A review by the Department of Veterans Affairs (VA) Office of Inspector General (OIG) found that an Oracle Cerner-designed element of the VA’s new electronic health records management (EHRM) system has resulted in cases of patient harm.
After hearing concerned raised by members of Congress and other stakeholders, the Veterans Health Administration (VHA) dispatched a public safety team to the Mann-Grandstaff VA Medical Center where they identified 60 safety concerns across nine core domains. An “unknown queue” feature of the EHRM system was described as one of three concerns with the highest patient safety risk.
“The OIG reviewed the unknown queue patient safety risk and found that the new 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),” VA wrote it its report. “Every version of Oracle Cerner’s EHR has an option to activate the unknown queue.”
The unknown queue’s intent is to capture orders from providers that the new EHRM system can’t deliver to the intended location. The new system did not alert healthcare providers that an order was not 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,” the OIG wrote. “Absent VHA actions, the existence of the unknown queue and the unfulfilled clinical orders may not have been identified, and many patient care orders may not have been completed.”
The OIG found that VHA determined the new EHR’s unknown queue created significant risk and caused harm to multiple patients after a clinical review in June 2021. The reviewers conducted 1,286 facility event assessments and identified and classified 149 adverse events for patients. Two of those adverse events were classified as “Major Harm,” 52 were classified as “Moderate Harm,” and 95 were classified as “Minor Harm.”
OIG made two recommendations for VA, which were agreed to by the agency, including:
- Reviewing the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and take actions as indicated; and
- Evaluating the unknown queue technology and mitigation process and take actions as needed.
