Computer glitches harmed 'nearly 150' patients after Oracle Cerner system go-live
Problems with the October 2020 veterans’ hospital software launch being fixed quickly, promises Oracle
Computer errors following the go-live of a new Oracle Cerner electronic health records system harmed nearly 150 patients at a Washington hospital, as revealed during a hearing in the US.
Four days after Mann-Grandstaff VA Medical Center in Spokane switched over to its new Cerner software, staff became aware of an "unknown queue" problem which had the potential to cause harm to patients, a US Senate Committee on Veterans' Affairs heard last week.
Oracle acquired Cerner — a specialist developer of electronic health records systems used throughout the world — for $28.3 billion in June.
With the acquisition, Oracle inherited a 10-year, $10 billion contract with the Department for Veterans' Affairs signed in 2018. The deal was to design a health records system for VA hospitals and communicate with an EHR system that Cerner was installing for the US Department of Defense, replacing legacy systems, some of which were 40 years old.
The committee heard the total budget for the project could bulge to $49 billion, $40 billion over early cost estimates, according to Senator Jerry Moran, (R-Kan), who was citing an Institute for Defense Analysis report.
Witnesses described how the early rollout at five hospitals had been fraught with problems.
Speaking at the hearing, David Case, deputy inspector general, Office of Inspector General, Department of Veterans Affairs, said (1:31:00) that the so-called "unknown queue" problem was among the top three.
He explained the Oracle Cerner EHR system requires a healthcare provider writing a medical order for tests or other services to match the order to a certain delivery location. If a provider's selected option does not match the order to the correct delivery location, then the order would go to the unknown queue. Healthcare providers were unaware that their orders were not being acted upon.
"Cerner leaders told us they had no knowledge that VA was told about the unknown queue before go-live. We were provided with exit documents noting a VA leader had approved of its use, but that official told us they had no awareness of it," Case said, adding, "This is reinforced by the fact that there was no training on the unknown queue, no planning for it and its existence was unknown at Mann-Grandstaff (hospital). As one VA clinician put it, 'We stumbled on the unknown queue'."
In 2021, Veterans Health Administration patient safety experts found 60 safety concerns with the new software: the unknown queue being among the top three highest risks.
The same experts identified "nearly 150 veterans at Mann-Grandstaff who suffered harm due to the unknown queue from go-live through to June 2021", Case testified.
Although Cerner and VA took action to minimize the problem during 2021 and 2022, every facility that uses the software would need to monitor and manage their unknown queue, Case said.
"We have concerns about the adequacy of the current mitigation plan," he said.
Other VA hospitals already using the Cerner system are Walla Walla (Washington), Columbus (Ohio), Roseburg (Oregon), and White City (Oregon). The VA plans for another 25 hospitals and medical facilities to go live with the system between now and the end of next year.
While the unknown queue problem lies in design and user training, the Cerner system has also hit stability problems. The EHR system in Walla Walla, Washington, went down for about 127 minutes in April.
Dr Gerard Cox, assistant under secretary for health for quality and patient safety, Veterans Health Administration, agreed that the unknown queue feature in the Oracle Cerner EHR was not working well and created instances of patient harm.
He said that since the first hospital went live on the system, technology and clinical teams had tried to mitigate the effects of the problem.
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"There have been strategies put in place to monitor that queue and make sure that the orders that were lost for several months are now identified and dealt with on a daily basis. I don't think I would say that a permanent fix is in place," he said.
Speaking to senators, Terry Adirim, program executive director, Electronic Health Record Modernization Integration Office, Department of Veterans Affairs, said: "The unknown queue is not something really to be fixed. It's a feature of the Cerner software. It is the way it is designed and people can talk about whether it is a good or bad design. What happened during the deployment was poor communication, nobody was trained in using this feature and a process was not put in place."
She also said that clinicians coping during height of the pandemic affected the implementation, adding patient safety was a top priority.
"Due to concerns in the first deployment, patient safety and risk reduction activities have been incorporated into every aspect of [further] deployments," she said.
Speaking before senators, Mike Sicilia, executive vice president at Oracle said Cerner and the VA had already implemented system changes to reduce the number of orders going into the unknown queue and to better address those orders that were sent into it.
Oracle planned to increase automation and alerts, as well as improve workflow designed largely to "prevent orders from ever entering the unknown in the first place," he added.
During the next six to nine months, with the approval of the VA and the DoD, Oracle would migrate the Cerner solution to an Oracle second-generation cloud infrastructure datacenter at no extra cost, he said.
"If something isn't working for caregivers or patients, we plan to fix it first and work out the economics later. Patients and providers will always come first. We won't let contract wrangling get in the way," he said. ®