- A new report by the VA Office of the Inspector General puts a military hospital in hot water once again after it was revealed that a lack of EHR documentation, the shredding of prescription records, and sight-unseen renewals of powerful opiates on a routine basis plagued patients at the Medical Practice Clinic in San Francisco. Following a similar exposé pinning three deaths on improper EHR use and poor patient monitoring in Memphis, the new report shows that workflow issues and overcrowding has contributed to a chronic lack of proper oversight for patients with severe pain.
The report found that providers did not routinely document prescription renewal problems in the EHR, nor did they often complete a narcotic instruction note template for such patients. Reviews of adherence and screenings for possible abuse were conducted in less than half of surveyed cases, with 53% of patient files reflecting no documentation that a qualified clinician assessed the patient’s pain management regimen. Fifty-nine percent of patients had no narcotic instruction notes and one third of patients did not have a documented urine drug test to detect correct use of the medication.
Additionally, the clinic used paper prescription request forms to communicate the status of renewal requests between clinical staff. However, these paper communications are shredded and never become part of the patient’s EHR file, leading to significant gaps in documentation.
The clinic serves 10,000 patients with 10 nurse practitioners and 30 part-time attending on duty (AOD) physicians. Since VA policy requires that many narcotics are only prescribed in 30-day doses, patients may experience a gap between the end of their prescription and the first available appointment with a primary care or specialist physician. The workflow was developed in order to keep prescriptions constant for chronic pain patients. However, due to the frequent rotation of AODs, none of whom work more than 20 hours per week, clinicians were often tasked with reviewing prescription renewal requests for patients unknown to them and without meeting with the patients in person.
While policy does not forbid providers from renewing medications for patients without seeing them, at least seven patients ended up hospitalized due to an overdose on an opioid. Three of the patients attempted suicide by overdose, while one combined their prescription with illegal drugs to adverse effect. No patients at the facility died due to improper drug use.
Bonnie S. Graham, MBA, Director of the San Francisco VA Medical Center, concurred with the report that the workflows and lack of proper EHR documentation were detrimental to patient care. The facility will discontinue the use of AOD staff in reviewing urgent renewal requests and will instead integrate the use of an opioid dashboard to manage prescriptions on the primary care side. Graham also noted that all clinical staff will be reeducated about the use of the narcotics instruction note, which will be mandatory for all patients receiving more than 120mg of morphine or equivalent drugs per day.