Transcript

12.8.25 · Washington Post

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Speaker 1: Good morning, everybody, and welcome to the reading of the
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Washington Post for this Monday, December eighth. As a reminder,
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radioized reading service intended for people who are blind or
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have other disabilities that make it difficult to read printed material.
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You're a reader for today, it's Rod Brotherton, and as
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you know, on Mondays, we start the broadcast by reading
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Paul Prather's weekly column from the Herald Leader. This week's
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article is entitled God has created a universe that teaches
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us necessary humility. The virtue Christians are supposed to practice
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above all other mortal qualities is love. Every ten year
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old Sunday school student knows that this is not to
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say we always do practice love, or even that we
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mostly practice it obviously, owned but we should. If there's
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the second most important spiritual virtue in the Christian schema,
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it's probably this one, humility. I discussed humility in a
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previous column about ways in which we can reduce the
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hate that's ever present in our divided culture. I want
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to say more about it, though, for it seems God
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considers humility so important He's built it into the very
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fabric of existence. It's visible on one thousand fronts, from
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the ridiculously minuscule role our planet plays in the Grand Cosmos,
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to the daily examples of older people and even pets.
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My mother, god rest Her, grew up during the Great
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Depression in a clapboard house on a farm in southeastern Kentucky.
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There were three generations under the roof of that little home, Mom,
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her parents, and her paternal paternal grandparents. I don't know
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if Mom put it in exactly these words, but I
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got the sense that if she had a favorite family member,
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it was her grandfather, Lee Chestnutt. She also told me
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many fond stories about Grandpa chested As a young man
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in the late eighteen hundreds, Lee apparently was daring, strong,
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even violent. He got into trouble with the law in
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Kentucky and Mom never found out what he'd done, and
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he hopped a freight train to Montana. Out west. He
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became a cowboy. In an altercation or cattle, he killed
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a man on the range, and with the help of
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his ranch foreman, hid the body. Later, when Kentucky had
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lost interest in his legal problems here, he came home
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and got married. He bought a piece of cheap land
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that was mainly forest and worked as a night watchman
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to pay his bills, and then labor days cutting trees
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and blasting the stumps with dynamite, trying to turn the
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place into a farm. That's the farm my mom grew
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up on. By the time Mom came along, Lee was
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an old man. Mom had little use for her grandmother,
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who she found controlling and cranky. Grandpa Cheston had become
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a church goer, even a deacon, I think, Mom said,
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he said at the very front church sanctuary, on the
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mourner's bench at the foot of the pulpit where sinners
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came to repent, because he was nearly deaf and that
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was the only way he could hear this sermon. If
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the preacher droned on too long, Grandpa would tug the
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tail of his frock coat to remind him it was
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time for dinner. At home, Grandpa knelt beside his bed
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at night to pray before turning. In the quiet house,
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Mom could hear him asking the Lord to please bless
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little Alice. That sweet old man, Mom would say, down
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on his knees praying for me. At some point, she
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started shaving Grandpa because his eyes and hands weren't steady anymore.
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Because the attention pleased him. In the end, he lay
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helpless in a bed in that same farmhouse he'd built
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forty years earlier, suffering from a broken hip, nursed by
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his son and daughter in law. And that's how his
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life ended, the former outlaw and energetic worker, reduced to
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helplessness and pain on the ministrations of others. In a
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new century and a different species, I've seen the same
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type of journey, echoed. My wife Liz brought to our
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marriage a kitten named Walter, who from the get go
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was full of sap and swagger. Nearly fifteen years later,
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he's still with us, still sleeping in our garage. I'm
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not a cat person, but I've always liked Walter. You
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couldn't not like him. He was both lovable and ferocious,
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enjoyed being petted, yet patrolled our yard as if he
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were a lion on the Serengetti stalking I heard of
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White wilderby'st I don't know whether cats have fantasies, but
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he seemed to think he was Simba or maybe scar.
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He scouted and skulked and slithered, and delivered to our
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door and the kitchen a steady supply of mice, rabbits,
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and chipmunks. He strutted around with his tail erect, and
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then for no reason, charged across the grass a low,
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dead run, as if shot from a cannon. Walter's not
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fast anymore. He's ar threading. His teeth are so bad
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he can only eat the mushiest cat foods. He's trembling
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and disoriented and wanders under the wheels of our vehicles.
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As we pull into the garage, we break and wait
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for him to take a notion to amble onto his bed.
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He can't groom himself. His furs become hopelessly matted and painful.
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Liz had to take him to the veterinarian to be shaved.
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His head still fluffy and so or his tail and paws.
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Otherwise he's hairless. It looks like a kitty poodle, which
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I'm sure is the vision he used to have himself.
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We can't let him outside for fear of hawk or
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a dog will kill him. The hunter has become prey.
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Watching him has reminded me that nearly every creature on
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Earth winds up slow, broken, afraid. We come into the
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world helpless, and we leave it helpless. If we humans
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are of the variety who happen to be teachable our decline,
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imbuse us with humility. Before we're gone, we lose our
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delusions of power. We discover our dependence on God and
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other people. We feel mercy or other poor souls who
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are struggling to We understand indeed why the greatest of
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virtues is love. And as you know, Paul Praether is
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pastor of the bethesta church near Mount Sterling, and you
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can email him at prtpd at yahoo dot com. Now
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let's look the news from today's Washington Post, and herefore
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a Change is an inspirational story. The lead story is
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the optimist. He set out to walk around the world.
