VAmalpractice.info-Information about medical malpractice by VA doctors, & VA nurses & how the VA handles medical malpractice tort claims, section 151 benefits, lawyers who represent veterans with malpractice claims and other things that adversely affect the quality of medical care that veterans receive from the Department of Veterans Affairs.
Information on medical malpractice by VA, or Veterans Administration hospitals, physicians, and clinics run by the Department of Veterans Affairs. While many veterans receive satisfactory medical care from the VA, others do not. This site is designed to provide information to those veterans, who have received negligent medical care, from a Veterans Administration hospital, doctor, physician’s assistant, surgeon or other VA medical provider and to encourage discussion about this problem. The VA is responsible for the US paying out millions of dollars a week for medical malpractice claims under the Federal Tort Claims Act. It would be better for our veterans, and for the taxpayers, if the VA chose to provide better medical care instead.
A fatal wait: Veterans languish and die on a VA hospital’s secret list
CNN) – At least 40 U.S. veterans died waiting for appointments at the Phoenix Veterans Affairs Health Care system, many of whom were placed on a secret waiting list.
The secret list was part of an elaborate scheme designed by Veterans Affairs managers in Phoenix who were trying to hide that 1,400 to 1,600 sick veterans were forced to wait months to see a doctor, according to a recently retired top VA doctor and several high-level sources.
For six months, CNN has been reporting on extended delays in health care appointments suffered by veterans across the country and who died while waiting for appointments and care. But the new revelations about the Phoenix VA are perhaps the most disturbing and striking to come to light thus far.
Internal e-mails obtained by CNN show that top management at the VA hospital in Arizona knew about the practice and even defended it.
Dr. Sam Foote just retired after spending 24 years with the VA system in Phoenix. The veteran doctor told CNN in an exclusive interview that the Phoenix VA works off two lists for patient appointments:
There’s an “official” list that’s shared with officials in Washington and shows the VA has been providing timely appointments, which Foote calls a sham list. And then there’s the real list that’s hidden from outsiders, where wait times can last more than a year.
It cost taxpayers $200 million for nearly 1,000 veterans’ wrongful deaths at the VA, but not a single dime of that came out of the VA’s budget!
Maybe the VA’s bureaucrats would improve the quality of care that veterans received if the VA if the cost of the VA’ medical malpractice actually affected the VA’s own budget and reduced the amount of money that the VA has to pay its bureaucrats bonuses!
An Iraq War veteran with post-traumatic stress disorder and a history of drug dependency is found dead on the floor of his room at the U.S. Department of Veterans Affairs hospital in West Los Angeles after doctors give him a 30-day supply of the anti-anxiety medication alprazolam and a 15-day supply of methadone.
In Shreveport, La., a veteran overdoses on morphine while housed in a locked VA psychiatric unit. In a Minnesota VA psych ward, a veteran shoots himself in the head. In Portland, Ore., a delusional veteran jumps off the roof of the VA hospital.
These are some of the deaths that resulted in more than $200 million in wrongful death payments by the Department of Veterans Affairs in the decade after 9/11, according to VA data obtained by The Center for Investigative Reporting.
In that time, CIR found the agency made wrongful death payments to nearly 1,000 grieving families, ranging from decorated Iraq War veterans who shot or hanged themselves after being turned away from mental health treatment, to Vietnam veterans whose cancerous tumors were identified but allowed to grow, to missed diagnoses, botched surgeries and fatal neglect of elderly veterans.
“It wasn’t about the money, I just thought somebody should be held accountable,” said 86-year-old Doris Street, who received a $135,000 settlement in 2010 as compensation for the 2008 death of her brother, Carl Glaze. The median payment in VA wrongful death cases was $150,000….
Glaze, a World War II veteran, became paralyzed from the neck down when he fell in the bathroom two days after being admitted to a VA nursing home in Grand Island, Neb. He died nine days later at age 84.
“I had asked them not to leave him alone, and then they left him in the bathroom,” she said. “We all get upset when these things happen.”
In a written response to questions, agency spokeswoman Victoria Dillon said that while “any adverse incident for a veteran within our care is one too many,” the wrongful deaths identified by CIR represented a small fraction of the more than 6 million veterans who seek care from the agency every year.
The agency, Dillon said, is “committed to continuous improvement.” When a death occurs, “we conduct a thorough review to understand what happened, prevent similar incidents in the future, and share lessons learned across the system,” she said.
The revelations come as the department faces intense scrutiny from members of Congress over the number of preventable deaths at VA facilities. The House Committee on Veterans’ Affairs has scheduled a hearing on preventable deaths for April 9.
In September, the committee held a hearing to examine patient deaths at VA hospitals in Pittsburgh, Atlanta, Dallas and Jackson, Miss.
At the hearing, lawmakers accused the agency of failing to discipline officials responsible for unnecessary deaths, pointing out that it has instead provided performance bonuses to these executives.
For example, after an outbreak of Legionnaires’ disease at the agency’s hospital in Pittsburgh left six veterans dead and at least 21 ill, the VA regional director, Michael Moreland, received a nearly $63,000 bonus.
A five-page performance evaluation, which led to the bonus, made no mention of the outbreak, which began in 2011. After receiving the bonus, Moreland retired.
“It’s not enough for VA to simply compensate the families of those who died,” said Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans’ Affairs. “In order to provide real closure for those struck by these heartbreaking preventable deaths, VA needs to hold fully accountable the employees who allowed patients to slip through the cracks.”
At a budget hearing March 13, lawmakers pressed Secretary of Veterans Affairs Eric Shinseki to provide examples of agency staff who had been disciplined after medical errors resulted in a veteran’s death.
Shinseki responded more generally, saying 6,000 VA employees had been “involuntarily removed” over the past two years, including six senior managers.
Independent legal analysts say the nearly 1,000 wrongful death payments in the decade after 9/11 represent a small percentage of the veterans who have died because of malpractice by the Department of Veterans Affairs.
Unlike the private sector, where survivors can file cases in state and federal court and often win large punitive damages, families of patients who die under VA care must exhaust a month slong administrative review process before filing a lawsuit. Even if they succeed, families can win only actual and not punitive damages from the federal government.
As a result, lawyers are reluctant to take cases, and many families never file – or see a dime…
Despite the reversal, Tracy Eiswert decided to press ahead with a wrongful death lawsuit against the VA, in part because of the toll her husband’s suicide took on their children. “We’re still living with it today,” she said.
The VA declined to comment on Scott Eiswert’s death. In court, the VA has defended itself on a legal technicality, arguing that Tennessee law supersedes federal law in the case and that the Eiswert family failed to follow procedures prescribed in the state statute.
Filed in 2010, the case is still pending.
CIR intern Nicholas B. Hirsch contributed to this story. It was edited by Amy Pyle, copy edited by Sheela Kamath and Nikki Frick and produced by the independent, nonprofit Center for Investigative Reporting, the country’s largest investigative reporting team. For more, visit cironline.org/veterans. Glantz can be reached at firstname.lastname@example.org, and follow him on Twitter at @Aaron_Glantz.
Issues in Obtaining Electronic Medical Records from the Department of Veterans Affairs VISTA CPRS System for Use in Medical Malpractice Cases
How the VA’s Public Affairs Office Simply Declared Victory Over a Problem So That We Would Go Home
W. Robb Graham, Esq.
The purpose of this paper is to try to address a few of the issues that I have encountered with the Department of Veterans Affairs’ VISTA CPRS electronic medical record system. The VA regularly extols the virtues of this system, in the public media, as well as in testimony before Congress. In 2006, Harvard’s prestigious Kennedy School of Government gave the VA its award for innovation in government. The VA proudly announced its receipt of this award on its web site, by saying:
July 10, 2006
WASHINGTON – The Department of Veterans Affairs’ (VA) model system of electronic health records, developed with extensive involvement of front-line health-care providers, has won the prestigious “Innovations in American Government Award.” The annual award, sponsored by Harvard University’s Ash Institute for Democratic Governance and Innovation at the Kennedy School of Government and administered in partnership with the Council for Excellence in Government, honors excellence and creativity in the public sector.
“This great honor is testimony to the vision of health care professionals throughout VA,” said the Honorable R. James Nicholson, Secretary of Veterans Affairs. “Our electronic health records are without peer and ensure that our nation’s veterans receive the best care this country can provide.”
… In addition to saving money, VistA saves lives and ensures continuity of care even under the most extreme circumstances. Many of the thousands of residents who fled the Gulf Coast because of Hurricane Katrina left behind vital health records. Records for the 40,000 veterans in the area were almost immediately available to clinicians across the country, even though the VA Medical Center in Gulfport, Mississippi, was destroyed and the New Orleans VA Medical Center was closed and evacuated. Veterans were able to resume their treatments, refill their prescriptions, and get the care they needed because their medical records were immediately accessible to providers at other VA facilities.
As a result of the publicity juggernaut that the VA has created, to publicize how wonderful VISTA CPRS is, it has managed to create an aurora of absolute accuracy for its electronic medical records, that is not always justified, and has made it difficult to get some courts to apply the same electronic discovery rules to the VA that they would ordinarily apply to private defendants.
While I have often questioned why the VA, or for that matter, any branch of the government, needs to spend the taxpayer’s money on a Public Affairs Office to help promote its image in the media, the reality of the situation is that the VA has a huge Public Affairs effort which is designed to obtain favorable coverage in the media for its programs; so it should not surprise anyone that the VA has obtained overwhelmingly positive coverage for its VISTA CPRS program from many well regarded publications.
In 2006 Fortune Magazine wrote an article which boldly proclaimed in its title “Technology has transformed the VA-Veterans’ hospitals used to be a byword for second rate care or worse. Now, thanks to technology, they’re national leaders in efficiency and quality.” Even the Washington Post, a publication that has long been recognized for its hard hitting investigations, has given VISTA CPRS glowing coverage:
Divya Shroff, a staff physician at the Veterans Affairs Medical Center in Northwest Washington, stops what she’s doing to answer her phone: It’s a doctor down the hall who needs help with a man struggling to breathe.
She calls up the patient’s medical record on the computer at her desk and scrolls through lab reports, doctors’ notes, X-rays and EKGs, thinking out loud with the medical resident, who is at the man’s bedside.
Strep pneumo in the blood. Chest film looks like he’s accumulating fluid. Supposed to get a chest tube. Hard to wake up. No new meds that would be sedating him. Looks like he needs the ICU.
