VA Health Care: Further Efforts Needed to Improve Hepatitis C	 
Testing for At-Risk Veterans (12-DEC-03, GAO-04-106).		 
                                                                 
Hepatitis C is a chronic disease caused by a blood-borne virus	 
that can lead to potentially fatal liverrelated conditions. In	 
2001, GAO reported that the VA missed opportunities to test about
50 percent of veterans identified as at risk for hepatitis C. GAO
was asked to (1) review VA's fiscal year 2002 performance	 
measurement results in testing veterans at risk for hepatitis C, 
(2) identify factors that impede VA's efforts to test veterans	 
for hepatitis C, and (3) identify actions taken by VA networks	 
and medical facilities to improve the testing rate of veterans at
risk for hepatitis C. GAO reviewed VA's fiscal year 2002	 
hepatitis C performance results and compared them against VA's	 
national performance goals, interviewed headquarters and field	 
officials in three networks, and conducted a case study in one	 
network.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-106 					        
    ACCNO:   A09009						        
  TITLE:     VA Health Care: Further Efforts Needed to Improve	      
Hepatitis C Testing for At-Risk Veterans			 
     DATE:   12/12/2003 
  SUBJECT:   Disease detection or diagnosis			 
	     Health care services				 
	     Infectious diseases				 
	     Medical information systems			 
	     Medical records					 
	     Performance measures				 
	     Veterans benefits					 
	     Veterans hospitals 				 
	     Hepatitis C					 

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GAO-04-106

United States General Accounting Office

    GAO 	Report to the Chairman, Subcommittee on National Security, Emerging
 Threats, and International Relations, Committee on Government Reform, House of
                                Representatives

December 2003

VA HEALTH CARE

Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans

GAO-04-106

Highlights of GAO-04-106, a report to the Chairman, Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives

Hepatitis C is a chronic disease caused by a blood-borne virus that can
lead to potentially fatal liverrelated conditions. In 2001, GAO reported
that the VA missed opportunities to test about 50 percent of veterans
identified as at risk for hepatitis C. GAO was asked to (1) review VA's
fiscal year 2002 performance measurement results in testing veterans at
risk for hepatitis C, (2) identify factors that impede VA's efforts to
test veterans for hepatitis C, and (3) identify actions taken by VA
networks and medical facilities to improve the testing rate of veterans at
risk for hepatitis C. GAO reviewed VA's fiscal year 2002 hepatitis C
performance results and compared them against VA's national performance
goals, interviewed headquarters and field officials in three networks, and
conducted a case study in one network.

To improve testing performance, GAO recommends that VA determine the
effectiveness of actions taken by networks and facilities to improve the
hepatitis C testing rates for veterans and consider applying such actions
systemwide. GAO also recommends VA provide local managers with information
on current fiscal year performance results in order for them to determine
the effectiveness of actions taken to improve hepatitis C testing
processes. VA concurred with these recommendations.

December 2003

VA HEALTH CARE

Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans

VA's performance measurement result shows that it tested, in fiscal year
2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at
risk for hepatitis C in VA's performance measurement sample, exceeding its
fiscal year 2002 national goal of 55 percent. Thousands of veterans (about
one-third) of those identified as at risk for hepatitis C infection in
VA's performance measurement sample were not tested. VA's hepatitis C
testing result is a cumulative measure of performance over time and does
not only reflect current fiscal year performance. GAO found Network 5
(Baltimore) tested 38 percent of veterans in fiscal year 2002 as compared
to Network 5's cumulative performance result of 60 percent.

In its case study of Network 5, which was one of the networks to exceed
VA's fiscal year 2002 performance goal, GAO identified several factors
that impeded the hepatitis C testing process. These factors were tests not
being ordered by the provider, ordered tests not being completed, and
providers being unaware that needed tests had not been ordered or
completed. For more than two-thirds of the veterans identified as at risk
but not tested for hepatitis C, the testing process failed because
hepatitis C tests were not ordered, mostly due to poor communication
between clinicians. For the remaining veterans, the testing process was
not completed because orders had expired by the time veterans visited the
laboratory or test orders were overlooked because laboratory staff had to
scroll back and forth through daily lists, a cumbersome process, to
identify active orders. Moreover, during subsequent primary care visits by
these untested veterans, providers often did not recognize that hepatitis
C tests had not been ordered nor had their results been obtained.
Consequently, undiagnosed veterans risk unknowingly transmitting the
disease as well as potential complications resulting from delayed
treatment.

