A glitch in the Cerner electronic health record system for the Department of Veterans Affairs led to 11,000 unfilled requests that caused harm to at least 149 patients at the Mann-Grandstaff VA Medical Center in Spokane, Washington.

Named Cerner Millennium, the system contained an “unknown queue” where orders for follow-ups, specialty care or lab work would go when they did not match a destination. Oracle Cerner built the queue but failed to inform hospital staff, causing orders to go missing between October 2020 and June 2021, according to a report by the VA's Office of Inspector General.

This led to two counts of major harm, 52 of moderate harm, and 95 of minor harm, with physicians receiving no warning that orders were not filled. One homeless veteran even called the VA’s crisis line with the means to end his life after his psychiatry referral was lost. First responders saved his life.

In a statement, House Veterans Affairs Committee Chairman Sen. Jon Tester, D-MT, called the flaw a “clear failure” and said Oracle Cerner needs to deliver a functioning, quality system.

VA employees discovered the problem when they filed a trouble ticket about the orders four days after the Mann-Grandstaff system went live. The hospital established a process for canceling and reentering them but still faced challenges due to the queue only being visible to Cerner employees.

In its report, the OIG recommended that VA Deputy Secretary Donald Remy review Oracle Cerner's failure to inform the VA and fix the technology.

While Remy agreed with the recommendations, he said the queue was purposefully created to capture undeliverable orders and was not "indicative of carelessness or negligence." He also said that it was not accurate that 11,000 orders were left unfilled, as many were X-rays or other radiological orders not made by physicians.

Purchased in 2018 for $16 billion, the VA system has faced numerous setbacks in its rollout, including outages, training issues and financial problems. In June 2022, the agency suspended further installations until 2023.

In a June 27 hearing, the Senate Veterans Affairs Committee called the system a “total mess” from which Oracle Cerner has been able to profit, and criticized VA Secretary Denis McDonough for the failures.

“At the end of the day Secretary McDonough has to take responsibility for it because he’s in charge of the VA,” Rep. Matt Rosendale, R-MT. told FedScoop. “So it’s up to him to hold everyone else accountable.”

Back to HCB News

Health IT Homepage