Poor prescription documentation in EHR jeopardizes patient safety at VA hospital

Electronic health record use continues to plague the Veterans' Administration, with incomplete EHR documentation of opioid prescriptions leading to patient misuse and hospitalizations at San Francisco VA Medical Center, according to a recently published report by the U.S. Department of Veterans' Affairs Office of Inspector General (OIG).

OIG, which conducted its inspection of the facility's clinic after receiving a complaint regarding improper opioid prescription renewal practices, found that providers were not routinely documenting patients' opioid prescription renewal problems in the EHR, despite the fact that they're supposed to assess patients' adherence of proper use of opioids and monitor for misuse, abuse or addiction.

More than half (53 percent) of renewals didn't have documentation of a provider's assessment. OIG also found that providers were not consistently completing the templated Narcotics Instruction Note for patients with opioid problems; 59 percent of applicable EHRs reviewed had no such note. What's more, one-third of patents had no urine drug test to test for opioids documented in their EHRs.

"While we recognize that the clinical pharmacists perform a comprehensive review of the EHR, VHA policy requires documentation of all elements of pain management including adherence," the report states.

OIG further found that the clinic was using paper prescription request forms that ultimately were shredded; to that end, they never became part of the EHR.

The facility has agreed to an action plan to resolve the problems.

The VA is one of the largest users of EHRs but evidently is running into some trouble with its use. A recent investigation revealed EHR workarounds and poor documentation caused the deaths of patients at the Memphis VA; the VA also is one of the largest violators of HIPAA's privacy rule, according to an investigation published in October by the Pittsburgh Tribune-Review.

To learn more:
- read the report (.pdf)