One of the more surprising statements in the Department of Veterans Affairs' Office of Inspector General interim report last month on the VA's Phoenix Health Care System is that audit controls in the venerable VistA electronic health-records system were not functioning prior to the start of the OIG investigation.
During its review at Phoenix, the OIG determined that “certain audit controls” within VistA “were not enabled,” the report said.
The absence of an audit trail for appointment scheduling limited the ability for both VA brass and OIG investigators “to determine whether any malicious manipulation of the VistA data occurred,” the report authors said. OIG recommended that the VA “immediately enable” this audit function at all VA facilities. “The VA completed this action,” the OIG report said.
How veterans were entered into a 12-year-old software component of VistA is at the heart of a politicized furor over scheduling processes and wait times for care that ended with the resignation of VA Secretary Eric Shinseki last week.
Shinseki's replacement, acting Secretary of Veterans Affairs Sloan Gibson, said in a statement Wednesday the VA has “ reached out” to all of the Phoenix veterans, including 1,586 who received phone calls. Gibson was scheduled to visit the Phoenix VA system , comprised of the Carl T. Hayden Veterans Affairs Medical Center and six outpatient clinics.
The OIG's 35-page interim report focused on the Phoenix system. But problems highlighted by the OIG were not limited to the Arizona systems, or to the recent past.
The investigators also found “inappropriate scheduling practices” throughout the vast VA network and over several years.
Some procedural variances VA employees and their supervisors used to mask that the VA was not meeting its 14-day maximum wait time target were mundane.
For example, schedulers scanning the system for open appointments would ask a veteran if an available date would be acceptable, and then book the veteran for that day, according to the OIG.
That's the same procedure schedulers for ambulatory care visits use in private practices across the country. With the VA, however, the scheduler also would record the appointment as if it were on the veteran's “desired date” of care, which is kept in a separate data field. The manipulated entry made the wait time, calculated as the difference between the desired date and the actual date of care, zero days.
Other manipulations had more serious implications for patient care, although the OIG was careful to point out it had not yet confirmed any cases of patient harm resulting from VA scheduling activities.
Schedulers reported that their supervisors had told them to “fix” internal reports that contained appointments with wait times greater than 14 days, with some rigging the appointment date to match the desired date, according to the OIG. Other staffers used the computer system to overwrite previously created appointments to manipulate and reduce reported wait times. Still others deleted or cancelled pending appointments, based on clinical referrals without review by the clinical staff.
An electronic wait-list package was added to the Primary Care Management Module of the VistA system in 2002, at the request of the undersecretary for health, according to the OIG. That post was held then by Dr. Robert Petzel, who resigned from the job last month in the wake of the wait-time uproar.
The OIG auditors said they began their review of scheduling procedures in Phoenix in December in response to allegations left on the agency's reporting “hotline,” and expanded its probe when allegations of wait-time problems surfaced in April at a House Veterans Affairs Committee hearing.
Their latest research is based on VA employee interviews and an analysis of a random sample of 226 test cases, but their report also notes that the OIG repeatedly cited the VA for inaccurate wait lists resulting from failures to follow its own procedures in scheduling appointments.
In 2007, for example, the OIG also found scheduling data inaccuracies and evidence that policies were not being followed. One of those policies was a requirement that schedulers document a patient's preferred date for care or treatment. That date is supposed to start the clock on wait times. In response to the OIG, the VA said complying with its own policy “was an unreasonable expectation,” the OIG said.
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