Over the next 10 minutes, Shroff visits the patient’s room and the ICU, and in both places summons his medical record on other computers while she talks with a half-dozen people about what needs to be done. She spends no time looking for the patient’s chart, riffling through paper or decoding handwriting. Nor does she ask anyone to take her word for things. She just lets the evidence — all of it right there for everyone to see — make the case that the patient needs to be moved as soon as possible.
It turns out to be the right decision. Soon after he gets to the ICU, he stops breathing. Doctors resuscitate him and put him on a ventilator.
Did the electronic medical record save this 71-year-old man? It’s impossible to say.
But this much is clear: Never again will a VA patient’s chart be an excuse for things not happening efficiently. Never again will information that is lost, hard to read or impossible to move from one place to another be a factor in the complicated calculus of what makes good medical care — and, on occasion, saves lives.
If the VA publicized some of VISTA CPRS’ warts and flaws, as prominently as its awards, the public, and the courts might be willing to treat this system in a more balanced manner. My point is to make you realize that if you are going to critically evaluate the accuracy of your client’s records, that you will find little objective information in the popular media to aid you in your analysis. Most of the coverage in the media appears to be based on the VA’s public affairs office press releases, rather than actual independent investigation and critical analysis by an investigative reporter.
The 2006 Fortune article stated “in his 2004 State of the Union address, President Bush noted that “by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.” In April of that year he pledged to make interoperable electronic health records available for most Americans within ten years.
How portions of the VISTA CPRS electronic medical records system actually worked in 2004, received a substantially less enthusiastic endorsement than President Bush had anticipated, from surgeons who taught at his alma matter, Yale. When one professor from the Yale School of Medicine was questioned at his deposition, about the use of VISTA CPRS in the treatment of a veteran at Yale’s VA affiliate, in West Haven, Connecticut VA, the surgeon’s opinion about the quality of the information provided by VISTA, differed sharply from President Bush’s opinion:
Q Back in 2004, did the electronic computerized medical record system here at the V.A. allow you to access CT scan images from the computer?
A Yes. There is the capability you could use Vista imaging. We don’t use it because it is, basically, useless.
Q Why do you say it is, basically, useless?
A Because the image quality is too poor.
The Harvard award states:
… In 1995, only 60% of paper charts for VA patients were immediately available. Ten years later, over 99% of patients’ records were available at all facilities at all times. Compiling all of this information into a single electronic file that is accessible to physicians from any one of the VA’s 1300 points of care prevents unnecessary repetitive testing, duplication of unsuccessful treatments, and provides a rich set of clinical information for accurate diagnosis…”
The VA claimed that the VISTA System had helped 40,000 veterans receive medical care after they were evacuated during Katrina. Fortune extolled the virtues of this system when it said “”Absolutely everything is available,” says the chief of staff at the Manhattan campus of the VA New York Harbor Health Care System. Up pops a reminder telling him the patient – a 44-year-old diabetic – is due to have an eye exam. Simberkoff dispatches the man to the eye clinic on the second floor, where an ophthalmologist administers the test. An alert soon flashes on Simberkoff’s screen saying the exam has been completed.” Unfortunately, what was actually happening at the VA’s Yale affiliate, differed from what the Harvard award, might lead one to believe was occurring. Although VISTA CPRS is supposed to allow VA doctors to access the veteran’s information from any of the 1300 VA’s facilities, the “richness” of the clinical information provided by VISTA CPRS, to the Yale surgeons at the West Haven VAMC depended as much on geography, as technology.
Q Here at the New Haven V.A., I take it, you treat neurosurgical patients from several different states?
A That is correct.
Q Often the veterans’ primary V.A. for medical care is not New Haven?
Q Back in 2004, did you have the ability to access the veteran’s medical records from facilities other than New Haven?
Q When you say variably, what do you mean by that?
A We had pretty reasonable access to Rhode Island and Boston. Outside of that sometimes we could get them, sometimes we couldn’t.
Q And do you have any understanding as far as what controlled that? Whether it was you or someone here in IT you had to go to?
A It certainly wasn’t me.
While many members of the public have heard about the President’s initiative to bring electronic medical records to the private sector, with the VA’s system as a model, chances are that they have not heard that in 2008, the VISTA CPRS system was displaying one veteran’s record to the doctor, but that the changes that were being made by the doctor, were actually being made in a different veteran’s record. The VA’s own Inspector General found that this problem occurred at 41 different VA medical facilities. The VA also discovered that the system was not properly handling certain medical orders, which resulted in delays in stopping continuous infusion orders at nine different VA medical facilities.
The VA OIG concluded that:
…OED’s national implementation approach of CPRS did not effectively mitigate risks associated with CPRS software development defects and their potential impact on patient safety. …In the weeks following the installation of CPRS v27 into production environments, 41 medical facilities reported experiencing functionality problems with the display of patient medical records and 9 facilities reported that discontinued orders were no longer properly presented in the sequence of discontinuation date/time
….We found an unwarranted delay in issuance of Patient Safety Advisory AD09-04 following multiple reports of inappropriate continuation of IV fluids.
As a result of these issues, on November 17, 2008, the VA decided to impose an additional level of review of internal review on updates to the changes to VISTA CPRS before they are released to the field. it is certainly laudable at the VA is going to increase the quality control program for future releases of the VISTA CPRS system; however, it should be noted that the VA is now taking this step, 12 years after it initially deployed VISTA CPRS to all of its facilities.
This was not the first time that the VA OIG has found issues that affect the integrity of the VA’s medical records system, the VAOIG regularly reports that its routine examinations of VA Medical Centers’ computer system, show that VISTA CPRS is not properly installed, and that because of improper installation, records that supposedly cannot be changed, were in fact changeable. The VA has given very clear guidance to all of it medical facilities that the records are supposed to be unchangeable and specifically addressed this issue in 2004 and 2006; however, these orders have not been uniformly implemented. This VA OIG report during 2007 showed that for nine types of records, it was possible for the veteran’s records to be changed, after the record had been digitally signed, something which is supposedly impossible, and strikes at the very integrity of the VA’s system.
VA OIG reports have found these issues at other facilities as well. In light of this one must seriously question how many flaws have existed within VISTA CPRS that have not come to public attention at any level and may have affected the quality of care provided to a veteran.
Many times the VA provides s good medical care. In some circumstances, it provides outstanding medical care. I have met many outstanding physicians in the VA system, who I would gladly seek medical care from, for either my family or myself. . The purpose of this article is not to argue that VISTA CPRS is horrible, it is not. I am simply trying to point out that it is not infallible. My purpose is merely to try to raise some of the issues that you may encounter with the records when you are faced with a veteran whose medical care may not have met the standard of care, so that you may consider them in your own analysis of the veteran’s case. A complete analysis of electronic records discovery is beyond the scope of this article, however, I would like to share some of my experiences with other members of the section, with the hopes that they may help to make you aware of some of these issues. When you find the answers to these issues, please send them to me.
1. Getting the veterans’ medical records. In order to evaluate any potential medical malpractice case, it is important to get the client’s complete medical records. Unfortunately, with the VA getting the records and getting a “complete set of records” is usually challenging and may be something that I may have never actually done. First, the VA has a policy that requires that any medical record that has been requested by an attorney, to be reviewed by the VA’s attorney, before it is released. No matter what the reason for this review, it adds to the amount of time that it takes for the VA to provide the records to the veteran’s counsel. This additional time is just as problematic in the digital age, as far as allowing for potential change of the electronic medical record, as it ever was, in the era of the paper medical record. Delay is not the only potential problem. Substantive treatment of the veteran’s record and his future medical care may be affected as well. The VA’s own regulations state that the electronic medical record may be kept under the direct supervision of the HIM manager, if the veteran has asserted a claim against the United States. 5Additionally, you should be aware of the fact that the VISTA CPRS system allows for various flags to be displayed to medical providers when they had access the veteran’s record. Essentially a small alert will appear on a computer screen to advise the doctor about something that the VA feels is important. Many of these flags are truly important, they include past problems such as violence towards health care workers or drug seeking behavior; however, whatever the wisdom behind the flag that warns health care provider that the veteran has filed a claim, it exists, and it may affect how the veteran is treated in future and it may also serve as reminder for the provider to review any past documentation issues in the veteran’s record, not to mention bringing this issue to the attention of less observant colleagues.
I encourage all potential clients to try to obtain their medical records from the VA immediately, before they see me. Most VA’s will usually reproduce the client’s medical records at no charge for the client, while they wait, if it is not a truly voluminous record. Some VA hospitals will release the medical records for free if they are sent to another health care provider, but will charge for the records, if they are released directly to the veteran. This policy is troubling, since it is the VA’s policy to provide records to the veteran under the freedom of information act for free in certain circumstances.
It is also better for the client to obtain his or her medical records from two different VA’s. Occasionally, the results will be different. The following records are similar, but not completely identical. They are for the same surgical consult. One was from the institution that ordered the surgical consult to be performed at another hospital, because the requestor’s laparoscopic equipment was obsolete; the other was from the institution that received the consult request and was supposed to schedule the consultation and perform the anticipated operation. The physician who ordered the consult requested that it take place inside of one week.
The records printed at the hospital that ordered it, appear to indicate that there was no activity on the request between 2/217/05 and 2/22/2005 and it appears that it took five days for the electronic request to travel a little more than a hundred miles;
However, the record for the same consult request, supplied by the hospital that received it includes another entry “(entered)” on 2/18/05 at 08:23:
This shows that it was received by the hospital that was supposed to perform the result the day after it was ordered. This entry apparently resulted in the surgical consult being sent to the psychology department, were it remained for several days before it was redirected to surgery. The point is that sometimes important details are not contained in every copy of what is supposedly the same record. It has taken me years to grasp this concept, only recently have I begun to understand some of the things that may cause this.
2. What is Vista CPRS and More Importantly Where’s My Client’s Data?
VISTA is the acronym for Veterans Health Information Systems and Technology Architecture. CPRS stands for Computerized Patient Record System. I have often been confused by these terms. They are often used incorrectly by many, including members of the VA. In order to avoid further confusion, this is an explanation of these two terms and how they relate to each other to form VISTA CPRS, from a recent Veterans Administration Office of Inspector General’s report:
CPRS is a Vista application that enables health care staff to enter, review, and update administrative, diagnostic, and treatment information for VA patients
Vista – Vista enables the creation of a comprehensive, integrated, electronic record for each patient that is viewable by all clinicians at VA medical facilities, thus eliminating the need for paper medical records. Approximately 100 separate applications are currently in use with Vista including: healthcare provider; registration; financial management; enrollment; patient data exchange and eligibility applications. In 2007, Vista Imaging was implemented which allows multimedia data (for example, radiology images) to be linked to patient’s electronic medical records. VistAWeb allow clinicians to see health data from any other VA facility where the veteran has received health care.