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After twenty seven years, his quest is nearly over. Carl
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Bushby made a barroom bet that he could walk from
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the southern tip of South America all the way home
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to England. His friends had little faith. Suddenly it became
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a challenge. Bushby said of the bet he made in
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his twenties, that conversation gathered steam, and eventually I did
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the math and thought, well, this is doable. I became
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semi obsessed what it would take to achieve something like this.
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A few years later, in nineteen ninety eight, he stood
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at the edge of Punta Arinez, Chile, about as far
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from his hometown of Hull, England as a person can
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get on foot, ready to begin a thirty one thousand
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mile expedition that he thought would take roughly twelve years.
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It's been twenty seven and Bushby, now fifty six, is
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still walking. The plan was to do something pretty extraordinary,
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he said. He's walked through Patagonia, the Andes, Central America, Mexico,
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the length of the United States, Russia, Mongolia, parts of Asia.
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He's traversed some of the most remote, hostile, and politically
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fraught places on Earth, across deserts, jungles, and war zones.
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At the start of his quest, Bushby made two rules
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for himself, neither of which he's broken. I can't use
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transport to advance, and I can't go home till I
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arrive on foot, Bushby said, if I get stuck somewhere,
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I have to figure it out. He initially mapped out
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a walk by hand. Back in those days, it was
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all paper maps and pencils and a calculator, he said.
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Bushby's trek, which has been called the Goliath Expedition, has
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taken far longer than he anticipated because of financial challenges,
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visa issues, travel bands, political barriers, and the COVID nineteen pandemic.
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All that thrown in has created massive delays. Bushby said
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he expected to drive home in Hall by September of
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twenty twenty six. It's a twenty seven year old story now,
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he said. Bushby was a paratrooper in the British Army,
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and experience, he said, sparked his appetite for challenge, travel
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and exploration. Once you're in the Army and you get
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to travel and see some of these amazing places, that
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really inspires and motivates a wanderlus Bushby said. Paratroopers are
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all about fitness and endurance and distance, so that all
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played into it. Bugeby said also being in the army
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and losing several friends made him think a lot about death.
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There was an emphasis on the fact that life is
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short and you should live it the best you can,
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he said. All these factors, Bushby said, shaped his desire
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to take on the Global Walk at age twenty nine.
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Back in the early days, I don't think anybody took
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me seriously, he said. Busgby started the trek with five
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hundred dollars. I had no support, he said, adding that
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he usually sleeps in a tent along the road, or
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sometimes in people's home if he's invited. The Americas very
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quickly became survival mode. This was literally finding food at
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the side of the road to keep yourself going. Bushby's
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family started helping him out financially, and people began donating
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as they heard of his trek. Companies reached out, offering
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to sponsor him, and by the time he got to
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Canada and twenty oh three, Bushby had a book deal,
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and later a production company contacted him to turn his
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story into a film. One of the lessons from this
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is the fact that nobody does this alone. Bushby said,
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I may be the guy on the road, there's a
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massive network of support that keeps me upright and moving forward.
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Even with support, Bushby has faced severally insurmatlem obstacles. He
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walked through the Darien Gap between Panama and Colombia, known
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as one of the most perilous jungle passages in the world. Later,
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he reached the Bearing Strait between Alaska and Russia, the
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midway point of his walk, in twenty oh six. It
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was the first of two bodies of water he'd cross
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in the winter, he said, the strait does not entirely
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freeze over. It is this massive body of crushed ice
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and seawater. You're literally climbing over the ice to make
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any short distance, he said. He met a fellow adventurer
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in Alaska who traversed the strait with him. No one
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believed we were going to make it, Bushby said, As
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it turned out, we managed to nail it on the
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first go, which no one expected, least of all us.
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Once Bushby arrived in Russia, he hit another hurdle. He
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was detained for entering the country at an incorrect border.
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He spent fifty seven days in detention, he said, and
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faced a trial until authorities agreed to let him continue
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his walk. It was just a whole series of miracles,
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Bushby said. Over the years, he encountered other challenges, including
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the twenty oh eight financial crisis, when his sponsors pulled out,
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stalling his travels. In twenty thirteen, he was banned from
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re entering Russia for five years due to his initial
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border violation. So Bushby walked from Los Angeles to the
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Russian embassy in Washington, d C. To petition his visa band,
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which he said was over turn. In August of twenty
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twenty four, Bushby reached the second body of water on
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his route. He he swam across the Caspian Sea from
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Kazakhstan to Azerbaijan to circumvent traveling through Iran or Russia.
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He swam for thirty one days, sleeping on support boats
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each night. Bushby then walked to Turkey and into Europe.
