Advises That Lost Orders Problem Being Fixed
Terry Adirim, MD, MPH, MBA, the program’s executive director
WASHINGTON, DC — VA has postponed the rollout of its new electronic health record (EHR) system to new facilities, including to Boise, ID, where it had been scheduled to go live last month.
This comes following a VA Office of the Inspector General (OIG) report that details how a lack of understanding of the new system led to thousands of missing patient orders and a new third-party cost estimate that suggests the cost of the system could skyrocket in coming years, thanks to delays in the rollout.
The OIG review found that, between when the system went live at the Mann-Grandstaff VAMC in Spokane, WA, in October 2020 and June 2021, more than 11,000 clinical orders were funneled to the “unknown queue”—a list within the system containing orders that could not be delivered to their proper location. The system did not provide an alert to the physician that the order was not delivered properly, and, due to a lack of training, VAMC staff did not know to regularly check the queue for missed orders.
A VA patient safety team review found that the error “created significant risk and caused harm to multiple patients.”
In February 2021, the system’s manufacturer, Cerner (now called Oracle Cerner after a purchase by the database management company), added a physician alert for when orders were sent to the unknown queue. In May 2021, VAMC staff reported, however, that the alert had not completely fixed the problem. A review at that time found 206 orders waiting unnoticed in the queue.
At a Senate VA Committee hearing last month examining the EHR delays, the program’s executive director, Terry Adirim, MD, MPH, MBA, explained that the unknown queue was a training error and not a flaw in the system.
“What happened during the Mann-Grandstaff deployment was poor communication,” she told the committee, “There were training failures, as well. No one was trained in using this particular feature and the process was not put in place. Since then, part of the system that caused people to put in orders that could not be filled—that part has been reconfigured. A process has been put in place and is communicated very clearly, and staff has been trained specifically how to use the unknown queue.”
One reason so many orders were funneled into the unknown queue is because of the complexity of the drop-down menu that physicians used to select where the order should go. The menu, Oracle Cerner Executive Vice President Mike Sicilia said, had “too many items and was not intuitive.”
Culling that drop-down menu should help prevent orders from going to the queue in the first place, Sicilia said.
“We’re also developing an automatic trigger [where a] physician will be alerted immediately if an order shows up as unassigned. That alert will continue to persist until they rectify the order and assign it to the proper location,” he added. “The name of the unknown queue is not so great. It should be the ‘look here’ queue because there’s something that doesn’t belong there.”
Legislators were also concerned about overall system stability. Since the October 2020 go-live, Mann-Grandstaff has experienced 48 outages of the system. Half were “degradations” where the system was live, but its functions were impeded. The other half were complete shutdowns.
“A lot of the problems were around where the system was designed to be resilient, but it didn’t perform in a resilient way,” explained VA Chief Information Officer Kurt Delbene. “So a piece failed, and it’s supposed to fail over to another piece of capacity, and it didn’t, so we’re pushing them to get those problems solved.”
Delbene also said that VA is pushing Oracle Cerner to ensure that the system will be recoverable in case of a more disastrous collapse.
“If the entire thing went down, do they have another site that’s fully available and deployed that they can switch over to? We’re pushing them to have an engineering plan across all of these issues,” Delbene said.
According to Sicilia, these kinds of outages are not unexpected since “the Cerner EHR system is currently running on a dated architecture and technology.”
“Today I am announcing our intention to move the Cerner application within a modern cloud data center within six-to-nine months that will deliver far better performance and stability for the end user,” he declared. “Candidly, we anticipate that this alone is the most important change we can make in terms of system reliability.”
The move, he added, will be done at no extra cost to VA or DoD, which is much farther along in its own rollout of the Oracle Cerner system.
As for the current pause on bringing the system to any new facilities, Adirim said that this represents a success in VA’s safety processes.
“We held a go/no-go decision with Boise today,” Adirim explained. “We worked with the VAMC director as well as the VISN director, and on this particular call we had VHA leadership in order to discuss the pros and cons and how we should move forward. And today we made the decision that the system … was not in place for us to be confident that we could have a successful deployment. That’s the change in the deployment strategy that I was able to bring to this program.”
She added, “As for the larger medical centers, we brought it to the VA secretary that we weren’t ready to go to larger, more complex, sites because of the system stability issues. We wanted to give Cerner more time to address those issues.”
While legislators have been pushing for just this kind of delay so VA and Oracle Cerner could solve existing problems, new projections have them concerned about the long-term costs. The Institute of Defense Analysis (IDA) issued a report that estimates the full cost at $50.8 billion over a 28-year span. That includes $39 billion during the 13-year implementation period and $17 billion to sustain it for the following 15 years.
Adirim told legislators that this estimate does not accurately reflect the cost of the EHR deployment.
“It’s really comparing apples to oranges,” she declared. “[The IDA estimate] is a life-cycle cost estimate. It’s a 25-year horizon, as well as including a risk premium in there in case certain things don’t happen and it’s going to cost more.”
Despite months of delays, VA still hopes to deploy the system on its 10-year schedule, but the agency is crafting back-up plans if they don’t hit their mark.
“Due to some of these delays and changes in the schedule, we are doing some contingency planning with regard to extending the schedule,” she said. “We don’t anticipate that the cost is going to be too much more. But we do anticipate if we have to extend that we will have to ask for money.”