• CPRS – CPRS is a VistA computer application and was initially released in 1996. CPRS provides an integrated electronic patient record system for clinicians, managers, quality management staff, and researchers. CPRS enables electronic order entry and management of all information connected with any patient. The goal of CPRS is to create a user-friendly product that provides critical information through clinical reminders, results reporting, and system feedback so clinicians can make medical decisions regarding orders and treatment. Twenty-eight VistA software applications are integrated with CPRS, which allows clinicians to use CPRS to request laboratory tests, medications, radiology tests, and procedures. Additionally, clinicians can use CPRS to: record patient’s allergies or adverse reactions to medications; request and track consults; enter progress notes, diagnoses, and treatments; and access clinical information from other VA medical facilities.
The VISTA CPRS is a software program that is available from the VA under the Freedom of Information Act, and has served as the basis for many other electronic medical record systems that are in use throughout the world. It was first implemented at many VA’s during the early 1990s. It was been implemented at all VA Medical Center’s by the end of 1996; however, there is a wide range of potential customization available within the program to address unique local practices.
We all have used computer programs that are marketed for use by the public, as they are, “off the shelf;” for example any of the Office 2010 programs, while the program is customizable based on our preferences, the program that you run and the file that is created in Word 2010, on your computer, can be saved as a data file, and then the data transferred by some media to my computer, where the same program should essentially open it up, and display the file on my computer the same way that you saw it. Many of these data files can be forensically examined to see when changes were made, and to analyze the data and metadata, at many different levels.
There are two differences between VISTA CPRS and “off the shelf” programs. VISTA CPRS has a tremendous amount of options, and levels of customization that differ depending, on how each facility chooses to install and configure it. The only analogy that I can make is that the VISTA CPRS is a lot like Time Matters, and some of the other legal practice management software. These programs are designed to work at law firms ranging from a solo practitioner, to the mega firm with hundreds of attorneys in many different cities. For Time Matters to work at my office, it has required a considerable amount of adjustment to the program, by either a consultant, or me, by getting rid of features that I don’t use, and tweaking the features that I do use. VISTA CPRS is vastly adjustable to allow for the tremendous differences within the VA’s medical system as far as facilities and services that are available at each of the more 1,300 locations that the VA has it installed at. This customization is done through the installation of “business rules.” These are the same rules, that when not properly installed by a facility, result in allowing records to be altered after they have been digitally signed.
Several years ago, when I was younger and had less gray hair, I investigated setting up the VISTA CPRS software on a computer system in my office. I thought that I would be able to get my client’s files electronically from the VA and then be able to view them the same way that the VA’s health care providers did, silly me. I thought Iwould be able to get a forensic evaluation of the data and metadata to look for changes that may have been made. As VISTA CPRS serves as the basis, for several other commercial medical records systems, I found a software consultant who could set up the software, but unfortunately, I have yet to be able to actually get the electronic data from the VA. The reason for this is the manner in which the VA stores the veteran’s electronic data.
Essentially, the veteran’s CPRS file is really nothing more than a directory of other files with the actual data containing the information is stored, somewhere, within the VA’s nationwide computer system for the veteran. The CPRS file for the veteran points to potentially thousands of other files, which contain data for other veterans and may point to data that is actually physically stored in many different physical locations. Recently, I deposed the Director of Information the for the VA’s Connecticut Healthcare System. He told me that in all likelihood most of the data containing my client’s medical information, for his treatment at the West Haven VA in Connecticut, was probably housed in a computer in Brooklyn New York, but that the information that was in Brooklyn, would point to numerous other computers throughout the country where the actual data resided .The VA’s budget documents which, admits that VISTA CPRS is based on twenty-year old technology which has become increasingly difficult to manage. It also confirms that the current system does not store the data in a veteran specific file. Perhaps this also indicates that in the future, the system may have more problems, than it has had in the past and that our own attention some of these issues should be raised as well.
On the occasions when I have tried to obtain the raw CPRS electronic data from the government, I’ve been provided with responses from the US attorney that it would take hundreds of hours to extract the electronic data for my client, so that it could be disclosed to me, without disclosing the data for the other veterans I have yet to encounter the Judge who appears to be interested in making the government provide the electronic data without a showing that there has been some alteration, unless I was willing to reimburse the government for the time that it has to spend “extracting “ it. So far I have passed on the extracting of data, while I am certain that it will extract a lot of money from me, I am equally sure that it will not extract any information from the VA. Call me a skeptic, but I think that any data that is turned over after the VA’s employees have spent hundred hours “extracting it,” is likely to have had any have had any useful data “extracted” in the process as well.. If anyone gets a different response, by all means let me know. In the right case, I know that I intend to revisit this issue with the government, but for the meantime I would like to submit some items for you to consider when dealing with the paper copies of these electronic medical records.
What You Get Now is Not What They Saw When They Were Treating the Veteran
The first thing you’ll probably notice is that the electronic medical record will look different, depending upon where it was printed. If it is printed somewhere where it is not intended to be part of a record that is being officially provided pursuant to a medical records authorization, it will have “unofficial copy not for record release on it.” If it is printed pursuant to a medical release, it will not have these words on it. This can be tremendously frustrating and makes it difficult to compare the medical records that the client provided to you before suit, with what you will receive from the government.
As I indicated earlier, the veteran’s VISTA CPRS, file does not contain all of the data for your client. It will point to where thousands of other pieces of data reside. When the medical records department prints your client’s file, the results that you will receive will be based on the information that is available to that user, based on that user’s level of access to information in the system, as well as what the user chooses to print out and provide to you.
The VISTA CPRS system includes a lot of information about the veteran, which you may not truly think of as part of a medical record, for example there may be a lot of information contained within this record about your client’s eligibility for various VA benefits. VISTA CPRS also houses risk management reports concerning your client which are protected from disclosure by statute, which the medical records staff will not have access to and cannot print it even if they wanted to. Many of us probably send medical records authorizations asking for the “entire medical record.” Even when one uses the VA’s VHA Form 10-5345 REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS” one is not likely to get all of the records. This form is designed to mislead the veteran and allow the VA to release whatever it chooses to release as the language used on the form does not even match the VA’s own definitions.
The VHA HANDBOOK 1907.1 (April 15, 2004) defines “medical record” as:
Zz. Medical Record. See subparagraph 4nn, “Health Record”
Unfortunately the term “Health Record,” does not always equal “Medical Record.” “Health Record,” is subject to further definition, that term is defined into two divisions. Invariably, when I have asked for “the entire health record” and find that I did not get something, I am told the clerk interpreted my request using subpart (1) instead of the global definition of the term contained in nn and that I should have asked for the “administrative record” contained in subsection (2). Now I ask for both divisions in accordance with VA’s own terminology:
nn. Health Record. A health record includes the electronic medical record and the paper record, combined, and is also known as the legal health record. A health record can be comprised of two divisions, which are the:
(1) Health Record. This is the documentation of all types of health care services provided to an individual, in any aspect of health care delivery. It includes individually identifiable data, in any medium, collected and directly used in and/or for documenting health care. The term includes records of care in any health-related setting used by health care professionals while providing patient care services, to review patient data or document their own observations, actions, or instructions. The health record includes all handwritten and computerized components of the documentation.
(2) Administrative Record. This is an official record pertaining to the administrative aspects involved in the care of a patient, including demographics, eligibility, billing, correspondence, and other business-related aspects.
Similarly, requests for medical records, often this may be interpreted to mean progress notes, consult reports, discharge summaries and operative reports. “Orders” are usually not provided, unless they are specifically requested. When they are provided a request for “Orders” may result in the clerk printing merely the “orders” that currently exist and not ones that have been discontinued. How each of these printed entries will appear, may also be affected by the medical records department, based on the amount of detail that they have access to, and in turn chooses to release you.
What They Saw and Proving That They Saw It
Virtually everyone at the VA has some level of access to the veterans VISTA CPRS file. Including a wide variety of individuals who you may not expect. For example most Veterans Administration medical facilities are served by its own police department and fire department. The VA police have access to certain portions of the veteran’s record and may make entries in certain portions of the veterans record. Generally, anyone who wants to record something in your client’s record, begins by opening a template in your client’s file. Once the template is opened, it will indicate when the note was started based on a time that is assigned from the system. The author can complete this template either by “cutting and pasting” prior entries, which results in length repetitive notes, or filling in text by typing it. Some templates will give the doctor the option to choose from various predefined field.
A note remains “free text,” and subject to editing by anyone until it is digitally signed. There are very good reasons why the note should be changeable, while the doctor is still working on it. Any mistake or change can be removed easily, up until the time that an electronic signature is applied to it. After the electronic signature is applied any change to that note is supposed to be impossible, assuming that the local VA’s “business rules” are correctly installed. If the doctor wants to supplement the note, or correct, the note, it is supposed to be done with an addendum that is attached to the original note. If the physician prepares an electronically signed note on April 1, 2010 saying that the veteran’s “right arm” needs to be removed and then realizes after he signed the note, on April 2, 2010 that he meant to say “left leg” instead of “right arm”, the original note is supposed to remain, but the April 2, 2005 addendum should always be attached and displayed as an addendum to the original incorrect note.
The important thing to take away from this is that any time a note remains unsigned by applying an electronic signature, it is changeable. When you read through the veterans’ medical records and see that the note was started on April 1, 2005, but was not digitally signed until September 1, 2005, it should raise some suspicion. First, during the time from April 1, 2005 through September 1, 2005 anyone could have edited this note. Is there a reason why the doctor would have chosen to leave this note unsigned? Notes that go unsigned for an abnormally long time bear really close scrutiny. When problems arise I have encountered situations where notes had been created by residents, but not signed them.
In one case, after more than 100 days of being unsigned an abnormally long time, the note was signed by the chief of the service. The explanation that was provided was that the resident had moved on it was necessary to electronically sign the note so that it would be “completed” within the system. Now that I have a better understanding of the system, I realize that the electronic signature that was applied by the chief was applied to whatever text was visible when they signed the note. It could be what the resident wrote, or it could have been completely rewritten by the chief, prior to signature. If you see that the resident has entered other notes, or applied electronic signatures after the date of the note in question, this should really raise some red flags in your mind
Second, since many notes are created in a template for a specific condition, the template will control not only what the doctor recorded, and was prompted to do, when the doctor completed it, but changes to the template may affect how this information is presented several years later. If the suicide prevention template in 2005 had a field for “last consumption of alcohol” when it was completed, and the suicide prevention template is revised in 2008 to omit that field, when the VA prints the veteran’s records in 2009 that field may not be printed, so any information that was recorded in 2005 may not be given to you.