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He recently reached Hungary and and now is in his
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final stretch, with about nine hundred and thirty two miles
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left until he's in Hull. I've had to do every
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inch of this thing by either walking or swimming, which
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be said, and every time I stop, I have to
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start from that point and continue. Due to visa limits,
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Bushby has had to break up his walk in Europe,
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he can stay for only ninety days before leaving for
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ninety so he flies to Mexico to rest and then
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returns to resume the route. He started the exposition, he
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would walk about nineteen miles a day, but he has
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recently cut back to fifteen. Mushby said he's learned a
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lot over the past nearly three decades, but one thing
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stands out. Ninety nine point nine to nine percent of
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the people I've met have been the very best in humanity.
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The world is a much kinder, nicer place than that
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it often seems. Mushby said that anytime he was ill
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or down on his luck, a stranger would swoop in
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and help, either with shelter, a meal, financial support, or guidance.
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It has just continued through every culture and every country,
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he said. The overwhelming kindness of strangers was a shaka
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for me. He said he has only suffered one major
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end of injury. He slipped and gashed open his wrist,
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and he gave himself stitches. He also had one serious illness,
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a stomach infection, stayed with the doctor he met in Peru,
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who nursed him back to help. Bushby said he struggles
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with loneliness sometimes, but he knew from the outset the
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walk would be as mentally taxing as it was physically.
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Bushby said he has made friends from all around the
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world and has had two significant relationships over the course
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of the quest, both of which ended due to the
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unusual circumstances of his life. We're not supposed to live
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like this, he said. Despite hiking through twenty five countries.
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Bushby said his feet are in fine condition. They look
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up to themselves pretty much, he said. Although Bushby knows
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globe trotting is not for everyone, he hopes to inspire
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people to take on more adventure in their life. You
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need to see how the world really is and the
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people who are living in it, he said. It's one
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of the best educations you'll get. Bushby said he has
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mixed feelings about nearing the end of his track. For
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the last twientty seven years of my life, my purpose
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of living has been getting up and moving forward, and
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that's going to stop abruptly, he said. It's hard to
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adjust to that's obviously going to be the case. Bushby
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is passionate about science education, and he plans to shift
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his focus to that once he's home. His main takeaway
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from his adventures is how people along the way have
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treated him, He said. He hopes to pay it forward
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in the ways he can. The world will wrap itself
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around you and help you achieve things and keep you moving.
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He said. It's been absolutely astounding and the next door. Sorry.
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Veterans Administration staff flagged dangerous errors ahead of new health
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records expansions. On the eve of a major expansion, a
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multi billion dollar project to upgrade the computer systems of
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all Department of Veterans Affairs hospitals is beset with problems.
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According to some medical staff who already use it, critical
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patient notes disappear, prescriptions logged the wrong dosages. One nurse
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said the system incorrectly listed one of her patients as dead.
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Mike Fought, a case manager at Man Grand Staff Via
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Medical Center in Spokane, Washington, said he lost access to
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his patient's records for two days after a software update
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in August. It's amazing to me that there are still
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so many problems, Fought, said. Every time there's an update,
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there are unintended consequences. The program law lunched in twenty
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eighteen to replace the aging computer system used across VA's
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healthcare network, which there was more than nine million veterans,
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with an off the shelf product that could handle many
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of the same tasks organizing important information including appointments, referrals, prescriptions,
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and patient histories. After the system went live in twenty
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twenty at Man Grand Staff, doctors and other users began
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flagging errors that caused delays in treatment and medication mix
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ups and grappling with the system that was routinely offline,
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According to documents and interviews. As VA expanded to other
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hospitals and clinics in Washington, Idaho, Oregon, and Ohio, the
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problems followed. In twenty twenty three, VA disclosed person to
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a Freedom of Information Act request that the new record
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system played a role in more than forty four hundred
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cases of known harms raging from minor to catastrophic. VA
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has subsequently confirmed that those cases included six deaths. In March,
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VA announced plans to accelerate the federal Electronic Health Record
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Modernization program in twenty twenty six to hospitals and clinics
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in five more states. Officials say many of the problems
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have been addressed, and they are on track to expand
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an improved version of the system to thirteen additional medical
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centers and their affiliated clinics next year. The system does
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work now, via Deputy Secretary Paul Lawrence, said in an
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interview with The Washington Post and The Spokesman Review in July.
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He added that the department will be monitoring the individual
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medical centers that are preparing for the transition and would
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not proceed if they weren't ready. Obviously, if they didn't
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have the infrastructure ready, we couldn't go live yet. More
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than a dozen medical professionals at man Grand Staff and
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five other VA hospital networks using the system said in
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interviews that had many problems that have plagued the rollout, persist,
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slowing care and in some cases, threatening patient safety. To
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examine the issue, the Post and Spokesman review also reviewed
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VA records obtained through the FOIA, copies of internal emails,
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conversations on employee message boards, congressional testimony, and reports from
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the VA Office of the Inspector General and the Government
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Accountability Office. VA staff at hospitals and clinics using the
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new system said they feel a steady stream of email
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alerts from VATO support about problems. On July first, for example,
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users were notified of massive degradation issues, freezing issues, and
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delays in reconnecting after an emergency software patch. On August
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twenty ninth, VA warned that the system was failing to
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record information about upcoming patient appointments, a problem that had
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been unresolved for two days. On September fifth, doctors and
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pharmacists were informed that they should not use a tool
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in the system that verifies appropriate medication dosages because users
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cannot verify which content is correct. The issue was first
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reported to VA eight weeks earlier, according to an email.
