Veterans hospital failed to follow up on cancer screening alerts

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The New Mexico VA Health Care System has not been consistently notifying patients of positive colorectal cancer screening results despite providers’ receipt of electronic alerts, according to a new audit released by the VA Office of Inspector General.

The VA OIG, following up on an anonymous complaint regarding a lack of follow-up care, reviewed the health system’s colorectal cancer screening procedures for fiscal years 2013 and 2014. The audit found that lab personnel did not keep lists of patients with positive fecal occult results but flagged the results in the patients’ EHRs. While this generated a “view alert,” providers failed to consistently notify patients of the results. As a result, four patients experienced delays that placed them at risk for adverse clinical outcomes.

The audit also found that some EHRs did not contain documentation of completed colonoscopies and that the health system did not have a process to monitor provider compliance with colorectal cancer screening follow-ups.

A manager acknowledged that providers received hundreds of view alerts a day; once viewed, the alert disappears from the computer screen. If the provider does not check the “standard letters” box in the EHR to generate a letter or a consult, the provider is not reminded of the test results and may fail to generate a notification letter to the patient.

The OIG recommended, among other things that providers communicate positive test results to patients and document notification in the EHR according to Veterans Health Administration notification policies.

“Although we recognized that providers may receive hundreds of “view alerts,” it is each provider’s responsibility to follow up on results of tests they order to ensure patients are notified of positive [results] and to initiate appropriate and timely follow-up care,” OIG says.

The health system concurred with the audit’s findings and recommendations.