The Washington PostDemocracy Dies in Darkness

Massive digital health system for veterans plagued by patient safety risks, watchdog finds

Three reports released Thursday by VA inspector general point to unresolved safety issues a week before the $16 billion electronic records system is scheduled to be rolled out at a second veterans’ hospital.

The Veterans Affairs headquarters in Washington, D.C., seen on May 19, 2014. (Karen Bleier/AFP/Getty Images)
Placeholder while article actions load

More than a year after a disastrous deployment at its first hospital, the $16 billion effort to modernize veterans’ medical records still poses grave safety risks to patients, from medication errors to failures to safeguard patients at high danger of suicide, the Department of Veterans Affairs’ internal watchdog has reported.

Three reports on the project’s rollout in Spokane, Wash., cast doubt on how smoothly it will expand next week, when VA plans to bring its digital health records system to a second Washington hospital, in Walla Walla, then accelerate implementation at other hospitals and clinics in the Pacific Northwest and elsewhere by December.

The clinical, technical and management challenges laid out by Inspector General Michael J. Missal late Thursday provide the first systemic look at what happened when the software overhaul being built by technology giant Cerner deployed in Spokane and four connected clinics in Washington, Idaho and Montana just before the November 2020 presidential election.

The crisis that followed led productivity to plummet as the medical staff struggled to use the system, leaving many veterans to fend for themselves.

Medical appointments took months to schedule, investigators found. Veterans could not log in to the secure website that gives them personal health information and lets them communicate with their doctors. The system gave bad computer links for telehealth appointments. Many tickets from the medical staff asking the contractor to troubleshoot problems — almost 40,000 were filed from October 2020 through the end of March 2021 alone — went unanswered. Patients’ email addresses and phone numbers were not accurately transferred from VA’s old records system.

VA chief halts multi-billion-dollar health records system for veterans, citing serious flaws

Physicians could not tell if their patients’ medications were discontinued or expired, and drugs disappeared from medication lists. Outpatient orders for drugs went unprocessed. Medications sent by mail order had confusing instructions or no instructions at all. Registered nurses were able to order medications without reviews and approvals by doctors, investigators found.

And when the software went live, some patient records that should have shown patients at high risk for suicide and disruptive behavior failed to activate for patients who had been flagged in VA’s legacy system, a mishap that was particularly alarming to the medical staff given that suicide prevention is one of VA’s top clinical priorities, investigators found. The staff had no access to necessary suicide-prevention risk assessment and reporting tools.

The majority of these issues are still outstanding, the reports said, although investigators were not able to determine whether any serious medical issues or deaths resulted from the mishaps.

“These three reports found serious deficiencies and failures in the implementation of the new electronic health record at the Mann-Grandstaff VA Medical Center, which increased the risks to patient safety and made it more difficult for clinicians to provide quality health care,” Missal said in a statement. The reports released Thursday follow six others that found problems with training, scheduling, cost estimates, access to care and VA’s readiness to roll out the project, an innovation to federal technology championed by the Trump administration that was designed to link veterans’ medical records from their military service to private life in a seamless system.

Thursday’s findings quickly reverberated on Capitol Hill, where Senate and House leaders in both parties scheduled hearings on the continuing problematic rollout.

Sen. Patty Murray (D-Wa.) called on VA to postpone any new deployments in her state until the issues are fixed.

“It’s clear to me that VA is not ready for go-live of the EHR system at the VA Medical Center in Walla Walla and we need to put a pause on this rollout right now,” Murray said in a statement.

She accused VA leaders and Cerner of “minimizing very serious problems or wrongly claiming that ongoing issues have been ‘resolved.’”

“It’s absolutely unacceptable to me that VA knew about widespread, egregious patient safety risks … but in conversations with my office, VA has been expressing confidence and readiness for the go-live date at the Walla Walla VA,” she said. “This was simply not the case.”

In a joint statement, House Veterans Committee Chairman Mark Takano (D-Calif.), Senate Veterans Committee Chairman Jon Tester (D-Mont.) and Rep. Frank J. Mrvan (D-Ind.), who leads the House committee panel overseeing the project, said the reports identified “unresolved issues that currently do not have a timeline or plan for mitigation.”

At least one House Republican, Rep. Matthew M. Rosendale (Mont.), has suggested scrapping the program altogether.

Terry Adirim, a physician and former Defense Department leader who took over the electronic health records program at VA in January, acknowledged the rocky start and continuing problems in Spokane but in an interview said “we’ve made a substantial number of changes,” including a new round of training of the hospital’s medical staff.

“These deployments are really complex, and they’re really hard,” Adirim said. About half of digital medical records programs at private hospitals fail at first, she said. DOD, which is ahead of VA in its own Cerner overhaul, also had problems that have now largely smoothed out.

Adirim acknowledged that “there are issues still left to be resolved” in Spokane but called many of the issues cultural. “We’re really saying this is not about IT, it’s about health care transformation.” Many physicians did not realize that the Cerner system would differ dramatically from the homegrown VA system known as VistA that it is meant to replace: “I understand how anxiety-provoking this can be,” she said.

But Adirim said VA will move forward with the rollout on March 26 in Walla Walla — where the agency has added extra support staff from VA and the contractor and plans to have physicians from outside the hospital on hand in case things go wrong — followed by Columbus, Ohio, in late April, then back to the Pacific Northwest.

Earlier this month, the records system in Spokane was offline for roughly 20 hours following a glitch with data migration issues. The blackout disrupted multiple clinical operations, officials said.

Deputy VA Secretary Donald Remy told the inspector general’s office that the agency is working on plans to address the outstanding issues. He said he hopes to resolve them by mid-May.

President Donald Trump touted his administration’s effort to merge the medical records of active-duty service members and their post-service files as a long-overdue revolution in veterans’ health care. VA promised that veterans would receive better medical care when physicians could call up patients’ medical histories on their computers with a few strokes of their keyboard instead of relying on faxes to transfer the records from the Pentagon. The entire agency was scheduled to go online by 2028.

Cost estimates since the program’s inception ballooned from $10 billion to $16 billion — $5 billion of which is needed because VA leaders did not budget for technology and hospital upgrades to allow the new platform to work.

VA Secretary Denis McDonough announced shortly after taking office last year that he would pause future rollouts after a strategic review revealed a wide array of problems in Spokane.

McDonough cited serious “governance and management challenges” that have dogged the project. He ordered an overhaul that he said would include better training for clinical staff, more reliable oversight of Cerner and a leadership shake-up.

Adirim was hired from the Pentagon in December to run the project, replacing John Windom, whom McDonough promoted to a role coordinating the implementation at both the Defense Department and VA.