Unplugged VA computer affects treatment of cancer patients

This article was updated at 5:46 pm on Tuesday.

It took officials at a Veterans Affairs Department hospital in Philadelphia more than a year to learn that a computer used to assess patient's response to treatments for prostate cancer had been unplugged, delaying assessments, according to an inspector general report released on Monday.

The computer ran an application called the VariSeed treatment planning system, which oncologists use to focus radiation treatment on cancer hotspots. But the computer was disconnected from the hospital's network in November 2006 when a vendor and a VA information technology technician unplugged it from a jack that linked it to the main network so they could connect another piece of hardware.

That year, VA clinicians performed 17 procedures to insert radioactive seeds that treat prostate cancer. Without the network connection, X-rays showing the location of radioactive seeds could not be transferred to the VariSeed computer, making it difficult for doctors to determine the patients' response to treatment, the inspector general found. No patient was injured by the error.

The Philadelphia Inquirer reported on Tuesday that 38 veterans or their wives have filed claims against the hospital for alleged injuries. Two have filed federal lawsuits.

The inspector general report comes on the heels of a fine the Nuclear Regulatory Commission levied against the Philadelphia hospital in March. NRC, which oversees the use of nuclear medicine, said the medical center incorrectly placed radioactive seeds in 97 patients who were being treated for prostate cancer between 2002 and 2008. The agency's $227,500 fine was one of its the largest ever, highlighting the significance of the mistreatment of veterans at the hospital.

In this most recent case, clinicians in the Philadelphia hospital's Radiation Oncology Service hospital repeatedly reported the computer problem every quarter for a year, but the computer was not reconnected to the network until November 2007, the inspector general report said. Employees could find no indication that the issue was brought to the attention of top hospital managers, according to the report.

Once radioactive seeds are implanted, clinicians then conduct a CT scan to determine if they were placed correctly.

The inspector general reported the studies "are a generally accepted practice," and added that until the computer problem was resolved, the hospital should not have conducted prostate radiation treatments.

The report also said the hospital didn't follow proper cybersecurity procedures. VA requires hospitals to isolate computers containing personal medical information from other computer systems. But the inspector general found the VariSeed computer operated outside the Philadelphia hospital's secure networks and was used by the oncology service staff to check e-mail and access the Internet.

The inspector general also uncovered computer problems in the radiation oncology service at the VA hospital in Jackson, Miss., where the VariSeed computer also was not operating on a secure network. A clinician in charge of monitoring the placement of radioactive seeds in patients did not know where to find the folders containing CT scans on the network server and was unable to review the images from May 2007 through February 2008, the inspector general noted.

Despite the computer problems at the Philadelphia hospital, the inspector general concluded the rate of failure in the seed treatment and the recurrence of cancer for the patients involved in that hospital "appear within the norm."

Dr. Robert Petzel, undersecretary of health at VA, said he concurred with the inspector general's findings and recommendations, including those that called for quick fixes to network connectivity problems and isolation of the VariSeed computers.