Charlie
rights pending
Charlie Bourg. Chewelah, Washington. Army, Vietnam era. Since 2016, he had served as a patient advocate at Spokane VA — the person veterans came to for help navigating the system.
2020
Spokane became the first VA hospital in the country to switch to the new electronic health record. That December, a routine blood test flagged possible prostate cancer, and Bourg's provider sent him to a urologist.
"She tried to put in the referral to urology, and it took her three times to get it in. And at that time she goes — got it this time."
— Charlie Bourg"got it this time"
She didn't get it that time. Instead, the referral went into what the system calls the unknown queue. Nobody at urology saw it. Nobody told his provider it hadn't arrived. Charlie waited for a call that was never coming.
"the new EHR did not alert the provider but accepted the entry as successful and then routed the order to the unknown queue."
— VA Office of Inspector General, Report #22-01137-204, July 2022
His prostate cancer diagnosis was delayed by seventeen months. By that time, it had spread to his lymph nodes.
Meanwhile, as patient advocate, Charlie spent that time helping other veterans — working with reporters and advocates to find someone the new system had hurt.
"We were out hunting to find out who it was being injured, and one day I had to call Charlie and tell him, 'Hey, I found the first guy.'"
"It's me.
I'm dying."
— Charlie Bourg
screen grab · rights pending
Charlie Monroe served in the Navy as a Seabee. He and Charlie Bourg have been friends for seven years.
"At first, I didn't believe him, and then it just took all the wind out of my sails. I'm losing a brother. What else can I tell you? We've been together through thick or thin for the last seven years. It's like taking my right arm off."
— Charlie Monroe, Navy Seabee veteran"I've got two little 7-year-old granddaughters. I know I'm not living forever, but I would have liked to see them graduate from high school."
— Charlie BourgDecember 2021
"This is dangerous, and they're going to inflict it on my fellow veterans."
— Monica McLaughlin, Navy veteran and nurse at Mann-Grandstaff"My fear was that somebody was going to die."
— Heather Hill, psychotherapistThe Marine
identifying details withheld · screen grab · rights pending
A 77-year-old Marine. Vietnam. A patient of the Columbus VA.
September 2022
He checked into a hospital unable to breathe, days from starting cancer treatment. Antibiotics were ordered into the new VA system. When his wife called the VA pharmacy to confirm they had shipped, an employee read her a tracking number from the system.
It belonged to a different veteran, two thousand miles away.
His prescription was sitting in a Columbus VA pharmacy. Nobody told her. His breathing collapsed that night. The antibiotics arrived thirty-six hours late. He died eight days later.
The department classified the delay as catastrophic.
"VA failed on the prescription." "It might have given us more time."
— his widowThe count
These are not outside estimates. These are the department's own numbers.
"A healthcare provider entered a follow-up psychiatric care order for a homeless patient identified as at risk for suicide."
"The new EHR sent the order to the unknown queue."
"The patient was not scheduled for follow-up care and later contacted the Veterans Crisis Line reporting a razor in hand and a plan to kill himself."
"The patient was psychiatrically hospitalized."
— VA Office of Inspector General, July 2022
What the company knew
"Oracle Cerner was aware of the EHR's unknown queue prior to VA's go-live with the new EHR."
"VHA assessed the risk as major severity, frequently occurring, and very difficult to detect."
"On an Oracle Cerner user help forum, the OIG found several instances, going back to 2014, where Oracle Cerner customers identified challenges with the unknown queue."
— VA Office of Inspector General, July 2022
"Our findings show that nothing related to the EHR's functionality or performance had anything to do with the care this veteran received."
— Michael Egbert, Vice President of Corporate Communications, Oracle · September 2022
Right now
Fourteen hospitals were running the system as of July 2026. Thirty-six more are scheduled through January 2028.
On August 19, 2026, the department raised the vendor's contract ceiling by another $17 billion, to nearly $27 billion total, and extended the contract to 2031.
"no changes to the nature of the work"
— Contract modification, August 19, 2026
Charlie Bourg's referral is still the reason he is dying. The system that lost it is being installed in more hospitals right now.