Wednesday, May 28, 2014

"Texas VA Run Like a ‘Crime Syndicate,’ Whistleblower Says" - Can Reports About the Benefits of EHRs at the VA Healthcare System Be Trusted?

More and more is leaking out about alleged executive malfeasance at the Veteran's Administration healthcare system in the U.S.

This article just appeared:

Texas VA Run Like a ‘Crime Syndicate,’ Whistleblower Says
May 27, 2014

For years, employees at a Texas VA complained that their bosses were cooking the books. For years, the VA insisted there was no widespread wrongdoing.

New whistleblower testimony and internal documents implicate an award-winning VA hospital in Texas in widespread wrongdoing—and what appears to be systemic fraud.

Emails and VA memos obtained exclusively by The Daily Beast provide what is among the most comprehensive accounts yet of how high-level VA hospital employees conspired to game the system. It shows not only how they manipulated hospital wait lists but why—to cover up the weeks and months veterans spent waiting for needed medical care. If those lag times had been revealed, it would have threatened the executives’ bonus pay.

What’s worse, the documents show the wrongdoing going unpunished for years, even after it was repeatedly reported to local and national VA authorities. That indicates a new troubling angle to the VA scandal: that the much touted investigations may be incapable of finding violations that are hiding in plain sight. 

“For lack of a better term, you’ve got an organized crime syndicate,” a whistleblower who works in the Texas VA told The Daily Beast. “People up on top are suddenly afraid they may actually be prosecuted and they’re pressuring the little guys down below to cover it all up.”

Read the linked article in its entirety.  It contains document images of altered electronic orders, the EHR system apparently being used for "creative storytelling" to allow for "good metrics", and an employee "performance plan" evaluation submitted by a whistleblower containing perverse incentives:

... The VA’s 2012 performance plan, provided to The Daily Beast by the whistleblower, contains five critical elements to evaluate success, each one containing multiple sub-criteria. But critical element No. 5, the “Results Driven” component that contains the “wait time” criteria, is worth 50% of the overall score. That’s as much as all the other elements combined.

I won't delve into the gory details of the article it yourself...but I do raise the following issues:

1.  The VA EHR system VistA CPRS has been touted as among the best EHR's in the world, based on reports that come out of the VA.

  • Can these reports on the benefits and safety of VistA CPRS be trusted, considering what may be going on systemically regarding altered data related to "making the numbers" and getting bonuses?
  • It is well known that EHRs slow clinicians down, through annoying alerts and reminders and other decision support, cryptic and complex order-entry processes, and the general need to navigate multiples screens and templates to perform what used to take seconds on pen and paper.   Is it also possible that the inability of the VA system to meet its care obligations in a timely manner is related to adverse effects on productivity of the EHR system itself?

2.  EHR audit trails are an automatically-generated log of user activities, such as viewing, printing, altering or deleting an electronic document or other data.  They are the only way to authenticate an electronic record as complete and unaltered, since all paper/handwriting cues are gone in the computer world.

  • It may be of interest to investigate the electronic audit trails generated by the VA electronic health records (EHRs)... or the lack thereof, for as I understand it those audit trails are often only active for VIPs ("very important persons") in the VA VistA CPRS EHR system.
  • Even worse, in the commercial sector hospitals admit they can alter or delete the EHR system audit trails - see my post at  It's likely the same applies in the VA, and it would be of concern that any audit trails of test and visit scheduling or other activities could be undergoing a "disappearing act" in the wake of this scandal, in addition to the actual test/scheduling data itself.

It is unfortunate that this scandal sheds doubt on claims made about activities, including EHR use, at the VA hospitals.  I myself have taught my students that the VA model has been a model for others to emulate, at least as far as EHRs are concerned.


As an important aside:

I am personally familiar with very odd events at the VA, namely in 1995.  At regarding the computer-related radiation brachytherapy debacle at the Philadelphia VA Hospital I wrote [and I am adding some additional comments now in brackets]:

... I have some familiarity with odd events at the Philadelphia VA Hospital. (Not including the fact that I spent a few months there as a medical intern in the early 1980's). In the mid 1990's I took my father there for evaluation for increased service-related disability. He had been treated for skin lesions in the Army in WW2 and after by the VA with Fowler's solution (an arsenical) and as a consequence of this (even then-outdated and dangerous) treatment, had developed widespread basal cell carcinomatosis over a major portion of his body, with chronic bleeding and discomfort.