The three networks GAO looked at-5 (Baltimore), 2 (Albany), and 9
(Nashville)-have taken steps intended to improve the testing rate of
veterans identified as at risk for hepatitis C. To do this, in two
networks officials modified clinical reminders in the computerized medical
record to alert providers that for ordered hepatitis C tests, results were
unavailable. Officials at two facilities developed a "look back" method to
search computerized medical records to identify all at-risk veterans who
had not yet been tested and identified approximately 3,500 untested
veterans. The look back serves as a safety net for veterans identified as
at risk for hepatitis C who have not been tested. The modified clinical
reminder and look back method of searching medical records appear
promising, but neither the networks nor VA has evaluated their
effectiveness.

www.gao.gov/cgi-bin/getrpt?GAO-04-106.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at (202)
512-7101.

Contents

  Letter

Results in Brief
Background
Thousands of Veterans Identified as At Risk Remain Untested for

Hepatitis C Despite VA Exceeding Its Testing Goal
Several Factors Impeded One Network's Efforts to Test Veterans
Identified as At Risk
Some VA Networks and Facilities Have Taken Action Intended to

Improve Hepatitis C Testing of Veterans Identified as At Risk
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

                                       1

                                      3 5

                                       8

10

13 14 15 15

Appendix I Scope and Methodology

Appendix II Comments from the Department of Veterans Affairs 19

Appendix III GAO Contact and Staff Acknowledgments 21

GAO Contact 21
Acknowledgments 21

Related GAO Products

  Table

Table 1: Veterans in VA Performance Measurement Sample
Identified as At Risk and Tested for Hepatitis C-VA
National and Network Results, Fiscal Year 2002 9

Abbreviations

NIH National Institutes of Health VA Department of Veterans Affairs

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separately.

United States General Accounting Office Washington, DC 20548

December 12, 2003

The Honorable Christopher Shays

Chairman

Subcommittee on National Security, Emerging Threats, and International
Relations Committee on Government Reform House of Representatives

Dear Mr. Chairman:

In 1998, the Department of Veterans Affairs (VA) launched a major
initiative to screen all veterans treated at VA facilities by asking them
a series of questions about possible risk factors for hepatitis C and
performing blood tests for those veterans identified as being at risk for
contracting the disease.1 Hepatitis C is a chronic disease caused by a
blood-borne virus that can lead to potentially fatal liver-related
conditions. This initiative represents a major undertaking for VA, which
provided health care services to approximately 4.7 million veterans and
identified over 180,000 veterans with hepatitis C infections in fiscal
year 2002.

In June 2001, we testified before your subcommittee that VA was not
conducting hepatitis C risk factor screening for about 80 percent of
veterans making outpatient clinic visits to VA facilities and not testing,
on average, about half of the veterans it identified with at least one
risk factor at four VA facilities we visited.2 We concluded and VA agreed
that for VA to identify undiagnosed veterans, it would need to establish
early detection as a standard of care and hold managers accountable for
the testing of identified at-risk veterans who receive care in VA's
outpatient

1VA identifies veterans at risk for hepatitis C infection as those who
have one or more of the following 11 risk factors: Vietnam-era veteran;
blood transfusion before 1992; past or present intravenous drug use;
unequivocal blood exposure of skin or mucous membranes; history of
multiple sexual partners; history of hemodialysis; tattoo or repeated body
piercing; history of intranasal cocaine use; unexplained liver disease;
unexplained/abnormal alanine aminotransferase, which is an enzyme that is
present in high concentration in the liver and other organs; and
intemperate or immoderate use of alcohol.

2U.S. General Accounting Office, Veterans' Health Care: Standards and
Accountability Could Improve Hepatitis C Screening and Testing
Performance, GAO-01-807T (Washington, D.C.: June 14, 2001).

clinics. As a result, VA implemented a hepatitis C screening and testing
process and, in fiscal year 2002, included both screening and testing of
veterans for hepatitis C in its performance measurement system.3 VA's
hepatitis C screening and testing performance is measured by reviewing a
sample of veterans' medical records to determine the percentage of
veterans screened against a list of risk factors for the disease and the
percentage of at-risk veterans who are subsequently tested. To be included
in the hepatitis C testing performance measure, the veteran does not have
to have been tested in fiscal year 2002; testing may have occurred in a
prior fiscal year. VA established its fiscal year 2002 national hepatitis
C testing performance goal at 55 percent. For the veterans' medical
records to be included in the performance measurement sample, veterans
must have been enrolled to receive VA health care for 2 continuous years
and been seen at least once during the current fiscal year in one of VA's
primary care clinics.4