One of the advantages to the physician of the VISTA CPRS system is that the system drives various medical reports, reminders and alerts to the doctor’s in box, so that they do not need to go and find each veterans record, to follow-up on medical care that they order. I represented a veteran to the VA at West Haven Connecticut to have a fusion along with a pedicle screw implant. After the procedure was over, the resident ordered a CT scan and requested that it be performed on a stat basis. The CT scan was not performed by the time the veteran was ready to be released from the SI ICU, and observant nurse noted in the chart that the CT scan had not been performed and she called the resident who ordered the CT, to determine if it was okay for the veteran to be transferred to a regular floor before the CT scan was done. The resident approved the transfer without the CT scan. The resident who was scheduled to transfer in the near future, to another hospital dictated a discharge report indicating that the CT scan showed the hardware in normal placement. The resident did not sign the discharge report before the resident rotated.
When the veteran was ready for discharge, the replacement resident dictated a second discharge report which omitted any reference to the CT scan, one way or the other. Due to problems in the radiology department the CT scan was performed, but not read for more than a week after the veteran had been discharged to his home which was several hundred miles away. The veteran returned to the West Haven VA for his postop visit more than a week after he had been discharged. The resident, who saw the veteran at the post op follow up visit, did not follow up on the issue of the CT scan. The CT scan was later interpreted to show that the hardware had been misplaced so that it impinged the nerve. Several weeks later, the veteran returned with significant problems. This time the CT scan results were considered and ultimately a second neurosurgeon performed a second operation to reposition the hardware.
This veteran’s experiences demonstrated several failures within the VISTA system. First, tracking the CT scan, and receiving the results of the abnormal CT scan, as well as the existence of the first discharge report, which remained unsigned, for more than 90 days. A representative of the West Haven VA radiology department explained it this way:
Q Back in 2004, was there any process that you’re aware of where a clinician would be notified that radiology results had been completed for certain patients of theirs?
A Yes. There is a process of view alert for abnormal finding
Q. And what are view alerts for abnormal findings?
A. I can just tell you the view alert is we put in a diagnostic code, we put in diagnostic code that equaled abnormal finding. A view alert would go to that clinician saying the report is available for them to look at.
Q And how would it go to this clinician?
A Through the Vista system.
Q And was there any way for the radiology department to track whether or not the recipient of these view alerts had actually viewed them?
A. No. Not to my knowledge.
VISTA apparently does not leave any record that the doctor received the note, unless they open it and it requires an electronic signature. VISTA still leaves the doctor the argument, that they never got that CT scan that showed the veteran’s abnormal findings.
Q. When something comes to your inbox in the electronic medical record system, is there something you have to do to click on it someplace to acknowledge you have received it and gotten it?
A. You have to open it.
Q. And can you open it and choose not to electronically sign it?
A. You cannot sign it. You can only sign that which is designated for you to sign.
Q. So, when you get a report like this, somebody else can open it and close it and there is no indication you read this on December 1 or September 4 or whatever?
A. Not that I am aware of.
VISTA’s notification system is one of the benefits to the physician that is frequently touted by the VA. It truly is advantageous to both the physician and the veteran when it is properly used. Each day when the physician logs onto the CPRS system they’re provided with a variety of administrative reminders of things that they need to do, unsigned reports, is one of them. The system is supposed to provide the VA’s administration with the ability to oversee incomplete records, and at some point the administration is supposed to deal with the doctor over this. These “view alerts” and whether they are done or undone are kept, or not kept, or defined by the individual hospitals business rules that they use for VISTA CPRS. Unfortunately, when the VA’s doctors do not look at the records, or choose to no not sign a record for a prolonged period of time, the VA chooses to make sure that VISTA CPRS does not memorialize this phenomenon. I was told at one deposition that after 60 days the reports of unsigned reports are deleted by the system, “…to save space…” Why the administrative staff loses interest in reports that are unsigned for more than 60 days remains a mystery to me.
Eventually, after several months, the attending surgeon electronically signed the first discharge report indicating that the hardware was in normal placement. This was well after the veteran had his surgery to remove and reposition the hardware. The attending did not include any information as to why she was signing the resident’s note, there was not even the briefest of mention that the CT scan had in fact shown a different result than the discharge report, or the operation removing and replacing the screws months earlier. Since this document was not electronically signed, the attending could have easily changed the note to include the additional information that would have more accurately reflected what had happened. If it had been already electronically signed by the resident, she would’ve had to make an addendum to it.
In the days of a paper record, if something was changed, it would have to be crossed out, erased, whited out, or smudged in a manner that gave you a fighting chance to realize that something wasn’t right. Today you must be much more alert to see if something has been changed.. The records that you receive are merely a report based on what VISTA CPRS has been programmed to spit out in response to the request that is made of it. The report is pulled from various data fields. Some data fields are used in more than one report, other data fields are unique to specific reports. Some reports, and entries in the medical record, when they are either compiled, to be displayed on a screen at the VA Hospital, or in the clinic records that you receive or a combination of data pulled from various places within the clients electronic data.
To go back to my prior example of Time Matters, one of the features of practice management software is that it allows data to be entered in one field and the data from that field is used by various templates to supply the information for different forms. Entering the client’s name and address in one location in Time Matters, results in Time Matters using that information every time something requires the client’s address, whether it’s a letter of a pleading. When you change the client’s address, the client’s old address does not appear next to the new one, in the next letter all you will see is the new address.
The VA system operates in a similar manner. Some records are designed to show only the information that was present at a specific time period. You may never know what was contained in that field at the time that your client received medical care, if the data that populate that field ever changes. This makes finding changes in the medical record difficult to find. For example, I recently handled a case for a veteran who was scheduled for a routine laparoscopic chlostectomy. The procedure was converted to an open procedure, due to problems that were encountered after the trocar was inserted. What had been scheduled for 2 and ½ hours as a same day procedure, took 7 hours, and resulted in the veteran spending weeks in the hospital, instead of going home that day to her family as planned. When the operation was over, the surgeon, a well qualified attending came out and told the veteran’s husband that when she was opened up, it was more complex than had been anticipated and that he was rushed in to complete the operation.
The operation report, as well as the nurse before operative report both listed the attending physician as the surgeon as doing the entire procedure. The resident was listed as the first assistant surgeon on the copies of these records that my clients received after she was discharged. Neither report made any notation of the attending being called to the operating room, after things did not go well for the resident. All of the written documentation made it seem like the attending was there the whole time. The government claimed that the attending was there the whole time, the veteran’s spouse could not be correct.
When this veteran had originally gone to the ER at the VA, she was correctly diagnosed as having gallstones, within 24 hours of her presentation. The physician ordered that ordered the surgical consult, requested the veteran be seen within one week. Unfortunately, it took the surgical clinic more than a month to schedule the appointment for her to be seen by a surgeon. She was eventually overbooked into an appointment another two weeks that took place six weeks after the ER had requested it. Surgery was originally scheduled for another seven weeks after the consult actually took place.
When the operation was originally scheduled, it was listed with one surgeon. Three weeks before the surgery was originally scheduled for, the VA contacted the veteran and said that we have a cancellation in two days and we are going to move you into it. This resulted in the veteran being assigned to a resident in the surgery scheduling field, which is also what populates the “surgeon” field on the nurse inter operative report, as well as the nurse interoperative report. The nurse interoperative note is supposed to be the record of what happens during the procedure. This report tracts a variety of items including when nursing personnel arrived and be the operating room, as well as the presence of all individuals in the operating room. It notes times for the start and ending of many portions of the operation and it will it is started by the nurse at the beginning of the procedure and completed at the end of the procedure. Understandably this note is open for several hours while the veteran is being operated on. Like many of the VA’s records it is “free text” and editable until it is digitally signed; therefore, any changes or corrections are not visible.
When we received the scheduling document, printed with the request that he showed a history of deletions, it became apparent that one surgeon’s name had been displayed in this field for several weeks. Two days before the operation, it was changed to another surgeon’s name, this time the resident. The resident’s name “RO”was apparently displayed in this field the day before the operation, the resident’s name was there when the plaintiff arrived at the hospital several hours before the operation began, the resident’s name was there when the plaintiff was placed under anesthetic, and when the operation began. Ten minutes after the procedure had been converted, the name of the surgeon changed from the resident “RO” to the attending surgeon “MA”.
- The names of the doctors who performed the surgery were changed during the surgery. The first set of records made it appear that an attending began the procedure, in reality a resident was listed as the surgeon until well after the procedure began. This changed info is not provided unless specifically asked for,
The scheduling document shows when changes to various data fields were made:
The lesson that I’ve learned from this is to make sure that I’ve requested that only the records, all audit trails, records of changed values, records of receipt of notifications and alerts, of all record changes, and deletions as well records of all disclosures that have been made of the client’s record, as well as the facility’s business rules and information concerning their implementation.
I would suggest that if you are dealing with one of these cases for the first time that you consider going to the VA’s website and accessing some of the information that is available to you about the system. Currently they have a VISTA CPRS demo system, which you can use, so that you get the feel of the interfaced that the doctors use. Additionally, many of the VA’s VISTA publications can be found on the VA’s website. While my experiences have helped me focus on some these issues have gotten better, I am certain that I am not seeing all of them. I would welcome any other useful information on this issue, because it is going to be one that we are all going to struggle with, as we try to represent veterans
 Incorrect Patient Information Displayed: On September 30, 2008, a VA medical facility reported that when a clinician switched from one patient’s record to another, the first patient’s information was sometimes still presented within the second patient’s CPRS display. CPRS v27 was installed at the initial reporting facility on September 24, 2008. In total, 41 VA medical facilities reported this issue (The facilities are identified in Appendix D.), but no patient safety incidents were reported. The issue was reviewed by clinicians and software developers and it was determined that the integrity of the medical record was not comprised because of this software defect in the future.
2 Discontinued Orders No Longer Listed in Proper Sequence: On September 29, 2008, a VA medical facility initially reported that when viewing active orders, CPRS v27 displayed discontinued orders by original order date rather than the date the order was discontinued; hence, this information was improperly presented at the bottom of the screen. This software defect resulted in delays of stopping continuous IV infusion orders for at least nine patients. CPRS v27 was installed at the initial reporting facility on September 21, 2008. In total, nine VA medical facilities observed and reported this problem. Two sites reported that this defect involved one patient at each facility, while the third site reported that the error affected seven patients. The six remaining sites reported that the software defect did not result in any delays in stopping continuous infusion orders. After a review of the medical records for the nine affected patients, VHA determined that no patient suffered any harm resulting from this software defect.