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It's alert fatigue, said one provider at man Grand Staff,
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who spoke on the condition of anonymity because she was
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not authorized to speak publicly about her experience. This is down,
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that's down another word. Nurse who works at man Grand
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Staff said she keeps a separate spreadsheet of upcoming appointments
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for her patients because reminders have abruptly disappeared from the
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computer system. The system's broken, she said, whenever her patients
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received the wrong doses of heart medicine when test results
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from a non VA doctor were delayed in the system,
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she said. Overall care for veterans deteriorated at the hospital
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networks using the new system, According to findings of an
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internal VA study last year that was obtained by the
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Post and the Spokesman review, the study found that patients
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faced longer wait times and provide herself fewr patients. It
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concluded that the system had a large negative impact on vacare.
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According to a September twenty twenty four presentation of the findings.
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In primary care, total patient visits fell by thirty to
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forty percent and had not recovered at the time of
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the study. Technology giant Oracle took over the ten billion
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dollar modernization program in twenty twenty two after it purchased Cerner,
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a niche health IT company that began the work. Oracle
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declined to answer specific questions, but sent a statement in
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August from Sima Vandermann, executive vice president and general manager
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of Oracle Health and Life Sciences. Verma previously served as
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administrator for the Centers of Medicine and Medicaid Services in
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the Trump administration. The first time, Oracle is proud to
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be working with the VA and the Trump administration to
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finish the EHR modernization project. So we can't collectively deliver
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the world class this country's veticrans and the providers who
26:03
care for them deserve, Rma said, using the industry acronym
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for electronic health records. Officials at Man Grand Staff and
26:15
other VA hospital networks using the new system refer to
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all questions to VA headquarters in Washington. VA spokesman Pete
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Kasperuitz said in a statement that the record system is
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on track to improve care. Once complete, EHR will revolutionize
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the way VA works with the Department of War and
26:37
veterans to deliver care by improving customer service and convenience
26:42
for our patients. He said. Problems with the records program
26:46
were the fault of the Biden administration and the vast
26:50
majority of cases identified by VA as harms or minor.
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He added, Biden political appointees mismanaged the VA Electronic Health
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Record modernization effort, resulting in a program that was nearly
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dormant for almost two years. Casperwitz said the Trump administration
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won't repeat those same mistakes, as already moving quickly to
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accelerate deployment of the system and bring the project to
27:16
completion as early as twenty thirty one. Ask about the
27:20
frequent alert sent to staff, casper WIT's called them routine.
27:25
None of the incidents you sighed had any effect on
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patient care, and most were resolved within a few hours.
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Casper Witz asserted that staff's satisfaction has been rising, along
27:37
with veteran trust and health care at the medical centers
27:41
using the program, while the system crashes have decreased. He
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said that of September, five of the six sites using
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the system have greater productivity than they did in twenty
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nineteen before any of them made the transition. VA measures
27:58
productivity through a formula the takes into account providers work
28:02
and expenses. He accused reporters of cherry picking year old
28:08
reports and vents to make the Trump administration look bad.
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While VA is working to improve the system for veterans.
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The department has made hundreds of improvements to the system
28:21
since man Grand Staff went live in October of twenty twenty.
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He said. President Trump launched the project to upgrade the
28:29
health wret Care record system early in his first term.
28:32
He made a campaign promised to modernize VA by accelerating
28:37
and expanding investments in state of the art technology. David Schulkin,
28:42
the secretary at the time, announced that VA would negotiate
28:46
a contract to buy the record systems from Serner without
28:49
competitive bidding. The A leaders said they selected the program
28:54
because the Pentagon already had purchased a similar center system
28:58
for the military's more than seven one hundred hospitals and clinics.
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By adopting the same system, VA said it could improve
29:06
communications about patients with military hospitals. At the time, Hilkin
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told lawmakers that the program would save billions and could
29:17
be implemented at every VA medical facility, one hundred and
29:22
seventy medical centers and eleven hundred and ninety three outpatient
29:26
care sites within eight years. This was one of the
29:32
most significant and important decisions for the sustainability in the
29:36
future of caring for veterans that I could imagine, Shilkin
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said in a recent interview. But he said VA made
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a mistake by trying to implement the rollout from the
29:46
top down in Washington instead of allowing users to take
29:50
the lead. The implementation of this after I left was botched,
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he said, adding that since he left in twenty eighteen,
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he has to in contact with VA medical staff who
30:02
have experienced or observed the transition. This needs to be
30:08
brought in and led by clinicians from the start. Officials
30:13
underestimated the cost of the project and the time it
30:16
would take. In twenty nineteen, VA estimated it would cost
30:21
about sixteen billion dollars and take ten years to launch
30:24
across all hospitals and clinics. In twenty twenty two, the
30:30
Institute for Defense Analysis estimated it would cost nearly thirty
30:34
three billion dollars. Over thirteen years. At the congressional hearing
30:38
in February, Carol Harris, a GOAO director in the IT division,
30:44
estimated the long term cost of the program could be
30:47
in the hundreds of billions of dollars, potentially in Spokane.