I accompanied my father to the exam but did not identify myself as an MD, only as his son. [I was on vacation and was rather casually dressed.  I looked like any other schlep bringing his elderly veteran father in for care.]

My father was seen in an evaluation by several physicians and students (arsenic-caused basal cell carcinomatosis is quite rare now) in my presence, and he was then handed his (paper) chart to take with him back to the main desk.  [As we were walking] I told my dad I wanted to look at the note. The note by a physician who'd seen him stated (paraphrasing):

"Mr. Silverstein said he'd taken more than the prescribed dose of arsenic for years, and even shared it with his wife."

My father and I were shocked and dumbfounded. He'd said no such thing, and being a retired pharmacist of 40+ years, thought anyone making such a statement would have had to have been insane. (My mother had even harsher words when she heard about this.) [Along the lines of, "ARE THEY CRAZY???"]

Needless to say, I was upset. I [identified myself and] confronted the physician who wrote the note, but that physician [a relatively young woman] would not change it, bizarrely claiming that they "remembered my father telling that story in a visit several years prior." Needless to say, such a claim violated all the precepts of medical information integrity of which I was familiar.  [I wondered to myself, "what type of utter imbecile would even say such a thing to a Yale physician/medical informatics faculty member?"]

In an initial attempt to counteract this disability exam sabotage, I actually crossed out the statement in the chart, writing "this is untrue" or words to that effect and signed my own name.

The head of the Philadelphia VA Hospital would not return my calls on this matter.

That is, until Jesse Brown, then Secretary of the Department of Veterans' Affairs, inquired directly a few days later.

Unknown to the VA examiners, my father had been sent for the disability exam after reporting problems to Sen. Jay Rockefeller's office about prolonged delays in having his case heard.  Sen. Rockefeller's staff [specifically, Ms. Charlotte Moreland,, who my mother had befriended through many telephone conversations] had set up the exam!

Sen. Rockefeller's staff was rather upset at the story I reported upon my return to New Haven about the bizarre chart fabrication at my father's VA disability exam, and apparently relayed the story up the chain of command, as it were.

After that, the head of the Philadelphia VA Hospital really, really wanted to speak to me and called me at Yale several times. He wanted to set up a phone conference between me, himself, and the doctors who'd seen my father. I told his administrative assistant that there was "nothing to talk about", and that the false statement in my father's chart would be removed. Period.

I think it was. My father's increased disability was granted in the end, but what was going on here with disability exams was never fully investigated to my knowledge (having done disability exams myself years prior for the regional transit authority, police, fire etc. in Philadelphia, I suspected an "incentive" program to deny vets a disability determination). If I had not examined my father's chart, we might have never known a reason for his being turned down.

A culture of honesty and accountability seemed lacking then, and seems lacking now.

In retrospect, it seems there may indeed have been an "incentive program" for, in essence, limiting positive disability determinations by sabotage, thus causing negative determinations on benefits.

Ironically, among other experiences, it was the impoverished experiences at the Phila. VA as an intern in 1981, with a decade of computer experience under my belt at that time, that led me to pursue a career in Medical Informatics.

With inadequate staff and resources, especially at night when a medical student and I and a minimum of nurses covered something like 50 patients - and at that early stage of my career I am honestly admitting that I did not know what I was doing, really - and large amounts of time wasted on paperwork, I thought there had to be a better way via computing.

I never expected that computers in medicine could become a tool for "creative data alteration" for executive enrichment, an impediment to good care, and a risk in and of itself, as was outed by a whistleblower recently in Athens, Georgia as at

-- SS

May 28, 2014 Addendum:  

Also see "How VA Clinics Falsified Appointment Records" at

-- SS

1 comment:

Judy B said...

Wow, and I thought things could not get worse!