VA's hepatitis C screening performance result for fiscal year 2002 was 85
percent, a significant improvement from its baseline result of 51 percent
in fiscal year 2001. As a result, you asked us to focus our work on
testing performance and we (1) reviewed VA's fiscal year 2002 performance
measurement results in testing veterans it identified as at risk for
hepatitis C, (2) identified factors that impede VA's efforts to test
veterans for hepatitis C in one VA health care network, and (3) identified
actions taken by VA networks and medical facilities intended to improve
the testing rate of veterans identified as at risk for hepatitis C.

We reviewed VA's fiscal year 2002 performance measurement process results
in testing veterans it identified as at risk for hepatitis C, the most
recently available data at the time we conducted our work. Specifically,
to assess VA's fiscal year 2002 performance measurement results, we
compared VA's national and individual network performance results for
testing veterans in fiscal year 2002 or earlier against VA's national goal
and

3VA's performance measurement process is based on the External Peer Review
Program, which is a contracted program designed to measure quality of
patient care provided in VA medical facilities. VA officials select a
monthly sample of medical records, based on specific criteria, to be
reviewed for its performance measurement process. Criteria include a visit
to VA 2 years prior to the current year and a visit in the study year.
Contractors from the West Virginia Medical Institute conducted the medical
record reviews.

4VA's measurement of its performance in testing veterans identified as at
risk for hepatitis C cannot be generalized to the entire population of
veterans who seek health care at VA's medical facilities because of
limitations in VA's sample selection.

  Results in Brief

analyzed VA's method for calculating performance results. In addition, we
looked at one VA health care network's testing rate for at-risk veterans
visiting its clinics in fiscal year 2002. We identified factors that
impede VA's efforts to test veterans for hepatitis C through a case study
of VA's Network 5 (Baltimore), which included interviews with network and
facility officials and clinical staff. From the medical record review we
were able to determine if a hepatitis C test was ordered, if the ordered
test was completed, if the veteran visited the laboratory and provider
after the test was ordered, and if a test result was present in the
medical record. Network 5 was chosen for the case study because its rate
of hepatitis C testing was comparable to VA's national performance
results. To identify actions taken by networks and medical facilities
intended to improve the rate of hepatitis C testing, we expanded our
interviews of VA officials and clinical staff beyond Network 5 (Baltimore)
to include staff in Network 2 (Albany) and Network 9 (Nashville). For a
complete description of our scope and methodology, see appendix I. Our
review was conducted from April 2002 through November 2003 and in
accordance with generally accepted government auditing standards.

VA's performance measurement results show that it tested, in fiscal year
2002 or earlier, 5,232 (62 percent) of the 8,501 veterans identified as at
risk for hepatitis C in VA's performance measurement sample, exceeding its
fiscal year 2002 national goal of 55 percent. Thousands of veterans, about
one-third of those identified as at risk for hepatitis C infection in VA's
performance measurement sample, were not tested. Moreover, the percentage
of veterans identified as at risk who were tested for hepatitis C varied
widely among VA's 21 health care networks, with 14 networks meeting or
exceeding VA's national goal of 55 percent and 7 networks falling from 1
to 10 percent below the goal. VA's hepatitis C testing results are a
cumulative measure of performance over time and do not reflect only the
current fiscal year performance. When we looked at Network 5's testing
performance for fiscal year 2002, we found that 38 percent of veterans who
needed to be tested in fiscal year 2002 were tested as compared to the
Network's cumulative performance result of 60 percent.

We identified three factors that impeded the hepatitis C testing process
used by Network 5 (Baltimore), our case study, which was one of the
networks to exceed VA's national goal. These factors were tests not being
ordered by the provider, ordered tests not being completed, and providers
being unaware that needed tests had not been ordered or completed. For
more than two-thirds of the untested, at-risk veterans, providers did not
order tests, a crucial step in the testing process, mostly due to poor

communication between clinicians that a hepatitis C test was needed. For
the remaining veterans, tests were ordered but the testing process was not
completed. Tests were not completed primarily because orders were expired
by the time veterans visited the laboratory or test orders were overlooked
due to the cumbersome process used by laboratory staff. Instead of being
able to view a summary of active test orders, laboratory staff must scroll
back and forth through a daily list of ordered testsin two Network
5 facilities up to 60 days of ordersto identify laboratory tests
that need to be completed. Moreover, during subsequent primary care visits
by these untested, at-risk veterans, providers often failed to recognize
that hepatitis C tests either had not been ordered or the results of tests
had not been obtained. Consequently, neither the at-risk veterans nor
their providers know whether the veterans have hepatitis C. These
undiagnosed veterans unknowingly risk transmitting the disease as well as
potentially developing complications as a result of delayed treatment.