30:53
At Mann Grand staff clinicians eventually sent via leadership roughly
30:58
two hundred pages of testimonials the detailed breakdowns impacting patient care.
31:05
The Post and Spokesman Review obtained those records through an
31:10
FOIA request. Robert Fisher, the hospital director, wrote that the
31:16
system was unpredictable and that noted productivity was down. Staff
31:21
experienced prolonged hours to get through their day and mitigated
31:25
patient safety concerns that must have been persistent, said Fisher,
31:30
who declined to comment. And official with the hospital's behavioral
31:34
health unit warned that the system sometimes failed the flag
31:39
veterans who were deemed high risk for suicide. The hospital's
31:43
patient safety manager said the system's pharmacy module was a
31:48
major patient safety risk. It made clear that patients had
31:53
been harmed by the system errors. Reacting to a GAO
31:57
report and pressure from Congress, then via Secretary Dennis McDonough
32:03
in twenty twenty one, ordered a review and pause the rollout.
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He pledged not to launch the system at other hospitals
32:11
until safety risks were addressed. McDonald declined to comment for
32:16
this story after the pause and on the eve of
32:20
the system's next launch in April of twenty twenty two,
32:23
at the Chalmers P. Wiley Veterans Outpatient Clinic in Columbus,
32:28
Ohio and associated facilities, a VA official told a House
32:33
subcommittee that staff in Ohio were eager and well prepared.
32:37
Lawmakers were skeptical, but the official assured them that the
32:42
patients were not at risk. In Ohio. However, users reported
32:48
problems from the start. In an interview, Deb Wilson, then
32:54
a primary care doctor at the Wiley Clinic, said she
32:57
used the new system to renew pain medication morphine for
33:02
a patient. Later, she noticed from reviewing the prescription in
33:07
the system that the dosage was doubled what she entered. Panicked,
33:13
she called the patient who had caught the error because
33:17
the pills were a different color. What a moment of
33:20
Oh my god, Wilson said. Wilson said she quit her
33:24
job in December of twenty two, about eight months after
33:27
they began using the new system. Largely because of the
33:30
stress it caused. I'm burned out, she remembered telling her boss,
33:36
this is just an untenable work environment. Primary care doctors
33:42
who used the computer system in one of VA's hospital
33:46
networks said recently that when he renews prescriptions, the system
33:51
sometimes records the dose wrong. We have learned to adapt,
33:57
but there have been minimal improvements in the system, said
34:00
the provider, who spoke recently on the condition of Aminemity.
34:04
Out of fear of retaliation, I now write out prescriptions
34:09
to private pharmacies like old school, on paper because I
34:15
don't trust it. The provider said that constant updates to
34:19
the system and multiple steps required for simple tasks leave
34:24
room for error. With many people vying for my attention
34:28
at the office, mistakes get made, the provider said, I
34:32
always tell patients I'm pounding a nail with a wrench
34:36
by VA's on accounting. Each of the six rollouts has
34:40
been followed by reports of harmed veterans served by those
34:44
hospital networks. Last year. VA spokesman Gary Kunich confirmed by
34:51
email that the new system was deemed a potentially casual
34:55
factor in the deaths of six patients in August, via
35:00
disclosed updated statistics gathered by the Veterans Health Administration's National
35:05
Center for Patient Safety, which reviews reports a potential harm
35:11
of the patients from clinicians, noting that the new record
35:15
system played a role in four thousand, six hundred and
35:19
one cases of harm. VA medical staff are responsible for
35:24
filing a detailed report when there has been an instance
35:28
of patient harm according to information VIA provided in response
35:32
to an FOIA request. The form includes a box that
35:37
can be checked, asking is the event related to use
35:42
of an electronic health record, and asks staff to specify
35:47
which record system was used, including cerner and associated software.
35:53
A safety officer then evaluates the report to confirm the
35:57
harm and its severity. More severe cases of harm, VA
36:02
performs a root cause analysis to detail how the event occurred.
36:08
Ten of the cases in the most recent statistics were
36:11
classified as catastrophic, which VA defines as death or major
36:17
permanent loss of function. Another forty six cases were classified
36:23
as major, which is defined as permanent lessening of bodily functioning.
36:29
VA classifies the rest as either moderate or minor. In
36:34
one moderate case, a patient was hospitalized with an acute
36:38
worsening of congestive heart failure after the software incorrectly classified
36:44
the patient's heart medication, causing it not to be refilled.
36:48
According to what the VA official told Congress, one minor
36:54
case involved a patient being left in pain over an
36:58
extended period because of system errors. Ross Copple, a professor
37:04
of biomedical information at the University of Pennsylvania's Perilman School
37:08
of Medicine, said transitioning to a new health record system
37:13
creates safety risks, but VA's project is unprecedented its scale instinks.
37:21
He emphasized that any move to a new electronic health
37:24
record system risks patient harm, but he said VIA's efforts
37:31
have been complicated by the specialized nature of its existing
37:35
record system, poor preparation, and Oracle's acquisition of Serner, and
37:42
the best of circumstances, it's a perilous time, said Copple,
37:47
who studies the impact of health record systems on public safety.
37:52
In the case of the VA, we know from studying
37:55
some of the individual cases that it was particularly perilous.
