiologist at the Johns Hopkins School of Medicine, in a statement sent to Protocol.
Cerner did not respond to a request to comment for this story.
A report published last year by the VA’s OIG highlighted key problems arising from Cerner’s approach to training VA hospital staff in the use of the system. It cited “significant training gaps for business and clinical workflows” and a “lack of clinical knowledge” among Cerner trainers.