Failure of a Primary Care Provider to Complete Electronic Health Record Documentation and Inadequate Oversight at the Charlie Norwood VA Medical Center in Augusta, Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a primary care provider’s completion of electronic health record (EHR) documentation within the facility’s required time frame and accumulation of over 4,000 view alerts (EHR notifications) that may have resulted in patients’ adverse clinical outcomes. Also reviewed were actions taken by facility leaders to address the provider’s EHR documentation deficiencies. The OIG’s review of 220 identified patients’ care did not find adverse clinical outcomes related to the provider’s delinquent documentation. The OIG was unable to determine if patients experienced adverse clinical outcomes from the provider accumulating 4,000 view alerts, because the view alerts were addressed prior to the OIG inspection. Once addressed, view alerts are no longer active or viewable. Facility leaders reported finding no adverse clinical outcomes resulting from these view alerts. Facility leaders implemented actions to address the provider’s documentation deficiencies and monitored the provider for sustainable compliance with documentation requirements. The provider no longer treats patients at the facility. High numbers of accumulated view alerts were not isolated to the provider. However, facility leaders implemented strategies to reduce the number, and facility data showed a reduction of accumulated view alerts. Facility leaders need to continue to develop and implement strategies to manage and evaluate the effectiveness of view alerts and assess the need for retrospective reviews of patient care related to accumulated view alerts. During the inspection, the OIG also found that Health Information Management staff were not monitoring EHRs for patient care episodes without associated progress notes and facility policy did not define the time frame for providers to respond to view alerts as required by the Veterans Health Administration. The OIG made three recommendations related to providers’ view alert time frames and monitoring EHRs and view alerts.