38:01
In late twenty twenty, two months after the Columbus launch,
38:05
VA notified more than seventy thousand veterans that flaws in
38:10
the system may have delayed their treatment. Asked about the
38:15
cases of harm disclosed by VA's FIA office. Casperowitz, the
38:20
current VA spokesman, asserted that the vast majority were misclassified.
38:26
We've looked into these concerns and found that more than
38:30
ninety nine percent of them resulted in no actual harm
38:34
to veterans and instead were the result of instructions from
38:37
EHR leaders to aggressively flag every potential issue, he replied
38:44
in an email. Other records revealed that one of the
38:48
six deaths was a veteran in Columbus who missed a
38:52
medical appointment in twenty twenty two. The new record system
38:56
for the Columbus area VA clinic he visited failed to
39:00
add his name to a no show list that would
39:03
have triggered a routine attempt to reschedule and check his
39:06
well being. The clinic was not identified. After the man
39:12
missed his appointment, his health deteriorated. According to a letter
39:16
from Representative Mike Boast, Republican of Illinois, the House Veteran
39:20
Affairs Committee chairman, summarizing the case, the man suffered alcohol
39:26
withdrawal and died after checking into a private Hospitals reported
39:32
a second death involved the system error that delayed antibiotics
39:38
for seventy seven year old Raymond Sands, who had been
39:41
diagnosed with metastatic lung cancer. According to VA records, military records,
39:47
interviews with his family, and medical records they provided to
39:51
The Post and The Spokesman Review, Sand spent ten years
39:56
in the Marines, including a tour in Vietnam. He qualified
40:00
for vacare because of exposure to the herbicide agent orange
40:04
while in Vietnam. According to his wife, Sherry, in September
40:09
of twenty twenty two, Sans was preparing to start cancer
40:13
treatment when he checked into a private hospital in Columbus,
40:17
Struggling to breathe. Doctors at the hospital ordered a prescription
40:22
of antibiotics, which was logged into the new VIA record system.
40:27
They discharged Sands and he returned to his home in
40:31
a Columbus suburb. When Sherry Sans called VIA to check
40:36
on the antibiotics, she said she was told that the
40:39
medication had been sent by overnight mail. She said VIA
40:44
provided a tracking number, but the pharmacy employee relying on
40:49
the new VIA record systems had given her incorrect information.
40:53
According to an email by VA's chief pharmacist for the
40:57
Columbus area. This summarizes what went wrong. The prescription that
41:03
the system falsely identified as Sands was actually on its
41:08
way to Washington State for another veteran. SANS prescription meanwhile
41:14
was waiting for him at a nearby VIA pharmacy in Columbus,
41:19
but Sherry Sands didn't know that. Overnight, sans breathing worsened,
41:25
and he was admitted to the private hospital in Columbus
41:28
the next day, where he received his antibiotics after a
41:32
thirty six hour delay. Medical record show he died eight
41:37
days later. A week after that, a letter of condolence
41:42
from VA arrived at the Sands house. We have been
41:46
made aware that a change in our electronic health record
41:50
system contributed to a delay in processing a prescription, the
41:55
chief staff of VA's Central Ohio Healthcare and wrote to
42:00
Sherry Sands, this delay in his care is not acceptable
42:06
to the leadership of this organization. After the investigation, the
42:12
VA later classified the delay in ordering his Antibioteck antibiotics
42:17
as catastrophic. In the email written within days of Sans death,
42:23
the chief pharmacist in Columbus said the system error that
42:27
conveyed an erroneous USPS tracking number had been reported more
42:31
than once to cerner before the tragic turn in Columbus,
42:36
but it had not yet been fixed. Multiple tickets had
42:41
replaced a cerner, making them aware of this issue, the
42:44
email said. According to two VA employees familiar with the problem,
42:50
who spoke on the condition of anonymity because they were
42:53
not authorized to comment, the software problem was fixed within
42:58
weeks of Sands. Neither VA nor Oracle would comment on
43:03
the case. Sherry Sands said the error didn't cause her
43:08
husband's cancer, but VA failed on the prescription they had not.
43:14
Had they not, it might have given us more time together.
43:18
In February, the most recent Congressional oversight hearing focused on
43:22
the new EHR system. Lawmakers were given two very different
43:26
pictures of the program in determining whether it was ready
43:30
for use across the VA. Neil Evans, VA's official voice
43:36
now in charge of implementing the new system, assured lawmakers
43:41
that the version they planned to roll out next year
43:44
is entirely different from the one deployed at the sites
43:48
in twenty twenty and twenty two. I feel confident that
43:53
we are in a much better place, Evan, said the
43:57
program's acting executive director to VA officials who also spoke
44:03
on the condition of anonymity because they were not authorized
44:06
comment told the Post that there had been some improvements,
44:11
but they said the VA will deploy essentially the same
44:16
system that has been at Man Grand Staff and five
44:20
other networks to the hospitals and clinics in Michigan, Ohio, Indiana, Alaska,
44:28
and Kentucky at the same time. In the February hearing,
44:34
David Case, then the acting Inspector General, also said VA
44:38
had fixed some computer flaws, but others, like the system's
44:43
management of checking, changing schedules and misappointments, indeed had persistent.