3 Because of the reported software defects associated with CPRS v27, the Office of Information and Technology (OI&T) and VHA developed preliminary plans for strengthening the software release process. On November 17, 2008, VA implemented a requirement that all clinical software releases be approved by the USH. This is the first step in requiring higher levels of review prior to software release. VA is also examining its software testing processes and future releases of CPRS will benefit from any improvements identified in this evaluation. Furthermore, VA has established a Software Application Testing and Review Workgroup, to start in March 2009, to evaluate the testing, review, and approval of software applications to be deployed in VA medical facilities.
VHA HANDBOOK 1907.1 HEALTH INFORMATION MANAGEMENT AND HEALTH RECORDS April 15, 2004
6 o Sensitive Records
(1) Some specific record types are deemed sensitive and may be maintained under direct supervision of the health information professional, or be flagged as “Sensitive” in VistA, or other facility computerized record repositories. These include, but are not limited to:
(4) Individuals engaged in the presentation of claims before VA, including representatives of veterans’ organizations, or cooperating public or private agencies, or Administrative Tort Claims; and
(5) Records involved in Administrative Tort Claim acti
6. Primary achievement will be through transition of VistA-Legacy (VistA) to VistA-Applications Development (VistA-AD) program. VistA-AD will focus on the software applications, while the infrastructure and architectural foundations take place in parallel in the VistA-Foundations Modernization program. Over VistA’s lifespan, it has grown to become the largest and best electronic medical record system in the world. VistA is growing more difficult to support due to: technological age, product maintenance costs and integration difficulties associated with mainstream software languages, tools, and processes. VistA software is written in MUMPS, a 20 year old technology, resulting in diminishing qualified MUMPS software developers. In addition, improvements are also needed such as data storage in veteran-centric format and standard data that is shareable across the enterprise to provide advanced clinical decision support. VistA stores data in a facility-centric format rather than the more useful veteran centric format and the data is not standardized among facilities thus making decision support very difficult.
(2) Limitations on Frequency and Extent.
- USCS Fed Rules Civ Proc R 26
- (A) When Permitted. By order, the court may alter the limits in these rules on the number of depositions and interrogatories or on the length of depositions under Rule 30. By order or local rule, the court may also limit the number of requests under Rule 36.
- (B) Specific Limitations on Electronically Stored Information. A party need not provide discovery of electronically stored information from sources that the party identifies as not reasonably accessible because of undue burden or cost. On motion to compel discovery or for a protective order, the party from whom discovery is sought must show that the information is not reasonably accessible because of undue burden or cost. If that showing is made, the court may nonetheless order discovery from such sources if the requesting party shows good cause, considering the limitations of Rule 26(b)(2)(C). The court may specify conditions for the discovery.
- (C) When Required. On motion or on its own, the court must limit the frequency or extent of discovery otherwise allowed by these rules or by local rule if it determines that:
- (i) the discovery sought is unreasonably cumulative or duplicative, or can be obtained from some other source that is more convenient, less burdensome, or less expensive;
- (ii) the party seeking discovery has had ample opportunity to obtain the information by discovery in the action; or
- (iii) the burden or expense of the proposed discovery outweighs its likely benefit, considering the needs of the case, the amount in controversy, the parties’ resources, the importance of the issues at stake in the action, and the importance of the discovery in resolving the issues.
 Department of Veterans Affairs Press Release dated July 10, 2006
 Stires, David “Technology has transformed the VA Veterans’ hospitals used to be a byword for second-rate care or worse. Now, thanks to technology, they’re national leaders in efficiency and quality.” Fortune May 15, 2006
 Department of Veterans Affairs Press Release dated July 10, 2006
 Stires, David “Technology has transformed the VA Veterans’ hospitals used to be a byword for second-rate care or worse. Now, thanks to technology, they’re national leaders in efficiency and quality.” Fortune May 15, 2006
 “Incorrect Patient Information Displayed: On September 30, 2008, a VA medical facility reported that when a clinician switched from one patient’s record to another, the first patient’s information was sometimes still presented within the second patient’s CPRS display. CPRS v27 was installed at the initial reporting facility on September 24, 2008. In total, 41 VA medical facilities reported this issue (The facilities are identified in Appendix D.), but no patient safety incidents were reported. The issue was reviewed by clinicians and software developers and it was determined that the integrity of the medical record was not comprised because of this software defect. VA OIG Report “Review of Defects in VA’s CPRS Version 27 and Associated Quality of Care Issues” June 29, 2009 p. 3.
Now that VISN 4 is Moreland free I’d like to turn my attention to another pet peeve, the use of former Soviet Officers to treat veterans.The VA should be required to fire all former Soviet Military Officers, who are physicians or at least require that they disclose their former Soviet status to patients!
As shocking as this sounds, the VA currently employs physicians who are former Soviet officers to treat veterans.
It is inappropriate for veterans to be treated by former Soviet officers, particularly, if the physician does not disclose his prior status, it is particularly offensive, when Cold War era veterans receive psychiatric treatment from a former Soviet officer who may lack the basic understanding of our culture necessary to treat our veterans’ mental illnesses.
The VA should be required to fire these former soviet officers, or at a minimum require them to disclose their former Soviet military status so that veterans may chose whether they want to receive treatment from another medical provider.
As I have received some comments that my claim that the VA employs former Soviet Officers is baseless, and is completely without merit, and that I am crazy for saying such things here are some quotes form the deposition of the VA doctor in question, Iv’e omitted the name of the medical school that he attended because that would make it too easy to figure out which VA hospital I’m referring to:
Q………You went to medical school in –
A. I went to medical school in Russia. And where did you go?
A. The name is ———————————
Q. And could you tell me, when did you graduate from —————–
A. June, 1991.
Q. And how long is medical school or was medical school in Russia at that time?
A. Six years.
Q. And after you graduated from medical school in Russia, what did you do?
A. I did my — I did my residency in OB-GYN and after that I practiced as an OB-GYN.
Q. You practiced as an OB-GYN physician for how long?
A. 1990 till 1992.
Q. When you went to medical school in Russia, was it necessary for you to have any level of military service or governmental service obligation as a result of that education?
A. As a part of our education we went to we studied military medicine and also while in medical school we went to a special summer camp for two months and when I graduated I received I was lieutenant medical something. I had the rank of lieutenant.
Q. And was that in the Soviet Army, Navy?
A. Lieutenant of the Reserve..
Remember you saw it first here!
Veterans dying because of health care delays
CNN) — U.S. veterans are dying because of delays in diagnosis and treatment at VA hospitals.
At least 19 veterans have died because of delays in simple medical screenings like colonoscopies or endoscopies, at various VA hospitals or clinics, CNN has learned.
That’s according to an internal document from the U.S. Department of Veterans Affairs, obtained exclusively by CNN, that deals with patients diagnosed with cancer in 2010 and 2011.
Hospital delays are killing war vets
The veterans were part of 82 vets who have died or are dying or have suffered serious injuries as a result of delayed diagnosis or treatment for colonoscopies or endoscopies.
Barry Coates is one of the veterans who has suffered from a delay in care. Coates was having excruciating pain and rectal bleeding in 2011. For a year the Army veteran went to several VA clinics and hospitals in South Carolina, trying to get help. But the VA’s diagnosis was hemorrhoids, and aside from simple pain medication he was told he might need a colonoscopy.
Congress demands answers on VA deaths
“The problem was getting worse and I was having more pain,” Coates said, talking about one specific VA doctor who he saw every few months. “She again examined me and gave me some prescriptions for other things as far as pain and stuff like that and I noticed again she made another comment — ‘may need colonoscopy.’
“I told her that something needed to be done,” said Coates. “But nothing was ever set up … a consult was never set up.”
“I had already been in pain and suffering from this problem for over six months and it wasn’t getting better,” Coates said. “I told her that if you were in as much pain as I was and had been going through you wouldn’t wait another two months to see what’s going on. You would probably do it this week.”
Coates waited months, even begging for an appointment to have his colonoscopy. But he only found himself on a growing list of veterans also waiting for appointments and procedures. He was finally told he could have a colonoscopy, many months later.
“I took it upon my own self to call the department that scheduled that and ask them about it. And they said this was the earliest appointment that I could get. And I explained to the lady what I had already been through and how much pain I had, and I said if I wait this long there might not be … (anything) we can do about it then. I could be even dead by then. And the only thing she could tell me was ‘I understand that, sir, but I don’t have any control over that.’ ”
Finally about a year after first complaining to his doctors of the pain, Coates got a colonoscopy and doctors discovered a cancerous tumor the size of a baseball.
The now 44-year-old veteran is undergoing chemotherapy in an effort to save his life.
It is unclear whether anyone responsible at the VA has been fired, demoted or even admonished for the delays in care and treatment. Some of the people responsible may have even received bonuses in recent years for their work, despite the delays in care or treatment for the veterans.
According to the document obtained by CNN, 10 veterans are confirmed to have died in the South Carolina and Georgia region alone. And the document shows 29 vets or their families were sent the disclosures, notifying them they had serious “adverse events” because of delayed care. And according to the document the problems go far beyond Georgia or South Carolina.
In the Florida region, five veterans are dead, and 14 vets or their families were sent the disclosures, notified that they suffered “adverse events” because of delayed or denied care or diagnosis, according to the exclusive document.
In the Rocky Mountain region, two veterans died, and four families were sent the disclosures or notified. In the Texas region, seven vets or their families were sent disclosures about adverse events and serious injuries suffered because of delayed care.
Coates filed a legal claim, citing the “failure of the Columbia (South Carolina) VA Medical Center to timely diagnose his rectal cancer.” The VA settled, but admitted no wrong-doing.
“I don’t know what my outcome is going to be,” said Coates.
“I just try to live every day like it’s my last day.”
The new document obtained by CNN shows a worse problem than has previously been made public by the VA.
As CNN has previously reported, as many as 7,000 veterans were on a backlog list — waiting too long for colonscopies or endoscopies — at VA facilities in Columbia, South Carolina and Augusta, Georgia.
After CNN’s detailed accounting of dela-related deaths at the Columbia and Augusta VA hospitals, a bi-partisan group of Congressmen visited the hospitals, demanding answers.
“We have a duty to make sure that the veterans who serve get the best health care possible,” said Rep. John Barrow, D-Georgia. “And it is very obvious that for too long and for too many folks that hasn’t happened.”
The VA said the backlog at those two hospitals has been solved, but that is not a good enough explanation for Rep. Jeff Miller, the chair of the House Veterans Affairs Committee.
