Senior staff at the Department of Veterans Affairs (VA) responsible for overseeing new training for the electronic health record (EHR) system at the Mann-Grandstaff VA Medical Center in Spokane, Wash., submitted inaccurate data to inspectors, according to a new report from the VA’s Office of Inspector General (OIG).
An investigation from the OIG’s Office of Special Reviews (OSR) found that two members of the VA’s Office of Electronic Health Record Modernization (OEHRM) Change Management group – the executive director and the director for training strategy – failed to provide accurate, timely, and complete data to the OIG, which impeded oversight efforts.
“The OSR investigation found that Change Management’s responses reflected a careless disregard for the accuracy and completeness of the information they provided,” the report says.
While the OIG said it did not find that the senior leaders had intentionally misled OIG staff, “the leaders’ lack of due care and diligence resulted in misinformation being submitted.”
Specifically, the two senior staffers provided inaccurate proficiency check data with “significant errors,” which doubled the reported proficiency check pass rate from 44 percent to 89 percent.
The staffers then later inaccurately explained the difference “as the result of removing a relatively small number of data outliers.” However, OIG found that the two staffers had actually removed all failing proficiency check scores from the calculations and not just the outliers.
Additionally, the two senior leaders provided a training evaluation plan to OIG staff, without “disclosing that the action items had not been fully implemented and that no training evaluation plan had actually been reviewed or approved.”
The OIG made four recommendations, including that the OEHRM clarify to the office’s personnel that “all staff have a right to speak directly and openly with OIG staff and ensure that direct communication with OIG staff is not impeded when needed to clarify requests or responses.”
The OIG also recommended the EHRM Integration Office (IO) should provide guidance to the office’s staff on submitting accurate, timely, and complete responses to the OIG. This guidance should include disclosing to the OIG the methodologies used, data limitations, and other relevant context.
Additionally, the OIG recommended the EHRM IO consider whether administrative action is appropriate regarding the actions of the Change Management executive director and the director for training strategy.
The VA agreed with all four recommendations and noted that the executive director of Change Management accepted a new position with the Office of Health Technology within the Veterans Health Administration on June 5.
As for the director for training strategy, the VA said it will “review the record, conduct an analysis of the facts of the case and determine the appropriate action or other remedy to correct the behaviors discovered and reported in this finding.”
The report was released alongside another OIG report that found the EHR system has resulted in cases of patient harm.
“A year after the OIG raised issues with VA’s execution of the EHRM program, we are again receiving troubling reports on the EHRM program,” Senate Veterans’ Affairs Committee Ranking Member Jerry Moran, R-Kan., said in a statement.
“[The] reports illustrate patient safety issues that can be traced directly to failures at the highest levels at VA, including the department’s failure to ensure that personnel are candid and open with OIG investigators working to uncover problems in the system,” he added. “Patient safety and honesty within the VA should be the top priorities, and without those two things, we cannot even begin to address issues with the EHRM system.”