44:50
Case pointed to problems with the system's pharmacy management system
44:54
that were identified by a VA safety team in May
44:58
of twenty twenty one as being un resolved. He said
45:02
in a prepared statement that he was concerned that the
45:06
computer system will continue to be deployed at larger, more
45:10
complex medical facilities before resolving myriad known issues that remain
45:16
related to prescribing medications and medication safety. Case, who is
45:22
now Deputy Inspector General, declined to comment for this story.
45:28
A spokeswoman for VA's Investigator General, Jessica Rodriguez, declined to
45:34
say whether Case's assessments had changed since the February hearing.
45:40
We are engaged in ongoing communications with VA regarding the rollout,
45:45
she said. Three VA administrators who observed the most recent
45:50
EHR expansion in March of twenty twenty four at the
45:54
Level Federal health Care Clinic in North Chicago, said that
45:58
VA had to bully bolster staff to make the system
46:02
work for its pharmacy operations or for managing clinical trials.
46:08
They questioned whether there would be enough personnel to support
46:12
expansion to multiple hospitals at once. While the VA has
46:17
highlighted the transition at Louisville as a success, it is
46:21
catalog some harmed patients between the system's launch in March
46:26
of twenty twenty four. In August of this year, VA
46:30
logged forty eight safety events at level in which the
46:34
records systems played a role, according to the National Center
46:38
for Patient Safety Statistics obtained through the FOIA. Of those,
46:46
thirty four were classified as minor, thirteen as moderate, and
46:50
one as major. Stephen Braverman, who left VA on September
46:56
thirtieth after serving since November twenty four as the chief
47:01
Operating Officer for VA's Veteran Health Administration said in an
47:06
interview that he warned the program's leaders that moving forward
47:11
too quickly could make it harder to identify and fix
47:15
problems that arise at one hospital before deploying it at
47:18
the next. With all but one of the planned launches
47:22
next year in the same region, he said that other
47:25
local hospitals may not have the capacity to absorb the
47:30
veterans whose care is delayed by slowdowns that accompany each
47:34
new deployment. Whenever you have change, you introduce the opportunity
47:40
for error, he said. You're taking a risk by going
47:44
quickly with this new process. Casparrowitz, the VA spokesman, said
47:50
the agency plans to hire four hundred people in twenty
47:53
twenty six to support the system expansion. Shulkan, the former
47:59
VA secretary, he said Lawrence, the Deputy Secretary, is taking
48:03
steps to ensure that future rollouts succeed. He has learned
48:08
from some of the missteps in the past that that
48:11
type of local ownership and engagement must occur, and he's
48:16
empowering them to do that, shul Con said. Gordon Winners, sixty,
48:23
served on a VA council that advised the department on
48:26
the system before and after the implementation. Winners, who retired
48:31
in July as a nurse at Mann Grand Staff and Spokane,
48:35
said that at the beginning he was optimistic about the
48:38
project and its potential to improve health care for veterans,
48:43
but he came to believe that the design was too
48:46
complex and fostered mistakes like medication errors without safeguards. He said,
48:54
concerns he had early on have not fully been addressed.
48:58
For instance, system wide crashes have become less frequent, but
49:03
parts of the system still seized up or slowed to
49:07
a crawl, requiring resets that wasted time. He said. The
49:13
system should make us safer. We shouldn't have to figure
49:18
out how to make the system safer, said Winners, who
49:22
served in the Army's elite eighty second Airborne Division. As
49:27
I retire, I'm worried about government spending and it just
49:32
seems like now we're throwing good money at what is
49:35
at the best mediocre product. Many providers interviewed said that
49:42
the data entered into the system sometimes just disappears, and
49:47
other times alerts them with incorrect information. After a major
49:51
system updated in August, a nurse at Man Grandstaff said
49:56
she opened the record of a patient she had seen
49:59
a week earlier, and was shocked to see a pop
50:02
up alert that said he was deceased. When she looked
50:06
more closely at the patient's file, she saw that another
50:10
provider had entered a note saying the alert was incorrect
50:14
and the veteran was in fact alive and had been
50:16
discharged from the hospital. Other VA clinicians using the system
50:22
said it has cut into the time they can spend
50:25
with patients. Rachel Orosco, who resigned in early October from
50:31
a position as a primary care doctor at White City
50:34
VA Medical Center in Oregon, said she saw some improvements,
50:39
such as the addition of a messaging function, but the
50:42
new system continued to slow care. She said she used
50:47
to see thirteen to fourteen patients a day, but after
50:50
three years using the new computer system, she said she
50:54
and her colleagues were just barely able to see about ten.
51:00
She said problems that she or her colleagues reported early
51:03
on had still not been fixed at the time of
51:05
her resignation. For instance, the system for accessing all of
51:10
the patient's medical files, which are sometimes voluminous, was hard
51:14
to navigate. It could not be searched by a keyword
51:18
that limitation not only wasted time, she said, but it
51:22
created the risk that the medical staff could miss important
51:26
treatment information. Rosco said she resigned in a large part
51:31
because of the stress of working with the new system
51:34
and her fear that whatever patience could be harmed. They
51:39
say they fix one thing and sometimes something else gets broken.
