[HN Gopher] VA staff flag dangerous errors in Oracle-built elect...
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VA staff flag dangerous errors in Oracle-built electronic health
record
Author : ksenzee
Score : 89 points
Date : 2025-12-03 15:32 UTC (7 hours ago)
(HTM) web link (www.washingtonpost.com)
(TXT) w3m dump (www.washingtonpost.com)
| Ancapistani wrote:
| https://archive.ph/4f6JE
| cratermoon wrote:
| I once flagged a bug in Epic, the big EHR system. The system had
| somehow mixed up kilograms and pounds. For example, a normal
| adult male weight of 150lbs would be ~68kg, But accidentally save
| it without converting and get 150kg. Convert back and it becomes
| 330lbs. Suddenly our reasonably slim man becomes grossly obese.
|
| It's not just wrong, it's extremely dangerous. In an emergency
| situations, where morphine is commonly administered for extreme
| pain, the dosage needed to relieve the pain of a 330lb man would
| kill a 150lb man. Granted the responder at the patient's side
| would probably realize something is amiss, but a pharmacist in
| another room filling an order wouldn't have the context, and
| could make the error.
| jermaustin1 wrote:
| I wouldn't trust that a nurse or doctor that is bedside to flag
| that either, though. Hospitals are woefully understaffed, and
| while they will do there best, we are all just humans.
|
| My wife's grandmother was killed by a second dose of metformin
| (well kidney failure after a second dose) because the attending
| that administered the first dose left the room, planning on
| coming back a moment later, when the next round nurse came in,
| they noticed the does hadn't been administered (wasn't in the
| chart), ordered another dose, and injected it.
|
| There were multiple layers that should have prevented that. The
| prescription shouldn't have been filled for a second time
| without someone noticing. The first doctor should have filled
| in the chart before leaving. And the pharmacist should have
| noticed that it had already been requested.
|
| Too many patients, too few doctors, and with Epic, too many
| button clicks.
| skeptical_md wrote:
| I am very sad to hear that your grandmother died as a result
| of a medical error, but the details of the story as you
| remember them aren't quite plausible.
|
| 1) Metformin is not available in an IV formulation 2)
| Metformin itself is not nephrotoxic
|
| It certainly is believable that a medical error caused kidney
| failure but it is very unlikely to have been caused by an
| incorrect second IV dose of Metformin.
| daveguy wrote:
| I expect GP mistook metformin-associated lactic acidosis in
| a patient with kidney disease as something metformin-
| caused. A separate but coincident IV misadministration
| could be an exacerbating factor. It would have been a rare
| case, but a plausible explanation for the misunderstanding.
|
| Metformin is relatively kidney safe and not administered by
| IV. Thank you for clarifying that for anyone that may
| currently on or considering Metformin. It would be great if
| medical professionals were infallible communicators and had
| time to verify understanding, but they are human and we
| need more doctors and less time-pressure by profit
| extracting private equity.
|
| Disclaimer: I am not a doctor.
| BobaFloutist wrote:
| Also even when medical professionals communicate
| flawlessly, they're communicating to non-professionals
| who will necessarily encode their understanding in an
| imperfect mental model that will likely degrade over
| time.
| jermaustin1 wrote:
| I'll defer to your expertise. I wasn't there, and just
| sharing what aunt was "told".
| cratermoon wrote:
| I don't see any mention of IV in the OP comment.
| cratermoon wrote:
| Oh absolutely, especially in an emergency. I mentioned the
| other scenario because when I've told this story before
| people have been skeptical that a bedside provider could make
| that kind of error.
| malcolmgreaves wrote:
| Damn, sorry to hear that a nurse killed your grandma :(
| kotaKat wrote:
| _Wired_ covered the story twelve years ago of an Epic
| implementation failure that led to a child's overdose (and
| recovery), of note:
|
| https://www.wired.com/2015/03/how-technology-led-a-hospital-...
| https://archive.is/1QPmK
| epcoa wrote:
| Opioids are not weight based dosed for adults. Typically pain
| protocols start at fixed doses based on prior opioid use and
| titrate up for effect.
|
| Also was this a bug in Epic proper or a site specific
| customization?