“The fact that we’ve had veterans who have died in the very facilities that are supposed to be taking care of them, and not by natural means, by means that could have been prevented is egregious,” said Miller, R-Florida. “And it’s not acceptable.”
Miller said the VA, from the top down, has consistently ignored his committee’s requests to find out who is responsible. Even with the delays in care which have led to deaths and serious injuries, the congressman said not a single person has been fired or even demoted, and in fact some of those responsible may have even gotten bonuses.
“I grieve for the families who lost loved ones that could have been with them this Christmas that would be celebrating 2014 today had the backlog not existed,” said Miller. “That’s not what anybody in this country wants for our veterans.”
He said the lack of accountability is what angers him most.
“That’s why we asked the question again today, with members of the South Carolina delegation and Georgia delegation, tell us exactly who was disciplined and how. I don’t want to hear the excuse anymore that ‘It was multi-faceted. …There were many people involved’ ” said Miller.
“Well if there were many people involved then they all need to go. We are not asking for one particular person, we want to know exactly why things happened and who was held responsible, At this point publicly, we haven’t seen anybody held responsible.”
CNN has made repeated requests for interviews with top officials at the VA, including President Obama’s appointed head of the Department of Veterans Affairs, Secretary Eric Shinseki. The requests have all been denied, or ignored.
The VA did issue a written statement from Dr. Robert Petzel, the Under Secretary for Health at the department of Veterans Affairs. In the statement, Petzel wrote that “The Department of Veterans Affairs (VA) cares deeply for every Veteran we are privileged to serve. Our goal is to provide the best quality, safe and effective health care our Veterans have earned and deserve. We take seriously any issue that occurs at any one of the more than 1,700 VA health care facilities across the country.”
He also stated: “As a result of the consult delay issue VA discovered at two of our medical centers, the Veterans Health Administration (VHA) conducted a national review of consults across the system. We have redesigned the consult process to better monitor consult timeliness. We continue to take action to strengthen oversight mechanisms and prevent a similar delay at another VA medical center. We take any issue of this nature extremely seriously and offer our sincerest condolences to families and individuals who have been affected and lost a loved one.”
In August 2007, presidential candidate Barack Obama gave a campaign speech to veterans specifically addressing wait lists, denied care and poor treatment of vets. He promised his administration would be different.
“No veteran should have to fill out a 23-page claim to get care, or wait months — even years — to get an appointment at the VA,” said then-candidate Obama.
“When we fail to keep faith with our veterans, the bond between our nation and our nation’s heroes becomes frayed. When a veteran is denied care, we are all dishonored.”
But Coates said for him the speech is an empty promise.
“Someone needs to stand and face the person who suffered and the veterans who have died and say, ‘Hey it was me, I let the ball drop,’ ” he said.
“How many lives are we going to lose from this?”
“When is it going to be corrected?”
VA agrees to $12,000,000 settlement for medical malpractice during brain surgery on veteran at a VA hospital.
December 2, 2013 (WLS) – A Chicago-area Vietnam veteran will get a $12 million medical malpractice settlement from the federal government.
John Johnson suffered severe brain damage during surgery at the Hines VA Hospital five years ago.
His lawyers say doctors did not adequately prepare for and monitor his heart condition when he was put under anesthesia.
His lawyers say the money will be used to help cover his medical and day-to-day living expenses.
Trouble in Tennessee!
VA OIG confirms that malpractice at the Memphis VA emergency room contributed to the deaths of 3 veterans!
The VA OIG has released an investigation that confirms medical malpractice was responsible for the deaths of 3 veterans at the Memphis Tennessee VA. The substandard medical care that led to the deaths of these veterans all took place in the emergency department. In the first case, the veteran was administered a drug that he had a documented allergy to. He died 8 days later. In the 2nd case, a veteran was found not breathing and unresponsive in the emergency department; a subsequent review revealed that his monitoring equipment had stopped functioning forty minutes before he was found unresponsive. This veteran died 13 days later. A 3rd veteran was admitted to the emergency room with signs and symptoms that should’ve resulted in more aggressive management. Due to a combination of mistakes in the emergency department there was a tremendous delay in diagnosing the fact that there was bleeding occurring in the patient’s brain. He died the next day.
These are the OIG’s descriptions of the cases:
Patient 1. The patient arrived at the facility ED complaining of back and neck pain. The ED triage1 nurse documented in the EHR that the patient’s condition was non-urgent, listed the patient’s allergies, including aspirin, and indicated that the allergies were verified with the patient. A physician’s progress note entered approximately 3½ hours later made no mention of allergies. The physician ordered ketorolac (a non-steroidal anti-inflammatory pain medication) to be administered intramuscularly for the patient’s back pain. This medication is contraindicated for patients with an allergy to aspirin. The physician’s order for ketorolac was hand-written rather than being entered into the EHR as required by local policy. Entering the order electronically would have generated an alert that the medication was contraindicated due to the patient’s drug allergy. A few minutes after the physician wrote the order, a staff member administered the ketorolac, and the patient was discharged from the ED approximately 10 minutes after receiving the medication. An hour later the patient returned to the ED by ambulance in full cardiac and respiratory arrest. A different physician saw the patient and noted the drug allergy. The patient had a breathing tube inserted, was placed on a ventilator, and was transferred to the Medical Intensive Care Unit (MICU). The patient died 8 days later after the family agreed to discontinue life support
Patient 2. The patient arrived at the facility ED complaining of back pain described as “10” on a scale of 0 (no pain) to 10 (unbearable pain). A physician saw the patient and hand-wrote orders for hydromorphone (a narcotic pain medication) 2 mg to be administered intravenously2 (IV), ondansetron (an anti-nausea medication) 4 mg IV, lorazepam (a tranquilizer) 1 mg IV, and dexamethazone (a potent steroid medication with anti-inflammatory properties) 4 mg IV). Both hydromorphone and lorazepam have sedating properties.
The patient was in a “Level 2” ED bed, not in the main ED area. The patient rooms in this area are not visible from the main ED and do not have bedside electrocardiographic, oxygen saturation, or vital signs monitors connected to the central monitoring system in the main ED. The patient was connected to a portable oxygen saturation monitor that should alarm if there is a critical change in oxygen saturation level; however, staff would have to be within hearing range of the monitor since it was not connected to a centralized monitoring system. According to the EHR, the registered nurse (RN) checked on the patient 45 minutes after administering the medications and found him to be unresponsive and not breathing. ED staff began resuscitation efforts, a breathing tube was inserted, and the patient was placed on a ventilator. He was transferred to the MICU, where he remained in a coma until he died 13 days later. A retrospective review by the facility revealed that the oxygen saturation monitor had stopped recording data approximately 40 minutes before the patient was found unresponsive.
Patient 3. The patient had a history of frequent hospitalizations and complex medical issues, including hypertension, diabetes, congestive heart failure, and end stage renal disease requiring dialysis. The patient arrived at the facility ED complaining of shortness of breath and eye pain. He was noted to have an extremely elevated blood pressure and an ED physician entered an order in the EHR for hydromorphone 1 mg IV and hydralazine (a vasodilator3) 20 mg IV. Approximately one hour later, a nurse documented that the patient was confused, but a subsequent note stated that he was alert and oriented. EHR progress notes reflected that the RN notified the physician that the patient’s blood pressure readings remained very high, but there is no notation that the physician was alerted about the patient’s confusion. A second dose of hydralazine was administered about two hours after the first dose, and the physician documented about an hour after the second dose that the patient was “improving slowly.” Shortly afterwards, another physician came on duty and documented that patient was awaiting admission to an inpatient unit. About an hour later, the RN documented that the patient again complained of eye pain. A few minutes after that, the patient was found unresponsive. A CT scan4 detected bleeding in the patient’s brain. A breathing tube was inserted and the patient was placed on a ventilator in the ED, transferred to the MICU approximately 4 hours later, and died the following day.
These are the OIG’s findings:
We substantiated that a patient was administered a medication in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had a critically high blood pressure that was not managed aggressively, and experienced bleeding in the brain approximately 5 hours after presenting to the ED.
We found that the facility took actions as required by VHA in response to the unexpected patient deaths, but noted that implementation of action plans developed through RCAs was delayed and incomplete.
We found inadequate monitoring capabilities for patients in some ED rooms, an issue identified during our site visit last year.
We also found that nursing ED-specific competency assessments had not been completed.
This is the link to the complete report:
Let’s applaud Chairman Jeff Miller as he takes on the bureaucrats that adversely affect the quality of care that veterans receive.
p executives at the nation’s 152 Department of Veterans Affairs medical centers and regional directors could draw faster penalties for major leadership failures under a House bill expected to be introduced on Tuesday.
Rep. Jeff Miller, R-Fla., chairman of the House Veterans’ Affairs committee, said he plans to introduce the legislation in response to the fatal Legionnaires’ disease outbreak at the VA Pittsburgh Healthcare System and other significant health care failures scattered across the country. If approved, the measure would allow the VA secretary in Washington to fire directly or demote any VA senior executives for subpar job performance, according to a copy of the three-page bill obtained by the Tribune-Review.
“This legislation would give VA leaders a tool to address a problem that continues to get worse by the day. VA’s widespread and systemic lack of accountability is exacerbating all of its most pressing problems, including the department’s stubborn disability benefits backlog and a mounting toll of at least 31 recent preventable veteran deaths at VA medical centers across the country,” Miller said.
“While the vast majority of the VA’s more than 300,000 employees and executives are dedicated and hard-working, the department’s well-documented reluctance to ensure its leaders are held accountable for mistakes is tarnishing the reputation of the organization and may actually be encouraging more veteran suffering instead of preventing it,” he said.
VA spokeswoman Ramona Joyce said the department generally does not comment on pending legislation.
“At least in my observations, the nonprofessional administrative staff is just this self-perpetuating network. It seems to be beholden to no one except itself,” said W. Robb Graham, a Cherry Hill, N.J., attorney who specializes in VA malpractice cases. “If they’re coming up with a way to begin getting rid of some of these directors and senior people, more power to them.”
VA officials in Washington have yet to make clear whether any Pittsburgh VA executives will be disciplined for the Legionnaires’ outbreak.
Pittsburgh VA leaders were repeatedly criticized by lawmakers last year when the Centers for Disease Control and Prevention tied the Legionnaires’ outbreak to Legionella-tainted tap water at VA campuses in Oakland and O’Hara. The water likely sickened at least 21 veterans from February 2011 to November 2012 as the Pittsburgh VA failed to control the common bacteria under standard hospital practices, the CDC found. Five of the patients died.
