Tech Mod Chairman Rosendale’s Opening Remarks at Hearing on Continued VA Electronic Health Record Patient Safety Issues

Hearing

"Good morning. The Subcommittee will come to order.

Before we proceed, I would like to ask unanimous consent that Rep. McMorris Rodgers and Rep. Schneider be permitted to participate in this hearing.

Without objection, so ordered.

I want to welcome our witnesses back to discuss VA’s continued struggles with the Oracle Cerner pharmacy software.

I want to thank Ranking Member Cherfilus McCormick for proposing that we return to this subject.

The situation we found in our previous hearing, in May of last year, was dangerous and unsustainable, and it seems much the same today.

Simply put, the medical centers using the Oracle Cerner EHR have been turned upside down.

They have had to increase their pharmacy staffing by at least 20% to navigate all the bugs and workarounds—just to process roughly the same volume of prescriptions.

That costs millions of dollars. But these are just five small and medium-sized hospitals.

VA projects that large, complex medical centers will have to increase their pharmacy staffing by as much as 60% to mitigate the software’s problems.

If the EHR was implemented throughout the Veterans Health Administration, those personnel costs would quickly run into the hundreds of millions of dollars.

That’s money that could otherwise fund veterans’ health care, fight homelessness, or renovate aging hospitals.

And it’s all to prop up a system that is clearly inferior to what VA has today in Vista.

On top of the added costs, it’s a dangerous situation.

Nearly 20% of the patient safety reports from the five medical centers are related to pharmacy.

OIG has come forward with alarming new findings.

Mr. Case’s office discovered widespread errors in VA’s internal drug codes and the health data repository.

When veterans are treated at a facility using the Oracle EHR and then treated at a facility using Vista, their medication information may be incorrect.

That means drug-to-drug interaction checks and allergy checks may be based on inaccurate information.

According to OIG, this problem may affect at least 250,000 veterans, and it has been going on for years.

In one incident that OIG documented, a veteran in a VA residential treatment facility was repeatedly denied his medication because it was showing as inactive in the system.

It took five days for the veteran to convince the staff that he needed the medication, but by then he was in danger and had to be transferred to the emergency room.

An Oracle software update last April corrected some of the system errors, but there is still no solution to many of the others.

However, VA still hasn’t notified any of the veterans who were impacted or are still being impacted.

Apparently, the VA has been hiding this problem.

According to OIG, the Department to no action to go back and correct the veterans’ medication information in the health data repository after the April software update resolved the underlying error.

Instead, the VA has been quietly waiting for the prescriptions to expire and the inaccurate medication information to fall out of the database.

And VA seems to have been concealing the errors that are still ongoing.

That is a breach of trust, and it is absolutely unacceptable.

I question what other dangerous pharmacy problems have not been uncovered.

What we do know is that the results of VA and Oracle’s strategy to improve the EHR have been one step forward, one step back.

Two and a half years ago, the pharmacists in the field created a list of 79 problems with the pharmacy software.

VA prioritized seven of these, and Oracle rolled out fixes over a series of software updates. The most recent, called Block 10, happened a few days ago.

The most important fix aimed to eliminate the confusing, error-prone double entry process in the core EHR pharmacy software and Medication Manager Retail, which is used for the mail outpatient pharmacies and community care.

This originally went live in the April 2023 software update, but VA had to immediately roll it back because it caused yet another problem with dosage instructions getting lost.

The fix was supposed to happen again, a few days ago, but it was postponed due to testing problems.

This particular item demonstrates the larger issue.

These are piecemeal, painfully slow improvements to software that seems to be fundamentally inferior to Vista.

And they involve VA paying Oracle most of the costs to overhaul the system that VA already bought.

The taxpayers are getting billed twice for this EHR.

Even worse, many of the changes introduce new complications, unexpected errors, and safety risks that the pharmacists have to manage with yet more workarounds.

The VA pharmacists are telling us very clearly that they are fed up, and they can’t do this forever.

We are way past piecemeal solutions, and we are not going to tolerate VA sweeping any more dangerous errors under the rug.

The definition of insanity is doing the same thing over and over again while expecting a different result.

I have come to believe that continuing this effort—to transform the Oracle Cerner pharmacy software into something completely different—is insanity.

With that, I yield to Ranking Member Cherfilus-McCormick for her opening statement."

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