| cratermoon wrote:
| OK, so my example is flawed, but the scenario remains valid.
|
| I don't know anything about the bug other than my provider
| who I'd communicated and demonstrated the bug to came back to
| me confirming that it was a real bug and was being fixed.
| harvey9 wrote:
| In emergency situations (or even routine ones) where I'm
| administering morphine, I don't need a computer to help me
| figure out the dose. There are more complex dose calculations
| where good tech matters far more. Harold Thimbleby has some
| very accessible talks on safety in health tech:
| https://www.youtube.com/watch?v=AobMb3S5OtY&t=1034s
| kotaKat wrote:
| Every user I've heard coming from a Cerner facility has said that
| Cerner is an unmitigated disaster.
|
| It almost makes sense that the only way to get a customer was to
| essentially lobby and force your way into a government contract
| for it, and it's still an unmitigated disaster.
|
| My heart goes out to those that are going to get fucked over by
| this piss-poor deployment and be actually, physically harmed by
| bad EMR decisions and implementation choices.
| Balinares wrote:
| Every single time I've heard about an org onboarding Cerner, it
| was a disaster. One wonders how they can possibly still be in
| business.
| sc68cal wrote:
| Oracle acquired them. So, now you have the full power of
| Oracle standing behind them to convince customers to adopt
| it, and the same power to keep customers from migrating.
| user2722 wrote:
| Nobody got fired from buying Oracle
| sema4hacker wrote:
| I'm amazed that city, county, state, and federal tech projects
| never want to clone best-of-show systems instead of starting from
| scratch. City needs a web site? Clone the best one you can find
| amongst the tens of thousands of cities already doing that.
| County jail needs tracking of inmate transports? Clone the best
| one you can find amongst the thousands of counties already doing
| that. State needs a sales tax system? Clone whatever other state
| system is the best. VA needs a system for hospital records? Don't
| develop from scratch, start by cloning the best system you can
| find amongst the thousands of existing hospital networks, and
| customize from there.
| sc68cal wrote:
| That's what they did. If you read the article, it discussed the
| whole program as being a change from an in house developed
| system, to an off the shelf system.
|
| > The program launched in 2018 to replace the aging computer
| system used across VA's health care network, which serves more
| than 9 million veterans, with an off-the-shelf product that
| could handle many of the same tasks: organizing important
| information including appointments, referrals, prescriptions
| and patient histories.
|
| > David Shulkin, the secretary at the time, announced that VA
| would negotiate a contract to buy the records system from
| Cerner without competitive bidding. VA leaders said they
| selected the program because the Pentagon already had purchased
| a similar Cerner system for the military's more than 700
| hospitals and clinics.
| nathan_douglas wrote:
| VistA is an old system, and it's definitely "aging." But the
| thing is that it actually works really, really well. For
| instance, it kills a remarkably low number of people, which
| is one of the benchmarks I personally value in an EHR.
|
| One of the interesting things about this is that, from my
| perspective, VistA's sort of a mesh of servers rather than
| the hierarchy we might expect from a federal system. Perhaps
| that's because of the complex interplay between federal and
| state and local laws. But anyway, there's probably a
| "station" for VistA near you that serves your area, and
| that's very similar (though not identical) to the "station"
| in the next neighboring area/metropolis/state/whatever.
|
| But weirdly it seemed like the plan to roll this out was to
| replace all of the functionality at a given VistA station,
| rather than to do a strangler fig sort of thing and work on
| supplanting VistA's functionality in a specific functional
| area (whether locally or nationally). I don't know if that's
| because of the aforementioned complexity of laws, or the
| complexity of how the system(s) is/are administered, or other
| reasons that would elude me.
|
| It's, uh, it's a fun situation.
| nradov wrote:
| VistA EHR works reasonably well for end users but the
| problem is that the underlying platform is kind of a dead
| end. There's no practical technical path to keep it moving
| forward with major new enhancements (some of which are
| legally mandated for compliance). Hardly any developers
| have the platform skills, no one wants to learn (career
| suicide in most cases), and modern tools don't support it.
| It's a shame but that's the reality.