Pittsburgh VA CEO Terry Gerigk Wolf and her supervisor at the time, regional VA Director Michael Moreland, received performance bonuses of $12,924 and $15,619, respectively, for fiscal year 2011, which included part of the outbreak period.
Pending legislation in Congress would ban such bonuses for senior VA executives for five years and tighten disease-reporting requirements for all VA hospitals, among other new accountability standards. Miller has asked the VA for a review of its performance appraisal system.
Under current regulations, the Congressional Research Service found that senior VA executives who might face discipline are entitled to a variety of special considerations. They include written notice, at least 30 days in advance, that identifies specific reasons for proposed disciplinary action. Executives are permitted “a reasonable time” to respond and can file an appeal, among other options.
In a statement released by Joyce, VA officials in Washington said they have limited the number of senior executives who receive high rankings and “hold those responsible accountable” any time there’s an “adverse incident.”
“Moreland is really on the Move”
He’s taking his $63,000 bonus and running!
Man are we going to miss that guy!He was a tireless self promoter who took bureaucracy to new heights and constantly gave us something to write about.
In what is hopefully the last edition of “Moreland on the Move,” VISN 4 Director, and tireless self promoter, Micheal Moreland has announced that he is keeping his $63,000 bonus and is “retiring” on November 1, 2013. By retiring and giving VISN 4 the opportunity to recover from the discontent, distrust and discord that has plagued it for the last two years, the man who lists on his resume as his specialty “Finding solutions to unsolvable problems,” may have actually taken the first step in solving the biggest problem that faces VISN 4: Michael Moreland.
During his last month on the job, we are going to be updating this post with some of the highlights of Mr. Moreland’s career. If there are any Congressional investigations, OIG reports or AFGE posts that we’ve missed, please send us the information and we will add them. We want to recognize the man who inspired our own “got bonus?” campaign.
Christopher Ellison went to a veterans medical center in Philadelphia to get eight teeth extracted in 2007. What should have been a routine dentist visit left him permanently incapacitated.
The $17.5 million Ellison and his family received in a malpractice judgment against the Department of Veterans Affairs was the largest against the agency in a dozen years — and one of more than 400 payments the U.S. government made last year to resolve VA malpractice claims, according to agency records obtained through a Freedom of Information Act request. The total cost came to $91.7 million, also the highest sum in at least 12 years.
The cases against the VA have included missed diagnoses, delayed treatment and procedures performed on wrong body parts. U.S. lawmakers and veterans’ advocates say they reflect deep flaws in the agency’s health-care system even as the department tends to more former troops, including those who fought in Iraq and Afghanistan.
“The rapid rise in malpractice judgments against VA mirrors the emerging pattern of preventable veteran deaths and other patient safety issues at VA hospitals,” Representative Jeff Miller, a Florida Republican and chairman of the House veterans committee, said in an e-mailed statement. “What’s missing from the equation is not money or manpower — it’s accountability.”
Miller’s committee held a hearing in Pittsburgh today to probe lapses that include a Legionnaires’ disease outbreak at a VA hospital that killed at least five veterans and also led to malpractice claims. The VA’s inspector general is conducting a criminal investigation into the outbreak, which involved bacteria in the hospital system’s water, Robert Petzel, the department’s undersecretary for health, said during the hearing.
Family members of veterans who died after being exposed to the bacteria said the VA didn’t immediately let relatives know there was a potential health problem.
“For sixteen days my father was allowed to shower and drink the water without any warning,” said Robert Nicklas, whose father, William, a Navy veteran, died last year after the Pittsburgh VA outbreak. “Why were we not warned?”
More veterans are taking advantage of VA medical care, including those requiring more complex treatment. As many as 1.2 million additional soldiers are due to become veterans in the next four years. Some of the soldiers from the wars in Iraq and Afghanistan are suffering post-traumatic stress disorder while others are living with injuries that would have been fatal in World War II or the Vietnam War.
The age of recent veterans may be a contributing factor in the rise of claims payments, said W. Robb Graham, an attorney in Cherry Hill, New Jersey, who has represented former troops filing claims against the agency. Younger claimants tend to get larger malpractice payouts, often tied to how long victims will suffer, he said.
The median age range of veterans who served after the Sept. 11, 2001, terror attacks in New York and Washington was 25 to 34 years old, according to a 2011 Labor Department study. That’s compared to veterans who served during the World War II, Korean War and Vietnam eras, whose median age range was 65 and older, the study said.
“If the VA cuts off the wrong leg of a veteran who is 70 years old and his life expectancy is 75, he’s entitled to five years of damages,” Graham said in a phone interview. “If they cut off the wrong leg of a veteran who is 25, you’re now dealing with someone who is entitled to 50 years of damages.”
The department has 152 hospitals and about 19,000 doctors. Last year, the VA tended to 5.6 million veterans, a 32 percent increase from fiscal 2002, according to agency data.
“It’s the largest health-care system in the U.S., and they do an incredible amount of good work,” said Jerry Manar, deputy director of national veterans service at the Kansas City, Missouri-based Veterans of Foreign Wars. “However, there are so many more things they could do in terms of oversight that they don’t appear to be doing now. As a consequence, sometimes you wind up with poor results that were avoidable.”
The department is “deeply committed to providing the quality care and benefits our nation’s veterans have earned and deserve,” Gina Jackson, a VA spokeswoman, said in an e-mail. “If employee misconduct or failure to meet performance standards is found to have been a factor, VA will take appropriate corrective action immediately.”
The 2012 malpractice payments stemmed from both court judgments and administration settlements. The payouts, made by the U.S. Treasury’s Judgment Fund, rose 28 percent last year from about $72 million in 2011, the VA records showed. Taxpayers have spent at least $700 million to resolve claims filed against the veterans agency since 2001, according to the data.
Many valid VA malpractice claims never get paid, said attorney Graham, who served as a judge advocate general in the Navy in the 1980s. Some are rejected because paperwork isn’t filed properly, he said.
“My strong belief is a lot of lawyers don’t know how to sue the VA,” he said.
Some law firms aren’t interested in representing people suing the federal government because of laws that limit attorney fees to 25 percent of malpractice awards, Graham said.
‘An Alarming Pattern’
In a May letter, Representative Miller asked President Barack Obama to help address “an alarming pattern of serious and significant patient care issues” at VA medical facilities.
The House panel is reviewing the Legionnaires’ outbreak in Pennsylvania, and the department’s handling of two overdose deaths and two suicides at an Atlanta veterans hospital. Also under scrutiny are poor sterilization procedures and possible patient exposure to infectious diseases such as HIV at VA locations.
“We are not here as part of a witch-hunt, to make VA look bad or to score political points,” Miller said during the hearing. “We simply want to ensure that veterans across the country are receiving the care and benefits they have earned.”
The agency isn’t holding employees, especially executives, accountable for preventable deaths, Miller said. Department officials also gave bonuses to doctors even if they practiced without a license or left residents unsupervised during surgery, according to a Government Accountability Office report last month.
The recipients of $150 million in bonuses to VA health-care providers in fiscal 2011 included a radiologist unable to read a mammogram and an emergency-room doctor who refused to see patients, the report found.
Miller has said the VA employees should be punished — not rewarded — for their incompetence.
The number of malpractice claims filed with the VA has remained at 1,544 for the past two years, said Jackson, the agency spokeswoman. The leveling off came after a 33 percent spike in cases to 1,670 between 2010 and 2005, according to an October 2011 GAO report.
The VA’s malpractice payment rates may be similar to national levels, said Anupam B. Jena, an assistant professor at Harvard Medical School and physician at Massachusetts General Hospital.
Less than 25 percent of the claims filed against the veterans agency result in payment, according to the VA. About 20 percent of malpractice claims filed with the largest insurer of physicians between 1991 and 2005 resulted in a payment, according to a 2011 study published in the New England Journal of Medicine, said Jena, who worked on the report.
Last year’s “noticeable increase” in medical malpractice payments was partly due to an “exceptionally large” $17.5 million court judgment, Jackson said in an e-mail. Such payments are “highly variable from year to year,” she said.
That record judgment went to Ellison, who was honorably discharged from the Marines in 2001. He was a 49-year-old electronics technician from Bridgeport, Pennsylvania, in 2007 when he visited the dentist to have eight teeth extracted because of tooth decay and gum disease.
During the procedure at a VA facility in Philadelphia, Ellison’s blood pressure dropped several times to “unusually low” levels, his attorney, Shanin Specter, a partner at Kline & Specter P.C., a law firm in the city, said during a 2011 trial.
Ellison wasn’t sent to the emergency room, and the dentist continued with the extractions, said Specter, son of Arlen Specter, the former senator from Pennsylvania who served as a Republican for more than 28 years and became a Democrat during his last 20 months in office. Arlen Specter died last year.
Ellison had a “catastrophic” stroke while driving his car shortly after leaving the dentist office, Specter said.
The government argued that the veteran’s existing health problems caused the stroke, not the care he received at the VA. Ellison had a history of smoking, diabetes, hypertension and many other stroke risk factors, Thomas Johnson, an assistant U.S. attorney, said during the 2011 trial in U.S. District Court in Philadelphia.
After the stroke, Ellison was left with limited vocabulary, “severe and pervasive deficits in all mental abilities,” and “negative personality changes,” according to court documents.
“He wound up being totally incapacitated, requiring 24-hour-a-day care,” Specter said. “This is about as devastating an injury as a person can have, and that’s what the award reflects.”
To contact the reporter on this story: Kathleen Miller in Washington at Kmiller01@bloomberg.net
To contact the editor responsible for this story: Stephanie Stoughton at email@example.com
VA declares victory over quality of care issues, despite the facts: or
“Maybe they’re drinking too much of their own Kool-Aid”
The September 25, 2013, VA OIG’s report “Quality of Care Issues: Erie VAMC & VA Pittsburgh Health System” is yet another in a series which should be called “More news from Michael Moreland and VISN 4.” The OIG’s 11 page report tells a sorry story about the medical treatment that a veteran received from August 15, 2102 through October 1, 2012 for his liver cancer, it tells an even sorrier tale about the “treatment” that this veteran and his family received from an institution that has the audacity to spend the taxpayer’s money to advertise that “it is better than the best.” These six weeks turned out to be the only medical care that the veteran would ever receive from the VA, as he died on October 6, 2012.
The OIG found:
We substantiated the allegation that VA providers did not diagnose the patient’s cancer..
