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Health Information Management Medical Documentation Backlog

Report Information

Issue Date
Report Number
18-01214-157
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Audit
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) performed this audit to determine if Veterans Health Administration (VHA) medical facilities are scanning and entering medical documentation into patients’ records accurately and in a timely manner. VHA healthcare staff rely on medical records to manage veterans’ care. Incorporating records into patients’ electronic health records is critical because it ensures complete, accurate, and readily accessible health information to guide clinicians’ decisions. The OIG found limited VHA monitoring and oversight created backlogs that put the continuity of patient care at risk. Based on provided data, the audit team calculated that VHA medical facilities have a cumulative medical document backlog of approximately 5.15 miles of stacked paper and at least 597,000 individual electronic document files dating back to October 2016. This 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 also found staffing shortages contributed to the backlogs. The audit team documented that officials at seven of eight medical facilities visited did not ensure compliance with mandatory quality assurance reviews to identify and correct any errors before medical documents were shredded. Officials at the eight facilities also did not meet training requirements or consistently follow training policy. The OIG made nine recommendations for VHA to define and promptly reduce backlogs; account for scanning demand in staffing decisions; and develop monitoring roles, controls, and procedures.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish a policy that formally defines “medical document backlog”—specifically, the age of unscanned and unindexed medical documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Implement formal controls to monitor medical document backlogs—specifically, the description of unscanned and unindexed documents, size of the backlog, and age of health records—as well as subsequent actions to reduce the backlogs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Direct Veterans Integrated Service Networks and facilities with a backlog to allocate additional resources to help clear them.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Implement policy to require chiefs of Health Information Management to notify facility directors when a medical document backlog exists and to take appropriate action.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Assess the scanning process, including staffing and productivity levels, within each facility to ensure authorized staffing levels can support future workload.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure facility directors act on staffing level assessments and obtain the necessary resources within scanning departments.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Implement standardized quality assurance monitoring procedures to improve accurate updating of patients’ electronic health records and completion of corrective actions when errors are identified.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure original documents are retained until the scanning supervisor or designee verifies that scanning staff have met quality assurance monitoring standards established in Recommendation 7.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Develop procedures to ensure facility directors provide adequate document scanning/indexing training, consistent with Veterans Health Administration Handbook 1907.07, prior to allowing employees to scan/index documents without direct supervision and as needed for corrective actions.