51:44
Is just like a merry go round. And finally, today
51:49
Generation Z is deeply concerned about the future and politician's
51:56
ability to fix it. Is gin Z all right? According
52:01
to a new poll from the Harvard Kennedy School Institute
52:04
of Politics, maybe not. More than forty percent of eighteen
52:10
to twenty nine year old surveyed last month say they're
52:12
struggling or just getting by. In one quarter believe they'll
52:17
be worse off financially than their parents. Many distrust the
52:21
White House and Congress, both major political parties, and to
52:27
some extent, each other. While most reject political violence, nearly
52:31
forty percent say it's acceptable under certain circumstances. The message
52:36
is clear, said John Dela Volpe, the Institute's director of Poland.
52:42
The systems and institutions meant to support young Americans no
52:47
longer feel stable or responsive to them, and they are
52:51
fearful for what comes next. Young Americans right now have
52:56
no clue what the future holds and are deeply concerned
52:59
about that, said Jordan Schwartz, the twenty year old student
53:03
chair of the Harvard Public Opinion Project. They don't think
53:07
the country is in a great place right now, and
53:10
they also don't see any reason to believe it is
53:12
going to get better anytime soon. It's been a tough
53:16
year for many Young Americans face a rough labor market,
53:20
layoffs across industries, high housing costs, and loneliness so dire
53:26
that it disrupts daily life. The findings of the Harvard poll,
53:31
which surveyed about two thousand people, reflect that with artificial
53:36
intelligence driving much of young people's fears about job security,
53:41
majority of young Americans see AI as a threat to
53:44
their job prospects, and a plurality believe AI will reduce
53:49
their own opportunities. Rayan Fayuji, a twenty two year old
53:54
living in New York City, said he was unsurprised to
53:58
see other people in his age group named the economy
54:01
as one of their top concerns. As a recent college
54:05
graduate working in the music industry, he said his day
54:08
to day concerns also revolve around rent and food prices.
54:14
Every conversation with friends or family, are even just strangers,
54:19
is about the cost of living. Paluji said, it's the
54:22
number one thing right now. Luis Rees, a twenty six
54:28
year old living in Los Angeles, was laid off from
54:31
his job at a film production company two months ago
54:34
and has felt frustrated that he hasn't been able to
54:37
find even part time work while he continues applying for
54:41
jobs in his field. I'll always end up in the
54:45
final stages of an interview and then somebody else gets picked.
54:49
And sometimes I'll go to coffee shops with cafes or
54:52
restaurants and they will tell me I'm overqualified. He said.
54:56
It feels like I can't even get jobs that are
54:59
supposed to be easy year to access. Initially, Ray's unemployment
55:04
claim was denied through a clerical error, preventing him from
55:08
accessing benefits like food stamps and Medicaid and forcing him
55:12
to go through a court process to appeal the decision.
55:16
Without the affordable health insurance he had through his job,
55:20
two medical scares, including a broken nose, had placed more
55:23
strain on his own expenses, he said. The poll also
55:28
found that a majority of young people carrying negative impressions
55:32
of both political parties. When asked to sum up Democrats
55:36
and Republicans in one word, weak was the most common
55:41
use to describe Democrats and corrupt was the most common
55:45
for Republicans. The poll's respondents also lacked confidence at President
55:50
Trump's administration and legislators from both parties, with approval rates
55:56
coming in below thirty percent for all three groups. Most
56:01
respondents also disapproved of the way the president is handling
56:04
the economy and health care, according to the polls finding.
56:09
And even though Democrats were still meaningfully favored among young people,
56:13
the poll found nearly half of all Democratic respondents described
56:19
their own party poorly. Support for the party persists not
56:24
because of genuine enthusiasm, but because young voters don't see
56:28
an alternative, according to the report, Faluji said he and
56:33
his peers felt this sentiment during the twenty twenty four
56:36
presidential campaign. Faced with what they said as poor candidates,
56:41
they're still frustrated, he said, by the amount of money
56:44
the country invests in the military and foreign conflicts, while
56:47
the domestic cost of living remains high. New York Marilet
56:52
Zohran Mandani, a socialist Democrat saw swelling support, Feluji said,
56:59
because he succeeded in addressing people's everyday concerns about costs,
57:05
a lot of people got a sense of reinvigoration and
57:08
that maybe electoral politics could be used to actually serve
57:12
people and to alleviate burdens people are feeling. He said.
57:17
Disillusionment with America's main economic system, capitalism, grew across party
57:25
lines after a spike and support in twenty twenty. Support
57:29
for other major economic ideologies, democratic socialism and socialism also
57:36
declined in the past five years. The survey found democratic
57:40
socialism saw the biggest, dropping support from forty percent in
57:43
twenty twenty to twenty nine percent last month, although support
57:48
remained steady among Democrats and some support. Socialism also decreased overall,
57:54
but it grew among Democrats. And this concludes the reading
57:59
of the World Washington Post for to Say Today, Monday,
58:02
December eighth. Your reader for today has been Rod Brotherton.
58:06
If you have any questions, comments, or suggestions concerning the program,
58:10
please feel free to call us at eighty five nine
58:13
four two two sixty three ninety. Thank you for listening
58:17
and hew please stay tuned for continued programming right here
58:20
on radio. I