VA OIG Audit Finds ‘Miles-High’ EHR Documentation Backlog

If the stack of back-logged work on your desk is more than five miles high, it’s a good bet that internal auditors will take note.

A Department of Veterans Affairs (VA) Office of Inspector General (OIG) audit has found a “significant” backlog in medical documentation that needs to be entered into patients’ electronic health records (EHRs). The OIG report released on August 21 found that VA medical staff has failed to scan documentation and enter electronic medical records in a timely manner to patients’ EHRs.

The OIG visited VA eight facilities and interviewed officials at an additional 78 facilities to gather information for the audit. The calculations from the data collected found that the cumulative medical documentation backlog of paper documentation was “approximately 5.15 miles high.” The office also found that the miles-high documentation hoard contained the records of at least 597,000 individuals, dating back to October 2016.

A lack of oversight, staff training, and resource management led to the backlog, and the VA OIG recommended improving the EHR process by ensuring staffing and resources are adequate. The office made a total of nine recommendations to the Veterans Health Administration to cover three areas, including:

  • Defining the backlog and reducing it;
  • Determining an appropriate amount of staff resources to address the backlog; and
  • Developing and defining oversight roles, controls, and procedures.

According to the OIG, VA’s Office of the Secretary for Health—the executive in charge—concurred with the recommendations and submitted corrective action plans considered acceptable for all nine recommendations.

The VA OIG conducted the audit to ensure that VA healthcare staff are maintaining patient healthcare records as effectively as possible, especially with the amount of patient medical documentation expected to increase.  That expected increase stems in part from the June 2018 passage of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, which will expand community care opportunities from non-VA 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 wrote.

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