Patient data errors force VA to close EMR system
Nextgov’s Bob Brewin reports that errors in patient data have forced the Department of Veterans Affairs to close access to the Bidirectional Health Information Exchange, the Defense Department’s vast electronic medical record system. The bug first surfaced in February when a physician noticed that the system claimed one of his female patients had been prescribed an erectile dysfunction drug. The errors have been blamed on old code in the six-year-old system which could not handle peak usage rates.
The glitch did not cause harm to any patient, but “the potential exists for decisions regarding patient care to be made using incorrect or incomplete data,” said Jean Scott, director of the Veterans Health Administration’s Information Technology Patient Safety Office, in the alert issued on Wednesday.
… The VA clinician may see the patient’s data during one session, but another session may not display the data previously seen,” the alert noted. “This problem occurs intermittently and has been reported when querying DoD laboratory, pharmacy and radiology reports.”
The system is expected to go back online March 9. Until then, Brewin writes, “VA doctors will have to obtain a patients’ health information from their paper medical files, faxes or PDF attachments that are e-mailed to the physicians.”
According to its tagline, Nextgov focuses on “Technology and the Business of Government.”
VA works toward improving care for female vets
Acknowledging that female veterans have gotten short shrift at VA hospitals, some are now working to improve the services and experience women receive, according to NPR’s Erin Toner.
For example, the Clement J. Zablocki VA Medical Center in Milwaukee now has a women’s clinic and one manager there says the hospital is working to change the culture.
Toner also reports that a bill pending in Congress would “authorize a study of women who’ve served in Iraq and Afghanistan to find out how the wars have affected their physical, mental and reproductive health.
“The bill also would require a review of the barriers women face in accessing VA health care.”
NPR also includes a map of how many female veterans are in each state.
Related
During a 2008 panel on veterans’ health presented by the San Francisco Bay Area Chapter of AHCJ, Tia Christopher described her difficulties getting the help she needed as a Navy veteran who survived military sexual trauma and has PTSD. She expressed concern for female vets, whose experiences and health issues are significantly different from those of male soldiers and are largely underreported.
Listen to Christopher and the other panelists talk about the health care challenges facing vetereans.
Philly VA doc defends himself before Congress
The New York Times‘ Walt Bogdanich has followed up his investigation into a “rogue” cancer unit at a Philadelphia VA hospital with a report on the questioning of one of the alleged rogue doctors, Gary Kao, at a congressional panel headed by Pennsylvania Sen. Arlen Specter. Kao defended himself by claiming that the mistakes he made during a process called brachytherapy (in which tiny radioactive seeds are inserted into a patient’s prostate) were nothing out of the ordinary.
Dr. Kao did not deny placing large numbers of seeds outside the prostate, but he said investigators were wrong to single him out. “It’s a recognized risk of the procedure,” he told the panel.
Dr. Kao’s assertion was disputed by Steven A. Reynolds, who oversees materials safety at the N.R.C., which regulates all nuclear materials. Cases where large numbers of seeds miss the prostate, Mr. Reynolds said, “happen very, very infrequently.”
Kao said he voluntarily appeared before the panel to set the record straight and correct what he called “very serious false allegations” made by Bogdanich’s initial article.
Philly VA botched 92 of 116 cancer treatments
Walt Bogdanich of The New York Times uncovered an astounding series of regulatory and oversight errors that allowed a “rogue” cancer unit operate with impunity at the Veterans Affairs Medical Center in Philadelphia.
Bogdanich reports that its doctors, primarily Dr. Gary Kao, had botched 92 of 116 cancer treatments in more than six years. The unit treated prostate cancer with radioactive implants, a process known as brachytherapy. Doctors in the unit avoided regulation in part by revising surgical plans to cover for mistakes.
The first clear signs of trouble cropped up in early 2003, the unit was suspended in 2008. Here’s a brief catalog of missed opportunities to reign in Johns Hopkins-trained Kao and associates:
- The unit did not have any peer review process in place.
- The V.A.’s radiation safety program didn’t intervene.
- Neither did the Joint Commission, the group that accredited the hospital.
- Doctors in the radiation implant program weren’t properly supervised.
- Or “trained in what constitutes a substandard implant and the need to report it.”
- Errors went unreported for months, or even years, while patients had no idea they were even made.
The whole house of cards only came tumbling down when a mistaken purchase of lower-radiation implants triggered an investigation of previous cases. Investigators didn’t find any lower-radiation implants, but they did find errors. Lots of them.
No patients are believed to have died from this mistake-riddled treatment; the unit was suspended in mid-2008 and similar programs (whose problems don’t seem to have been as severe) were shuttered in Jackson, Miss., and Cincinnati. Seven of the affected patients were flown to a more experienced V.A. unit for additional treatment.
Update
In a related story, The Philadelphia Inquirer reports that the problems came to light “not because the NRC finished its inquiry” but rather when a Nuclear Regulatory Commission advisory committee asked the agency for an update because “committee members had been hearing disturbing things about the Philadelphia VA’s program.”
VA hospitals faulted for lax infection control
The Veterans Affairs health system may be a model for electronic medical records and savvy drug purchasing, but all bets are off when it comes to the disinfection of equipment for colonoscopies.
After reports of problems piled up, the VA inspector general did some surprise inspections at the government-run hospitals and found they weren’t doing a good enough job sterilizing endoscopes. Yesterday, congressmen blasted the VA for not fixing the problems even after it became aware of them.
“The failure of medical facilities to comply on such a large scale with repeated alerts and
directives suggests fundamental defects in organizational structure,” said the report by the VA OIG. Inadequate cleaning of the equipment may have exposed more than 10,000 vets to hepatitis B, hepatitis C or HIV.
In all, more than 40 facilities got the once-over by investigators, including three which have been “the subject of considerable media attention.” Those are the Bruce W. Carter VAMC in Miami, the Tennessee Valley Healthcare System-Murfreesboro campus, and the Charlie Norwood VA Medical Center in Augusta, Ga.
The Tennessean has a handy chronology of the colonoscopy controversy and a recent story with reactions from affected patients. “There’s nothing they can say,” said Thomas Mayo, a 58-year-old Vietnam vet who learned in February that he has hepatitis C. “They’ve given me something that may kill me.”
For more, see testimony by the VA in this Associated Press video.
VA: Consent forms for human studies incomplete
According to a report released by the Department of Veterans Affairs Office of Inspector General, an audit of representative VA hospitals found that about 31 percent of informed consent documentation for human studies was incomplete. In the vast majority (97 percent) of cases, this was due to lack of a witness signature.
Among the report’s other findings:
- An estimated 1 percent (1,023) of the 110,231 non-compliant lacked the subject’s signature or that of their authorized representative, rendering them legally ineffective.
- An estimated 1.7 percent of the 367,103 consent forms could not be located, the report extrapolated the national range to be somewhere between 0.6 percent and 4.5 percent.
- In specific situations, Institutional Review Boards can waive informed consent. In two of the 33 such cases examined, sufficient documentation of this waiver was not found.
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