The final version of the VA Office of Inspector General's report on the electronic health record deployment at Mann-Grandstaff VA Medical Center was published on July 14.

As was noted when a draft of the report was released this past month, the VA watchdog undertook a rigorous review of the new Veterans Health Administration EHR, and found 149 instances of patient harm (mostly characterized as "minor," but with a couple significant adverse events detailed by the IG) related to an element of the Oracle Cerner EHR known as the "unknown queue" – a glitch where the tool to manage orders with incomplete routing information failed to alert VA clinicians when those notes didn't arrive where they were needed.

"The new EHR’s unknown queue represented an element that ultimately led to thousands of orders for medical care not being delivered to the requested service, placed patients at risk for incomplete care, and caused multiple events of patient harm," said the OIG report. "Oracle Cerner failed to inform VA end-users of the existence of the unknown queue and put the burden on VA to identify and address the problem."

Healthcare IT News has been chronicling the challenges with the VA's rollout for some time.

Back in May 2021, reports first surfaced of potential patient safety concerns with the EHR at Spokane, Washington-based Mann-Grandstaff, the first go-live site for the VA's massive health IT modernization project.

A team from the VHA National Center for Patient Safety team was sent to Spokane, where it identified some five dozen safety concerns across nine core domains, according to the report. "One of three concerns with the highest patient safety risk" was the unknown queue.

Upon review, the OIG discovered that the EHR "sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the intended care or service location (e.g., specialty care, laboratory, diagnostic imaging)." The report notes that "every version of Oracle Cerner’s EHR has an option to activate the unknown queue."

The goal of the queue is to capture provider orders that the software can't deliver to the intended location. The problem is that the new EHR didn't alert clinicians that the notes weren't delivered to the intended location.

"From facility go-live in October 2020 through June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services," according to the OIG report. Moreover, the inspector general "did not identify any evidence that Oracle Cerner provided actionable information of the unknown queue to VA prior to go-live."

In February 2022, "Oracle Cerner updated the new EHR with an alert to providers when they attempted to create an order with an unmatched location," the report notes. "However, in May 2022 a VHA leader notified Oracle Cerner that the technology mitigations were inadequate and had not been wholly successful.

"On May 16, 2022, the OIG used the new EHR to generate a report of the orders in the unknown queue for VHA sites and found 206 orders," it continues. "The OIG contacted facility leaders who reported using the VHA-established process to monitor and remediate the unknown queue but [explained] that gaps in the mitigation process could still lead to orders remaining in the queue."

Going forward, said the OIG, "each facility that goes live with the new EHR will require an ongoing commitment from facility staff to monitor and address the new EHR’s unknown queue."

OIG 'remains concerned'

"The clinical review was multistep and enlisted varied healthcare providers and substantial staff hours," said John D. Daigh Jr., assistant inspector general for healthcare inspections. "Assessments of patient safety events included evaluation of the severity of harm, likelihood of how frequently an event may occur, and detectability of the technology risk."

Daigh said reviewers conducted 1,286 facility event assessments and identified and classified 149 adverse events for patients; these included two instances of "major harm," according to the report.

In one of them, a provider "entered a follow-up psychiatric care order for a homeless patient identified as at risk for suicide," according to the OIG report. "The new EHR sent the order to the unknown queue. The patient was not scheduled for follow-up care and later contacted the Veterans Crisis Line reporting a razor in hand and a plan to kill himself. The patient was psychiatrically hospitalized."

There were 52 instances of "moderate harm," identified by OIG, including a patient whose lower leg edema got worse because they did not receive the compression hose that had been ordered.  And of the 95 examples of more minor adverse events, one of them involved a patient with uncontrolled diabetes who, because of a missed clinical note, was "not scheduled for care until 14 months later after a new order was entered."

Despite some of the preventative steps laid out in the report, the OIG emphasized that, "based on the multiple events of patient harm, insufficient mitigations that burden VHA staff, and continued risk to patient safety," it "remains concerned with the management of the new EHR’s unknown queue."

As Orion Donovan-Smith of the Spokane, Washington-based Spokesman Review – who has been following this story closely – reported earlier this month, Oracle Cerner executive VP Kenneth Glueck told the Congressional Committee on Veterans Affairs that the post-merger vendor is currently doing a "thorough analysis across the EHR system" and examining ways "Oracle expertise and technology can be utilized to rethink approaches not possible before the acquisition."

NEW: @Oracle EVP Ken Glueck sent a letter yesterday to @RepMrvan & @RepRosendale addressing the "unknown queue" issue that @VetAffairsOIG found caused harm to nearly 150 veterans in Spokane & the Inland NW.

Quick thread w/ some key takeaways... 1/ pic.twitter.com/RxO5Qhs0v1

— Orion Donovan-Smith (@orionds) July 7, 2022

With regard to the unknown queue, "if there is a problem we will fix it," said Glueck, "or if there is a better way to accomplish a task that enhances patient safety, we will develop and implement it."

So far, Congressional leaders are not mollified.

"The findings from the VA Inspector General’s investigation are even worse than I suspected," said Congresswoman Cathy McMorris Rodgers, R-Wash., in a July 14 statement. "Not only were 149 veterans in Eastern Washington harmed by the broken electronic health record system, VA and Oracle Cerner leadership downplayed the severity of the issue of the unknown queue, failed to adequately train providers on site and manipulated data to support a non-factual narrative about general system training and user proficiency."

Saying she is "appalled by all parties involved in this disaster," McMorris Rodgers also took VA leadership to task, saying its "manipulation of training and system proficiency data to save face has put veteran safety at risk and is morally bankrupt. This agency has completely lost sight of its mission and done irreparable damage to my trust in their ability to deliver results for Eastern Washington veterans.”

"Our nation owes a debt to our veterans that we will never be able to repay," said Rep. Dan Newhouse, R-Wash., on Thursday. "Providing them with high-quality medical care is the bare minimum." He added: "Today’s reports further prove that the EHRM system, and its implementation, are deeply flawed. I will continue to work with my colleagues on the House Veterans Affairs Committee to fix these issues and ensure that our veterans receive the care that they need and deserve."