OIG Audit Reveals Inaccurate VHA EHR Integration of Non-VA Records

Veterans Health Administration (VHA) staff do not adequately comply with VHA policies regarding the integration of non-VA medical records into a veteran’s EHR, according to a VA Office of Inspector General audit.

VHA leverages non-VA healthcare providers in the community to help provide veterans with timely access to care. After a veteran receives care at a non-VA facility, VHA employees must update the veteran’s EHR with documentation from that visit so VHA physicians have access to the patient’s full medical history.

While VHA medical facility Health Information Management (HIM) staff are responsible for records management, facility directors can delegate non-VA medical record scanning and indexing to the facilities’ community care staff.

However, the OIG audit found that community care staff has not sufficiently complied with VHA requirements for scanning and indexing non-VA medical records.

The audit team discovered that staff at six of seven VHA medical facilities did not always enter non-VA medical records into EHRs accurately.

According to OIG, community care staff at those facilities made errors in 44 percent of cases reviewed when indexing veterans’ mental health medical records into their EHRs (108 errors identified for 92 of 209 veterans). These errors included ambiguous or incorrect document titles, duplicate records, and records indexed to the wrong non-VA care referral or veteran.

The audit also revealed that VHA facilities lacked standard operating procedures for the EHR integration of non-VA records.

“While VHA facilities have the option to use their community care department staff to manage non-VA medical records, they are also required to create standard operating procedures that detail the process, timeframes, and responsibilities for scanning, importing, and indexing non-VA clinical records into veterans’ EHRs,” the report authors wrote.

The audit team found that none of the facilities fully met the standard operating procedure requirements; two did not have any written procedures for integrating non-VA records and five had some written procedures.

“Without full compliance with required standard operating procedures, facilities may continue to experience challenges in ensuring that records added to veterans’ EHRs are accurate,” OIG wrote.

The team also discovered that VHA community care staff often do not receive adequate health IT training. According to VHA regulations, there must be at least one full week of training, and employees must complete 100 consecutive document scans without error.

However, the team found that at all seven facilities, HIM departments did not always train care organization community care staff as outlined in VHA policy.

All seven facilities lacked adequate quality assurance monitoring for scanned documents as well. The chief of HIM, or a designee, is in charge of collecting a random sample of scanned documents and assessing their quality.

At four of the seven facilities, HIM leaders or designees did not monitor scanned documents by community care staff for quality. At the other three facilities, HIM leaders did not consistently perform quality assurance monitoring.

What’s more, all seven facilities did not abide by VHA regulations that require facility staff to conduct quality checks on all of the documents they scan. These quality checks include making sure the document is not a duplicate, is legible, and is assigned to the correct veteran.

The OIG recommended the under secretary for health ensure all VHA facilities create and fully implement standard operating procedures that outline HIM and community care staff responsibilities for accurately scanning and indexing non-VA medical records.

The OIG also called for the under secretary for health to ensure HIM leaders provide training, quality checks, and quality assurance monitoring for medical record management staff as outlined in VHA policies.