Some networks and facilities have made changes intended to improve their
hepatitis C testing processes. VA network and facility officials in the
three networks we reviewed-Network 5 (Baltimore), Network 2 (Albany), and
Network 9 (Nashville)-identified similar factors that impede hepatitis C
testing and focused on getting test results immediately following risk
factor identification. Officials at two networks modified clinical
reminders in the computerized medical record to alert providers that for
ordered hepatitis C tests, results were unavailable. Thus, if the
laboratory has not completed the order, the reminder acts as a backup
system to alert the provider that a hepatitis C test may need to be
reordered. Officials at two facilities in different networks created a
safety net for veterans identified as at risk for hepatitis C who remain
untested. Officials developed a method that electronically looks back
through computerized medical records, for any time frame specified, to
identify atrisk veterans in need of testing and identified approximately
3,500 untested veterans.

To improve testing performance, we recommend that VA determine the
effectiveness of actions taken by networks and facilities intended to
improve the hepatitis C testing rates for veterans and, where actions have
been successful, consider applying these improvements systemwide. Also,
because VA's cumulative measurement looks at performance over time, VA
should select a subset of the performance measurement sample of veterans
to determine current fiscal year performance and provide managers with a
tool for improving testing processes. In commenting on a draft of this
report, VA concurred with our recommendations and noted that its fiscal
year 2003 cumulative hepatitis C testing performance showed

Background

improvement. We incorporated updated performance information provided by
VA where appropriate. However, because VA did not include its fiscal year
2003 hepatitis C testing performance results by individual network, we do
not know if the wide variation in network results, which we found in
fiscal year 2002, still exists in fiscal year 2003.

Hepatitis C was first recognized as a unique disease in 1989. It is the
most common chronic blood-borne infection in the United States and is a
leading cause of chronic liver disease.5 The virus causes a chronic
infection in 85 percent of cases. Hepatitis C, which is the leading
indication for liver transplantation, can lead to liver cancer, cirrhosis
(scarring of the liver), or end-stage liver disease. Most people infected
with hepatitis C are relatively free of physical symptoms. While hepatitis
C antibodies generally appear in the blood within 3 months of infection,
it can take 15 years or longer for the infection to develop into
cirrhosis. Blood tests to detect the hepatitis C antibody, which became
available in 1992, have helped to virtually eliminate the risk of
infection through blood transfusions and have helped curb the spread of
the virus. Many individuals were already infected, however, and because
many of them have no symptoms, they are unaware of their infection.
Hepatitis C continues to be spread through blood exposure, such as
inadvertent needle-stick injuries in health care workers and through the
sharing of needles by intravenous drug abusers.

Early detection of hepatitis C is important because undiagnosed persons
miss opportunities to safeguard their health by unknowingly behaving in
ways that could speed the progression of the disease. For example, alcohol
use can hasten the onset of cirrhosis and liver failure in those infected
with the hepatitis C virus. In addition, persons carrying the virus pose a
public health threat because they can infect others.

The Centers for Disease Control and Prevention estimates that nearly 4
million Americans are infected with the hepatitis C virus. Approximately
30,000 new infections occur annually. The prevalence of hepatitis C
infection among veterans is unknown, but limited survey data suggest that
hepatitis C has a higher prevalence among veterans who are currently

5W. Ray Kim, MD M.Sc, MBA, "The Burden of Hepatitis C in the United
States," NIH Consensus Development Conference: Management of Hepatitis C:
2002 (Bethesda, Md.: National Institutes of Health, 2002).

