Improvements Needed in Adding Non-VA Medical Records to Veterans’ Electronic Health Records

The Office of Inspector General (OIG) evaluated whether VA’s community care staff accurately uploaded records for non-VA medical care to veterans’ electronic health records. Veterans receive non-VA care based on certain criteria, such as the distance from the veteran to the nearest VA facility or the wait time for a VA facility appointment. Records for non-VA care enable continuity of care by Veterans Health Administration (VHA) providers and inform treatment decisions. The audit team found that staff at six of the seven VA medical facilities reviewed did not always index, or categorize, these records accurately. Inaccurate indexing of medical records poses a risk to veteran care and increases the burden on the VHA staff who locate and correct the errors, reducing their time for other tasks. The team reviewed 209 veterans’ mental health medical records that VHA community care staff indexed between April 1, 2019, and September 30, 2019, and found 108 indexing errors for 92 veterans. (Some veterans’ records had more than one error.) Errors included using ambiguous or incorrect document titles, indexing records for non-VA care to the wrong referral or veteran, and entering duplicate records. These errors occurred, in part, due to inadequate procedures, training, quality checks, and quality assurance monitoring, and a lack of local facility-level policies. The OIG recommended the under secretary for health improve non VA medical records scanning and indexing by ensuring VHA facilities create and fully implement standard operating procedures. These procedures should clearly define responsibilities for Health Information Management and community care staff and the procedures for accurately scanning, importing, and indexing non-VA medical records. The OIG also recommended the under secretary ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for facility community care staff responsible for medical record management.