News Feature | December 5, 2013

EHR Mistakes Lead To More Problems For VA

Source: Health IT Outcomes
Katie Wike

By Katie Wike, contributing writer

Veterans Affairs hospitals are under investigation again for oversights in EHRs that put patient’s lives in jeopardy

In November, Health IT Outcomes reported that an investigation into preventable patient deaths in a Memphis Veterans Affairs Medical Center had “been attributed to poor use of the EHR system by hospital staff.” The electronic records, if used properly, would have warned staff of one patient’s documented allergy to a certain drug and alerted them to another patient’s conflicting medications.

EHRIntelligence now reports “a military hospital (is) in hot water once again after it was revealed that a lack of EHR documentation, the shredding of prescription records, and sight-unseen renewals of powerful opiates on a routine basis plagued patients at the Medical Practice Clinic in San Francisco. The new report shows that workflow issues and overcrowding has contributed to a chronic lack of proper oversight for patients with severe pain.”

The report EHRIntelligence refers to was issued by the VA Office of The Inspector General which confirms, “At the request of Senator Patty Murray, former Chairperson of the Senate Committee on Veterans’ Affairs, the VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted an inspection to assess the merit of allegations made by a complainant concerning improper opioid prescription renewal practices in the Medical Practice Clinic (clinic) at the San Francisco VA Medical Center (facility) in San Francisco."

EHRIntelligence summarized the report, writing, “Providers did not routinely document prescription renewal problems in the EHR, nor did they often complete a narcotic instruction note template for such patients.  Reviews of adherence and screenings for possible abuse were conducted in less than half of surveyed cases, with 53 percent of patient files reflecting no documentation that a qualified clinician assessed the patient’s pain management regimen.  Fifty-nine percent of patients had no narcotic instruction notes and one-third of patients did not have a documented urine drug test to detect correct use of the medication.

“Additionally, the clinic used paper prescription request forms to communicate the status of renewal requests between clinical staff.  However, these paper communications are shredded and never become part of the patient’s EHR file, leading to significant gaps in documentation.”

NBC Bay Area notes, “In September, The Center for Investigative Reporting revealed that VA prescriptions for four opiates – hydrocodone, oxycodone, methadone, and morphine – surged 270 percent between 2001 and 2012. That far outpaced the increase in patients and contributed to a fatal overdose rate among VA patients that the agency’s own researchers put at nearly double the national average.

It was also revealed that in 2010, the VA paid $150,000 to the family of a Vietnam veteran who was placed into hospice care after doctors at the San Francisco VA accidentally gave him “triple the intended dose of oxycodone” and 20 times the intended dose of morphine. These drugs came after falls during his stay in the hospital. His family says he was prescribed increased amounts of opioids after every incident.

Representative Jeff Miller, R-FL, chairman of the House Veterans’ Affairs Committee, told NBC Bay Area the VA should punish employees and executives responsible for the problems in San Francisco. “Until VA is willing to hold VA employees and executives who break department rules accountable, it is simply illogical to think these lapses in care will subside,” Miller said.

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