We found VA providers missed opportunities to identify the patient’s cancer and determined several factors that may have contributed to providers not making the cancer diagnosis…
We substantiated the allegation that the patient’s pain was not fully addressed…
We substantiated the allegation that there were scheduling delays in the patient’s referrals and follow-up care…
We substantiated the allegation that this patient did not receive comprehensive oversight through the continuum of his care…
During interviews, many referring providers from the CBOC, Erie VAMC, and Pittsburgh HSC told us it was difficult to communicate with the gastroenterology and Hepatology Clinic specialists. They told us their phones calls occasionally go unanswered and the specialists did not always return phone messages.
Unfortunately none of these finding are surprising; but what is amazing is the indifference to reality that allows the VISN 4 leadership to continue their tireless campaign of self-promotion and disinformation at the expense of the taxpayers. Let’s look at the dates of this veteran’s treatment and a few other things that were happening in VISN 4:
- 8/15/2012 Veteran’s first contact with VA system
- 9/30/2012 End of VA’s fiscal 2012 year (This is the year that Michael Moreland received the $63,000 presidential award for)
- 9/30/2012 VISN 4 is rated the worst in the country using the VA’s own ASPIRE quality measurement system for Ventilator Acquired Pneumonia
- 10/01/2012 Veteran’s last of 13 contacts with VA system since 8/15
- 10/06/2012 Veteran Dies
- Fall 2012 VISN 4 “Vision for Excellence” features stories proclaiming that healthcare provided to veterans in VISN 4 is better than the health care provided by the top 5 hospitals in the nation.
Despite the tragic care that this veteran received, the fall 2012 “Vision for Excellence” had no trouble extolling the quality of the medical that VISN 4 delivered to veterans and pointed out that its ad campaign “Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. I’ve seen this ad and it unilaterally declares that VISN 4 “beat” the competition in vague areas like “patient satisfaction” by statistically insignificant percentages. With no explanation if these figures were gathered in the same manner at VA and nonVA institutions, Mr. Moreland enthusiastically claims that VISN 4 took on the likes of Johns Hopkins and won! The odds are pretty good that the veteran in this OIG report, along with a few who died from Legionnaires’ disease probably didn’t return their patient satisfaction surveys, but if they did they might disagree with Mr. Moreland’s evaluation. No matter what you’ve got to give Mr. Moreland credit, not everyone can get up and say that we are better than the best when you’re in the midst of a Legionnaires’ disease outbreak, a congressional investigation and you have the worst record in the entire VA ventilator‐associated pneumonias.
Ironically, nowhere in this “public service announcement” does Mr. Moreland mention that VISN 4 had the worst ventilator acquired pneumonia rate in the entire VA system. Out of the VA’s 23 VISNs, VISN 4’s record was twice as bad as the second worst VISN. This sort of head to head meaningful comparison would have provided veterans with meaningful information and would have been a “public service” because it would have warned veterans that they would have been better off going to any VISN besides VISN 4 if they were concerned about possibly getting ventilator‐associated pneumonia. Instead Michael Moreland just uses a lot of fuzzy math and unilaterally declares victory over all quality of care issues in VISN 4 and led veterans to believe that all is well. This superior level of chicanery did not go unnoticed in Washington, where this sort of thing is considered career enhancing and resulted in appropriated recognition:
…“Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. This campaign won first prize in VHA’s annual communications awards program in 2012.
- 9/6/2013 Michael E. Moreland endorses the OIG report for the veteran who was treated so poorly at the Erie, VA, prior to his testimony at the 9/9/2013 HVAC hearing to examine preventable deaths and accountability at the VA. That must have put him in the right mood for the hearing. Maybe that’s why he looked so green?
Despite the overwhelming evidence contained numerous VA OIG reports and congressional investigations confirming patient safety lapses in VISN 4, during the last five years, VISN 4 continues to spend money explaining how it has done such a wonderful job dealing with patient safety.The VISN 4 web site continues to boldly state:
When VISN 4 compared its ability to provide quality health care with the best hospitals in the United States, we equaled or exceeded our competition in every category. This is proof that our nation’s heroes are being provided the quality of health care that they richly deserve.
Its most recent issue of “Vision for Excellence” it again extols how much VISN 4 has done in this area. This will be the subject of a future post called “VISN 4’s medical care “quality” publicity blitz, twisting the facts: Delusional fantasy, or indictable fraud?
VISN 4 Director Michael Moreland receives a $62,895 bonus in the wake of patient deaths at a hospital he oversees. Veterans Affairs Pittsburgh Health System receives first lawsuit as a result of Legionella at VAPHS under the Federal Tort Claims Act for the death of a veteran,
Family of VA’s Legionella victim sues government
Attorneys for the widow of a World War II veteran brought a wrongful death complaint on Friday against the federal government, alleging reckless disregard for patients in a Legionnaires’ disease outbreak at the Pittsburgh VA….
…The CDC traced the problem to bacteria-contaminated water at the Oakland and O’Hara campuses of the VA Pittsburgh Healthcare System. At least 21 patients probably or definitely acquired the illness, a severe form of pneumonia, inside the health system, according to CDC findings.
The Nicklas complaint seeks $8 million under charges of wrongful death, infliction of emotional distress and additional violations.
A VA attorney recently suggested negotiations but did not offer specifics, Cohen said.
Pittsburgh VA spokesman David Cowgill said the agency could not comment on pending litigation. A national VA spokesman said he was looking into the matter.
The Nicklases’ sons said in December that the family planned to sue and had initiated a preliminary claim. Federal officials had six months to investigate and respond before the family could formalize a full civil complaint in U.S. District Court. Cohen said the government did not respond to the initial claim.
The Nicklas complaint appears to be the first complete lawsuit filed in connection with the outbreak,..
Collectively, they indicated having filed at least four other preliminary claims over fatal and non-fatal cases during the outbreak, with more claims possible. Attorneys said their clients want to protect other veterans from meeting the same fate.
“I still think my brother would have had a lot more life left to him if he had not contracted that infection,” said Sandy Riley, 61, of Swissvale. She instigated a claim over the Legionnaires’-linked death of her brother, Lloyd “Mitch” Wanstreet, 65, of Jeannette and hopes to inspire some accountability, she said.
“These things never should have happened if they had maintained their systems properly,” Riley said.
The Nicklas complaint echoes that argument and makes several others, claiming the VA failed to control Legionella bacteria that cause the disease. The VA failed to give William Nicklas appropriate treatment and to test patients adequately for Legionnaires’ disease, among many failures, according to the lawsuit.
Read more: http://triblive.com/news/adminpage/4468137-74/nicklas-disease-government#ixzz2awxsCjQj
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WASHINGTON, DC – Today, Chairman Jeff Miller (FL-01) and American Legion
Do you really need to be licensed as a physician to get a physician’s performance bonus at the VA?
Of course not!
While there are many doctors and dentists at the VA who work hard, do a great job and deserve every penny of their salary and bonuses, there are a few who do not. The GSA has concluded that the VA’s leadership has not implemented its “performance bonus program” in a manner that is either consistent or actually rewards doctors for their performance.
The GAO found that the VA gave$11,189 to a surgeon :
“..who was supervising residents left the operating room and medical center before the surgery was completed, allowing residents to continue the surgery without supervision until another surgeon was found to supervise the residents. The surgeon was suspended without pay for 14 calendar days.
The VA gave $8,216 to a radiologist that a Professional Standards Board found failed to read mammograms and other complex images competently.
The VA gave $7,500 to a physician who was reprimanded after the physician refused to see assigned patients in emergency room because physician believed patients had not been triaged appropriately by the emergency department nurse. As a result, wait times increased. According to documentation provided by the medical center, 15 patients waited more than 6 hours to be seen, and 9 patients left without being seen.
The VA gave $10,529 to a physician could not be reached when he was required to be available, which delayed patient care. Physician engaged in inappropriate behavior that had a negative impact on the patient care environment. The physician “yelled” at other staff, and the outbursts were regularly witnessed by patients, contributing to an atmosphere of fear and poor morale in the emergency department. The physician was suspended for 3 days with pay and received a letter of alternative discipline
The VA gave $7,663 to a doctor who practiced for three months without a license.
Tampa VA Surgeon Arrested for Illegally Obtaining Drugs
Richard L. Carpenter an ears nose and throat surgeon has been arrested in Tampa, Florida for illegally obtaining prescription medicine. So far the VA appears not to have issued any explanation for this incident and not much information is available about Carpenter. According to the American Board of Otolaryngology website, he was certified as an ear, nose and throat surgeon in 1985. He was certified prior to mandatory re-certification and has not been re-certified since 1985. Until recently he practiced in Michigan as part of Mid-Michigan Ear, Nose & Throat PC. He is pictured in their current group picture, but his profile has been removed.
Read more about this on our crimes page!
ALBUQUERQUE — Dr. Frank Allen Zimba has been practicing medicine for 31 years, is board certified in neurological surgery — and has a disciplinary history in two other states of operating on the wrong part of his patients’ spines.
The 57-year-old Texas native was hired at the Veterans Affairs hospital in Albuquerque last August, even though disciplinary proceedings that resulted in a suspension of his Oklahoma medical license were pending.
The VA in Albuquerque isn’t saying whether Zimba has had any problems on the job so far — claiming it would be a personnel matter. But even if there have been, the state Medical Board has no jurisdiction to investigate.
That’s because under federal law Zimba is not required to be licensed in New Mexico, unlike most other physicians who work here. He only needs to be licensed in one state in the country, and he has licenses in Oklahoma, New York, Michigan and Pennsylvania.
That left Zimba — who, through a VA spokeswoman, declined to be interviewed for this story — able to work at the Albuquerque VA Hospital during the six months his Oklahoma license was suspended.
Disciplinary records show Zimba was suspended for allegedly operating on the wrong part of a patient’s spine in February 2010. The suspension ended in March of this year.
Several years earlier, he was alleged to have performed surgery on the wrong side of two patients’ spines at a hospital in Jamestown, N.Y.
“They call it a never event,” said Oklahoma assistant attorney general Libby Scott, because it should never happen if hospitals follow procedures and properly mark the sites for surgery.
We will also be posting other information about crime, fraud and other things that adversely affect the quality of medical care that veterans receive from the VA, so if you have any information about medical malpractice at the Veterans Administration, or by a VA doctor, nurse or other health care provider please let us know about it.
The information on this web site is designed to encourage a discussion about Veterans Administration medical malpractice, malpractice claims and procedures. It is not intended to be legal advice. Legal advice can only be obtained from an attorney. If you have a medical malpractice claim against the Veterans Administration, you should consult with an attorney who is familiar with handling medical malpractice claims against the Veterans Administration and the Federal Tort Claims Act.
In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.