Thousands of VA medical records have been lost or damaged in New York

24 May 2013

WASHINGTON – Thousands of patient records at the VA hospitals in Buffalo and Batavia have likely been misplaced or damaged, according to federal officials who have been prodding the facilities to improve their record-keeping.

VA officials uncovered the problem after the associate director of the Buffalo medical center initially dismissed worker complaints about shoddy record-keeping, according to officials at the Office of Special Counsel, which presses federal agencies to address complaints brought by whistle-blowers.

Four medical records technicians in Western New York “disclosed that medical files – including cardiac records, dental records and Agent Orange registry records – were randomly thrown in boxes rather than kept in any order, that many Social Security numbers were not properly attributed to the correct veteran name, and that mold-infested files were not handled properly to prevent further contamination and to ensure their restoration,” the Office of Special Counsel said. “As a result, veterans’ medical records were often deemed unavailable.”

Word of the lost and damaged records, coming just four months after reports that the Buffalo VA hospital potentially exposed hundreds of diabetic patients to contaminated insulin pens, prompted Rep. Chris Collins, R-Clarence, to call for the resignation of Veterans Affairs Secretary Eric Shinseki.

“I continue to be outraged” by the VA’s repeated problems, Collins said on Wednesday. “We’re coming up on Memorial Day, and here’s the VA, which is supposed to provide benefits that all of our veterans have earned in protecting our freedom, and what we have here is a bunch of bureaucrats in Washington and the district offices who seem content to collect a paycheck and not serve the public.”

While it’s impossible to know exactly how many patient records have been misplaced or damaged, it’s likely that thousands were, said Ann O’Hanlon, a spokesman for the Office of Special Counsel.

That’s because the internal VA investigation unveiled systemic problems with record-keeping in Buffalo and Batavia that would have affected not only the records of hospital patients, but also veterans who visited VA facilities for outpatient services, O’Hanlon said.

A spokesman for the VA in Buffalo, Evangeline Conley, noted that the hospital system had used electronic medical records since 1997. But that explanation didn’t sit well with O’Hanlon, who noted that the VA did not even mention electronic records in its report of the records problems.

“Clearly by the record and their response there were extensive paper records,” she said. “We don’t know how many there are, but there are both paper and electronic records.”

In a letter explaining its findings to President Obama, Special Counsel Carolyn N. Lerner said the four local whistle-blowers initially complained about 160 boxes of records, each containing 40 files, that had been stored for at least eight years at the facility in Batavia.

While the boxes were labeled according to medical categories such as “Cardiac,” “Dental” and “Agent Orange,” records were actually randomly filed in those boxes.

That meant all the boxes had to be searched whenever a doctor wanted to see any one patient’s records. As a result, “the four whistle-blowers personally know of at least 15 instances where veterans’ records were requested and deemed unavailable because the records could not be located,” Lerner wrote.

Later, in the midst of a “record retirement project” involving approximately 240 boxes of records, the whistle-blowers found five boxes contaminated with mold.

They then told Elizabeth M. Kane, Health Information Management System manager in Buffalo, about the moldy files, and she ordered the workers to put the moldy files in new boxes and ship them to a storage facility in Missouri.

Believing that the handling of all those files violated agency rules, the whistle-blowers complained to David J. West, director of VA Health Care Upstate New York Medical Center. In response, on Jan. 27, 2012, West asked Jason Petti, associate medical center director of the VA hospitals in Western New York, to investigate.

Later that very same day, Petti informed his boss that he had completed his investigation and that “the review did not substantiate any of the concerns” identified by the whistle-blowers.

Exasperated, the whistle-blowers complained to the Office of Special Counsel, which contacted Shinseki, the VA secretary, who asked the undersecretary for health to investigate.

“The investigation team substantiated most of the allegations and made seven recommendations regarding the steps that need to be taken” to correct the problem, Shinseki said in a letter to Lerner, the special counsel.

Those recommendations include developing a strategic plan for managing patient records, following existing VA policies and procedures, processing all the boxed records stored in Buffalo and Batavia to determine if they need to be electronically scanned and stored and evaluating all on-site record storage locations.

The VA then acted on those recommendations, said Conley, the local VA spokesperson.

“As a result of this second review, an improvement plan for storage and disposition of records was put in place as well as enhanced training for employees,” Conley said.

In addition, the VA’s lawyers gave Kane, the woman in charge of record-keeping, a “written counseling” to make sure she understood the severity of the problems. But the VA exonerated Petti, saying he responded quickly to the problems and provided appropriate oversight – a finding that flabbergasted Collins.

“The administrators congratulated him for doing well,” Collins said. “He did anything but.”

While Collins demanded Shinseki’s resignation, Rep. Brian Higgins, D-Buffalo, wrote a letter seeking a meeting with the VA secretary.

“There is a distinct pattern of mismanagement” at the VA in Western New York, Higgins said. “There are systemic problems that need to be addressed by the VA secretary.”

Officials at the Office of the Special Counsel, meanwhile, lauded the four whistle-blowers – Leon Davis III, Cathleen A. Manna, Tracy Harrison and Pamela G. Hess-Wellspeak – for taking the matter into their own hands and demanding change.

“They experienced pushback at every level,” O’Hanlon said. “They went out of their way to get someone to look at this issue, but no one would until they came to our office. We really admire their courage and fortitude.”

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