Two found information mix-ups in VA patient medical records

When Phyllis Sneed sought medical records for her late husband from the Dayton Veterans Affairs Medical Center, she received those records as well as the records for another veteran with a similar sounding name.

It’s not an isolated occurrence.

John T. Phillips Sr., a disabled Navy veteran, said that when he obtained his own medical records from the Dayton VA, the records of four other service members were mixed in with the records that the VA mailed to him. The other men’s records contained details of the service members’ medical conditions, their treatment plans, Social Security numbers and spouses’ names along with the service members’ identities, Phillips said.

“There were four of them, and they were spread throughout my records,” Phillips said. “It should have been checked.”

It’s unknown how often the most personal of military medical records are mistakenly put in the wrong hands. Sneed was erroneously given another veteran’s records after her husband’s death in 2001, while Phillips received the batch of mishandled records in 2010. Both Sneed and Phillips contacted the Dayton Daily News after reading an article in June in which the hospital acknowledged that the personal medical records of 16 veterans had been found in the attic of the Centerville home of a deceased former Dayton VA nurse. It has not been determined who brought the boxed records to the attic, and when.

Sneed and Phillips said they both alerted the Dayton VA to the problems, were advised to shred the records they had mistakenly been given, and were told that the problems would be corrected. Both told the newspaper in interviews that they still wonder what the VA has done to prevent additional errors that could put the privacy of other veterans at risk.

Dayton VA officials declined to address the particular issues raised by Sneed and Phillips. The VA said it cannot comment on individual cases, without permission of those individuals or their families.

The agency said in a prepared statement that patient privacy and information protection are top priorities for the department, and that it thoroughly investigates and acts upon complaints involving records privacy issues.

The Dayton VA hospital has come under scrutiny in the last couple of years after it was revealed that a dentist in the Dayton VA hospital’s dental clinic allegedly repeatedly failed to change gloves and sterilize dental equipment between patient visits. The alleged poor infection control potentially put the health of hundreds of VA patients at risk between 1992 and 2010. The dentist, who denied the allegations, retired after the problems were brought to light.

Sneed questions some of the information contained in her husband’s records. Sneed said the records furnished by the VA for her husband, who served in the Army Air Corps as a B-17 navigator during World War II, included mention of diabetes, which he didn’t have, and the possible health effects of exposure to Agent Orange, a chemical herbicide and defoliant that the United States didn’t begin using in battlefields until the Vietnam War.

David Nielsen, a state veterans’ advocate based at the Dayton VA hospital who helped Phyllis Sneed file her benefits claim, concluded that the Dayton VA had included mistaken information in the James Sneed records.

“It seems the VA has mixed things up a little,” Nielsen wrote to Phyllis Sneed in February 2003, in a letter that she shared with the Dayton Daily News. “They are obviously wrong about diabetes and Agent Orange.”

Her husband’s records also included a hepatitis diagnosis, something Phyllis Sneed was not aware of. Sneed had been a round-the-clock caretaker for the veteran, putting her at risk of exposure to the potentially contagious liver infection if her husband did have it.

Phyllis Sneed said she underwent a precautionary examination by her doctor. She also urged other family members to be checked, to determine whether they might have been infected during their exposure to James Sneed. None of the family were found to have hepatitis, she said.

“I went to the VA to get those records,” said Phyllis Sneed, 73, who lives near New Carlisle. “It wasn’t until I pulled his records that I found out. They never did tell me about his hepatitis.”

The widow said she received no other confirmation that her husband had hepatitis. Officials at the Dayton VA hospital declined to release any information to her, citing laws that protect the privacy of medical records, Sneed said.

“When it comes to a caregiver, I thought I had a right to know the details of that, because of my health and my family’s health,” she said. “They were very nice about it, but they said because of the privacy laws, they couldn’t release that information.”

James Sneed suffered from heart disease, an ulcer, emphysema and an aneurysm, his widow said. He died after an extended hospitalization, she said.

Dayton VA officials said they implemented a privacy-violation tracking system in 2007 in an effort to ensure accountability. The agency said it has investigated 10 privacy violations since 2007, resulting from the more than 80,000 records requests processed since then. The VA gave no details of the information that was mistakenly released.

“Veterans whose records were released in error received a letter of apology from the medical center director and information on the wrongful disclosure,” the agency said in its statement.

The VA said it will arrange and pay for credit-monitoring services for a year for any veteran who experiences a privacy breach. The agency said it has improved its records-release processing by adding a second level of review to bolster VA efforts to ensure that no misfiled or erroneous information is released.

Sneed and Phillips said they received paper records from the VA. Phillips and James Sneed, who was 80 when he died in November 2001 at the Dayton VA hospital, had served in eras prior to VA’s startup of a computerized patient records system in 1998.

Nielsen said this month that he could not recall details of the records confusion involving James Sneed. Nielsen, who has spent years helping veterans and their families to file claims with VA, said such records mix-ups by the agency have been rare, in his experience.

Officials with the Ohio Department of Veterans Services and the Montgomery County Veterans Service Commission said they could not recall receiving any veterans’ complaints about records mix-ups.

Phillips, 66, who formerly lived in Franklin and Urbana before moving to Jacksonville, Fla., in May 2012, contacted U.S. Rep. Jim Jordan, R-Urbana, as well as the Dayton VA for help in 2010 after receiving the records of four other service members.

In September 2010, Guy B. Richardson, then director of the Dayton VA Medical Center, acknowledged the error in a letter to the congressman.

“I deeply regret that records of other veterans were provided to Mr. Phillips. A review of Mr. Phillips’ paper medical record was performed and the record included misfiled original medical record documents of the four other veterans,” Richardson wrote.

Richardson promised a follow-up by the Dayton VA’s privacy officer, Cassandra Clay. In October 2010, Clay wrote to Phillips that she had investigated his concerns. Clay apologized and said the problems would be addressed. She said she found no evidence that any of Phillips’ medical records had been misfiled among the records of the veterans whose records he had wrongly received.

“This matter was brought to the attention of the staff person, and we would like to assure you that measures have been implemented to prevent this from happening again,” Clay wrote in the 2010 letter to Phillips, which he shared with the Daily News. “We hope that you would continue to bring issues to our attention so that we can continue to take the privacy of our veterans very seriously.”