using VA's health care system than among the general population because of
veterans' higher frequency of risk factors. A 6 year study-1992-1998- of
veterans who received health care at the VA Palo Alto Health Care System
in Northern California reported that hepatitis C infection was much more
common among veterans within a very narrow age distribution-41 to 60 years
of age-and intravenous drug use was the major risk factor.6 VA began a
national study of the prevalence of hepatitis C in the veteran population
in October 2001. Data collection for the study has been completed but
results have not been approved for release. The prevalence of hepatitis C
among veterans could have a significant impact on current and future VA
health care resources, because hepatitis C accounts for over half of the
liver transplants needed by VA patientscosting as much as $140,000
per transplantand the drug therapy to treat hepatitis C is
costlyabout $13,000 for a 48-week treatment regimen.7

In the last few years, considerable research has been done concerning
hepatitis C. The National Institutes of Health (NIH) held a consensus
development conference on hepatitis C in 1997 to assess the methods used
to diagnose, treat, and manage hepatitis C infections. In June 2002, NIH
convened a second hepatitis C consensus development conference to review
developments in management and treatment of the disease and identify
directions for future research.8 This second panel concluded that
substantial advances had been made in the effectiveness of drug therapy
for chronic hepatitis C infection.

VA's Public Health Strategic Healthcare Group is responsible for VA's
hepatitis C program, which mandates universal screening of veterans to
identify at-risk veterans when they visit VA facilities for routine
medical care and testing of those with identified risk factors, or those
who simply want to be tested. VA has developed guidelines intended to
assist health

6Ramsey C. Cheung, MD, "Epidemiology of Hepatitis C Virus Infection in
American Veterans," The American Journal of Gastroenterology, vol. 95, no.
3 (March 2000).

7See Samuel B. Ho, MD, "Managing the HCV Veteran," The HCV Advocate
Medical Writers' Circle (April 2002), and GAO-01-807T.

8NIH Consensus Development Conference, Management of Hepatitis C: 2002,
June 2002. The 12-member consensus panel is an independent, nonadvocacy,
and nonfederal panel including representatives from internal medicine,
gastroenterology, infectious diseases, family practice, and the public.
The panel heard presentations from 28 hepatitis C experts and reviewed an
extensive body of medical literature and a report prepared by the Johns
Hopkins University School of Medicine Evidence-based Practice Center.

care providers who screen, test, and counsel veterans for hepatitis C.
Providers are to educate veterans about their risk of acquiring hepatitis
C, notify veterans of hepatitis C test results, counsel those infected
with the virus, help facilitate behavior changes to reduce veterans' risk
of transmitting hepatitis C, and recommend a course of action. In January
2003, we reported that VA medical facilities varied considerably in the
time that veterans must wait before physician specialists evaluate their
medical conditions concerning hepatitis C treatment recommendations.9

To assess the effectiveness of VA's implementation of its universal
screening and testing policy, VA included performance measures in the
fiscal year 2002 network performance plan. Network performance measures
are used by VA to hold managers accountable for the quality of health care
provided to veterans. For fiscal year 2002, the national goal for testing
veterans identified as at risk for hepatitis C was established at 55
percent based on preliminary performance results obtained by VA.10 To
measure compliance with the hepatitis C performance measures, VA uses data
collected monthly through its External Peer Review Program, a performance
measurement process under which medical record reviewers collect data from
a sample of veterans' computerized medical records.11

Development of VA's computerized medical record began in the mid-1990s
when VA integrated a set of clinical applications that work together to
provide clinicians with comprehensive medical information about the
veterans they treat. Clinical information is readily accessible to health
care providers at the point of care because the veteran's medical record
is always available in VA's computer system. All VA medical facilities
have computerized medical record systems.

Clinical reminders are electronic alerts in veterans' computerized medical
records that remind providers to address specific health issues. For
example, a clinical reminder would alert the provider that a veteran needs

9U.S. General Accounting Office, VA Health Care: Improvements Needed in
Hepatitis C Disease Management Practices, GAO-03-136 (Washington, D.C.:
Jan. 31, 2003).

10For fiscal year 2003, VA increased its hepatitis C testing performance
goal to 82 percent.

11The sample includes veterans with 2 years of continuous enrollment in VA
who have been seen at least once in one of VA's eight primary care clinics
during the current fiscal year. The eight clinics are primary care,
general medicine, cardiology, endocrinology/ metabolism, diabetes,
hypertension, pulmonary/chest, and women's. A veteran's medical record can
only be included in the performance measurement sample once during any
fiscal year.

