The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding the availability of breast images from community providers and the potential impact on patient care at the VA Eastern Colorado Health Care System (facility) in Aurora. Following the departure of the facility’s sole mammographer in February 2024, the facility’s in-house mammography program closed, and all breast imaging was referred to community care.
The OIG substantiated that delayed receipt of images from community care providers, and delayed uploading of images by facility staff once the images were received, did not ensure timely availability of breast images for facility providers to coordinate patient care. The OIG found factors contributing to the delays included community providers not sending breast images with reports, facility staff not following medical request processes, and VA technology limitations.
The OIG found the facility lacked guidance and processes for required women’s health tracking of abnormal mammography results. The OIG also learned facility primary care staff did not fully implement processes to identify patients due for breast cancer screening. Additionally, the OIG identified deficiencies with the credentialing and privileging of a mammographer.
The OIG made nine recommendations. The Under Secretary for Health and the Veterans Integrated Service Network and Facility Directors concurred with eight recommendations and concurred in principle with one recommendation. Acceptable action plans were provided, including plans to communicate expectations of community care providers related to breast images; address the request, receipt, and uploading of breast images; take action to modernize image sharing technology; address processes for breast cancer screening and care coordination; and address processes for credentialing and privileging.
CO
United States
