VA’s New Electronic Health Record Causes Veterans Harm

If you've ever received treatment at a VA Medical Center, you've undoubtedly experienced delays. Depending on your facility, these delays could be significant.


I, personally, have experienced VA delays for relatively simple procedures of more than six months and I have waited in the emergency department for more than 8 hours.


Your wait times can certainly depend on the facility. One medical center or clinic might be more crowded than another. Of course, when VA does a poor job of reporting these wait times or actively hides the wait times - as the Phoenix VA famously did in 2014 - veterans can be harmed. This was the impetus to the improvement to the Veterans Choice Act, including an expanded set of reasons to refer a veteran to non-VA medical care.


Recently, the VA Office of the Inspector General found that the Mann-Grandstaff VA Medical Center in Spokane, Washington lost more than 11,000 referrals between October 2020 and June 2021 due to a software flaw. It is incredibly lucky that only 149 veterans experienced any harm, but the OIG report noted (without revealing any veteran's private medical data) that two experienced "major" harm.


The problem was caused by VA's new Electronic Health Record (EHR) software made by Oracle Cerner (Cerner was acquired by Oracle in June of 2022). This software had its initial rollout at the Spokane VA. We previously noted the delays in deploying the new system for testing and the concerns the Government Office of Accountability (GAO) had with the software at the time.


Well, the GAO did not predict this particular problem. The programmers at Oracle Cerner created a special folder for referrals whose destination was not able to be identified by the system. Specifically, the software allowed for care providers to select a location for the referral from a dropdown list and if that location did not have a match for the type of referral, that referral then went into a folder called "unknown." That, in itself, is not the problem.


The problem is that the software failed to notify your doc that the referral went into the "unknown" referral folder. So, your doc thinks the referral is in, but nobody actually knows about it, and the referral just sits there. And you wait. If what you're waiting for is important, you suffer harm.


Fortunately, VA noticed the flaw which has since been fixed. However, some veterans were already harmed.


You can read the OIG report below.


More information:


https://www.va.gov/oig/publications/report-summary.asp?id=5170


https://www.vet4vet.net/post/new-va-electronic-health-records-system-delayed-again-because-of-serious-problems


https://www.military.com/daily-news/2022/07/19/roughly-150-patients-harmed-flaw-new-va-medical-records-system-watchdog-finds.html?ESRC=eb_220720.nl


https://www.azcentral.com/story/opinion/op-ed/2022/04/26/va-still-fudging-wait-times-veteran-care-years-after-scandal/7415443001/


https://www.cerner.com/perspectives/oracle-acquisition-of-cerner-the-future-of-healthcare