VA's paper health records digitization backlog is 5 miles high, VA OIG says

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A VA OIG audit blamed limited VHA monitoring and oversight and significant staffing shortages for creating a massive backlog in medical records that have yet to be entered into the EHR. (turk_stock_photographer/Getty Images)

If every single one of the paper documents that still need to be digitized at Veterans Health Administration medical facilities were stacked, it would reach more than five miles up, a federal watchdog said.

In addition, VHA medical facilities currently have a backlog of nearly 600,000 electronic documents that still need to be entered into the electronic health record system of July 2018, with some documents dating back to October 2016, according to an audit conducted by the VA's Office of Inspector General.

The OIG blamed limited VHA monitoring and oversight for creating the massive backlog.

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The backlog occurred because "staff did not scan documents and enter them into the electronic medical records in a timely manner. Staff also did not always perform appropriate reviews and monitoring to assess the overall quality and legibility of scanned documents," the OIG report said.

RELATED: VA to spend $4.9B maintaining EHR over next decade as it rolls out Cerner replacement

Staffing shortages also have hindered efforts to clear the backlog, OIG said. Staffing levels and productivity standards varied significantly among the medical facilities that the OIG audit team reviewed, even between facilities with comparable veteran populations. VHA facility directors are not consistently assessing staffing needs based on scanning demand, OIG said.

Veterans Affairs healthcare providers rely on digital medical records to manage veterans' care and to guide their clinical decisions. But it's almost impossible for physicians to ensure continuity of care for their patients if the records never get entered into the system.

The scope of the problem

Since the Veterans Access, Choice and Accountability Act passed in August 2014, more than 70 million appointments with non-VA providers have been completed, generating at least as many medical documents, according to the agency watchdog.

Non-VA providers send medical documents to VA medical facilities for staff to scan or import into patients’ EHRs, which helps ensure continuity of care by healthcare providers. "Incorporating these non-VA medical documents into the patients’ EHRs is critical to supporting patient care because it contributes to more complete, accurate, and readily accessible health records that guide clinicians’ decisions," the OIG report said.

These issues put patients’ continuity of care at risk, OIG officials said. The lack of current medical documentation makes it challenging to ensure they receive accurate diagnoses and timely quality care.

In June 2018, President Donald Trump signed the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, expanding opportunities for community care for veterans from non-VA providers. The MISSION Act has the potential to significantly increase the volume of documentation VA medical facilities will receive from outside providers for scanning, as well as any related backlog.

RELATED: Lawmakers fear lack of governance of DOD-VA EHR project will derail progress

The VA OIG's audit was based on data provided by eight VHA medical facilities that the team visited and 78 facilities that the team interviewed.

Among the audit team's findings, at seven of eight medical facilities, the chiefs of health information management did not ensure compliance with mandatory quality assurance reviews to identify and correct any errors before medical documents were shredded.

Staff at the eight facilities also did not meet training requirements or consistently follow training policy, according to the report.

"VHA needs to improve the management of scanning activities—including importing, indexing, and legibility checks—and ensure related resources and staffing are adequate," OIG said. "These steps would facilitate medical records being scanned and indexed to EHRs in a timely manner and support appropriate quality assurance monitoring throughout the scanning process."

"In addition, VHA needs to establish and implement an adequate training program for personnel performing scanning and indexing roles within medical facilities. These actions are necessary to help ensure veterans receive appropriately informed quality care in a timely manner," OIG said.

The OIG made nine recommendations for VHA officials focused on three areas—reducing backlogs, accounting for scanning demand in staffing decisions, and developing monitoring roles, controls, and procedures.

RELATED: VA plans to go live with Cerner EHR pilot by March 2020

VHA officials agreed with all nine recommendations and submitted "acceptable corrective action plans for all recommendations," OIG said.

The VHA has already taken steps to try to clear the document backlog. The Office of the Acting Deputy Under Secretary for Health for Operations and Management issued a memo in February directing medical facilities with scanning backlogs to allocate the necessary additional resources to eliminate the backlogs, such as potentially using contract staff to help with scanning documents or approving overtime for VA employees, the OIG report said.

The VA plans to roll out its new health records at hospitals in March 2020, but Politico reported today that the EHR modernization project faces significant delays and unanticipated challenges. The March 2020 rollout for the new Cerner system is almost certainly to be partially or completely delayed until October, sources told Politico.

That platform, developed by Cerner, will take 10 years to implement at a cost of at least $10 billion and will be interoperable with the Department of Defense's system. The DOD has already started integrating Cerner’s MHS Genesis system.

VA officials said in July they have transferred 23.5 million health records, covering some 78 billion data points. from the VA EHR to a shared data center with the DOD.

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