|
| https://worldvista.org/
| nathan_douglas wrote:
| I don't disagree at all (disclaimer: I don't work on
| VistA, but systems that communicate with VistA... close
| enough that the "career suicide" phrase hits a little
| close to home).
|
| I think the bigger problem is that we're not meaningfully
| grappling with the reality of what it takes to replace
| legacy government systems.
|
| Another grain of sand on the beach of things that we're
| completely unequipped to deal with, I guess.
| BobaFloutist wrote:
| A _lot_ of government procurement is bound by strict
| "competitive bidding" laws that seek to give everyome and their
| grandmother a fair shake at the contract, in the name of
| avoiding graft, corruption, and bribery.
|
| This has led to somewhat of an arms race where government
| workers desperately collaborate with contractors to find a way
| to sidestep or subvert the bid process and other contractors
| aggressively seek to inspect and enforce the process.
|
| Developing in-house governmental talent, institutional
| knowledge, and capacity is of course strictly off the table, as
| it would reduce opportunities for private profit in basic
| government services.
| Y-bar wrote:
| Meanwhile in Sweden:
|
| > Scrapping the millennium: introduction of a health record in
| Sweden fails
|
| > The introduction of a new, heavily criticized electronic
| journal system from Oracle in two Swedish health districts has
| failed spectacularly.
|
| https://www.heise.de/en/news/Scrapping-the-millennium-introd...
| harvey9 wrote:
| "An external audit by the auditing firm KPMG..." Piling one
| nonsense upon another. I worked with them on a different health
| project. After much song and dance we ended up with another
| bland slide deck.
| nradov wrote:
| The audit and consulting practices at KMPG and similar
| organizations are almost completely separate. And in fairness
| to KPMG, a bland slide deck is exactly what their customers
| want. If a hospital wanted groundbreaking disruptive
| innovation then they wouldn't hire a management consulting
| firm in the first place.
| cerneroracle wrote:
| I used to work at Cerner for a couple years. Honestly working at
| Cerner was a decent experience. Biggest private employer in
| Kansas City so everyone knew about the company. Huge campuses
| across Missouri and Kansas. Huge gym in HQ campus.
|
| I was aware of this VA project at the time, although I was no
| part of it. I knew it was going to take years and we basically
| had no competition. Shortly before I left the company we got a
| new CEO from Google (Health?). Now looking back this guy was
| probably brought specifically for preparing for the Oracle
| acquisition.
|
| We were a team of 5. After the Oracle acquisition everyone left.
| That team basically disappeared. Three of my teammates left for
| another IT company in Kansas. Things must have gotten really
| tough after the acquisition.
| throwaway48476 wrote:
| What will it take to blacklist oracle from government contracts?
| stronglikedan wrote:
| an end to crony capitalism
| bastard_op wrote:
| After some 25 years of consulting/professional services in IT and
| working probably a dozen or more health care industry businesses
| or hospitals themselves, I can honestly say they are the worst
| clients and most I will simply refuse now as a rule. I've never
| met one that wasn't run poorly run, overly political, low paying,
| high spending, morale/morally deprived... I could go on, but
| mostly mismanaged applies, and more so this is universal when it
| comes to their EMR software systems, as every one needs one.
|
| One need only google "Oracle failure" or visit theregister.com to
| see a list of atrocities committed yearly by Oracle for ERP and
| Financial system implementation fiascos, buying Cerner for their
| EMR that was already bad to use could only make it worse. It's
| like bad and worse got together to make a baby, but what are your
| alternatives in the space? I never met an ERP that wasn't a mess,
| or the staff that tend to manage them. Oracle just keeps
| expanding, because why be a lesser evil?
|
| If you work in the medical IT field, you have my condolences, and
| my best advice is don't. The only ones that win are the
| executives above their meat shields and the investors. If you
| have to visit one in the US, you also have my condolences, as
| you'll see first hand the product above commentary.
| nradov wrote:
| Vanilla is the best flavor. The decision makers at large health
| systems often waste fortunes customizing EHR configurations
| based on the mistaken belief that they know better than the
| vendor. But often it would be better to stick with the software
| defaults and retrain the users. Of course this is politically
| difficult when experienced physicians who bring in a lot of
| revenue threaten to leave if they don't get their way.
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