  Thousands of Veterans Identified as At Risk Remain Untested for Hepatitis C
  Despite VA Exceeding Its Testing Goal

to be screened for certain types of cancer or other disease risk factors,
such as hepatitis C. In July 2000, VA required the installation of
hepatitis C clinical reminder software in the computerized medical record
at all facilities. This reminder alerted providers when they opened a
veteran's computerized medical record that the veteran needed to be
screened for hepatitis C. In fiscal year 2002, VA required medical
facilities to install an enhanced version of the July 2000 clinical
reminder. The enhanced version alerts the provider to at-risk veterans who
need hepatitis C testing, is linked directly to the entry of laboratory
orders for the test, and is satisfied once the hepatitis C test is
ordered.

Even though VA's fiscal year 2002 performance measurement results show
that it tested 62 percent of veterans identified to be at risk for
hepatitis C, exceeding its national goal of 55 percent, thousands of
veterans in the sample who were identified as at risk were not tested.
Moreover, the percentage of veterans identified as at risk who were tested
varied widely among VA's 21 health care networks. Specifically, we found
that VA identified in its performance measurement sample 8,501 veterans
nationwide who had hepatitis C risk factors out of a sample of 40,489
veterans visiting VA medical facilities during fiscal year 2002.12 VA
determined that tests were completed, in fiscal year 2002 or earlier, for
62 percent of the 8,501 veterans based on a review of each veteran's
medical record through its performance measurement process.13 For the
remaining 38 percent (3,269 veterans), VA did not complete hepatitis C
tests when the veterans visited VA facilities. The percentage of
identified at-risk veterans tested for hepatitis C ranged, as table 1
shows, from 45 to 80 percent for individual networks. Fourteen of VA's 21
health care networks exceeded VA's national testing performance goal of 55
percent, with 7 networks exceeding VA's national testing performance level
of 62 percent. The remaining 7 networks that did not meet VA's national
performance goal tested from 45 percent to 54 percent of at-risk veterans.

12Of the 40,489 veterans selected as part of VA's performance measurement
sample, VA providers had completed hepatitis C risk assessment screenings
for 34,310 of them. Thus, the prevalence of risk factors among those
assessed was approximately 25 percent (8,501 of 34,310).

13At the time of our audit work, testing data for fiscal year 2003 were
unavailable. In commenting on a draft of this report, VA stated that its
testing rate for fiscal year 2003 was 86 percent.

Table 1: Veterans in VA Performance Measurement Sample Identified as At
Risk and Tested for Hepatitis C-VA National and Network Results, Fiscal
Year 2002

Number of Percentage of

veterans Number of at-risk veterans identified VA network identified as at
risk veterans tested for as at risk tested (location) for hepatitis C
hepatitis Ca for hepatitis Cb

                               1 (Boston)        548                      381 
                               2 (Albany)        308                      181 
                                3 (Bronx)        284                      226 
                           4 (Pittsburgh)        528                      315 
                            5 (Baltimore)        288                      173 
                               6 (Durham)        424                      288 
                              7 (Atlanta)        539                      289 
                            8 (Bay Pines)        375                      214 
                            9 (Nashville)        436                      219 
                          10 (Cincinnati)        277                      165 
                           11 (Ann Arbor)        429                      229 
                             12 (Chicago)        327                      169 
                         15 (Kansas City)        392                      231 
                             16 (Jackson)        566                      348 
                              17 (Dallas)        198                       90 
                             18 (Phoenix)        428                      224 
                              19 (Denver)        303                      208 

             20 (Portland)             505            327              65 
          21 (San Francisco)           590            472              80 
            22 (Long Beach)            353            187              53 
           23 (Minneapolis)            403            294              73 
                 Total                8,501          5,232             62 

Source: VA.

Note: In January 2002, VA merged Networks 13 and 14 to create Network 23.

aThese numbers include veterans tested for hepatitis C prior to fiscal
year 2002.

bThese percentages are rounded.

VA's fiscal year 2002 testing rate for veterans identified as at risk for
hepatitis C reflects tests performed in fiscal year 2002 and in prior
fiscal years. Thus, a veteran who was identified as at risk and tested for
hepatitis C in fiscal year 1998 and whose medical record was reviewed as
part of the fiscal year 2002 sample would be counted as tested in VA's
fiscal year 2002

performance measurement result. As a result of using this cumulative
measurement, VA's fiscal year 2002 performance result for testing at-risk
veterans who visited VA facilities in fiscal year 2002 and need hepatitis
C tests is unknown. To determine if the testing rate is improving for
veterans needing hepatitis C tests when they were seen at VA in fiscal
year 2002, VA would also need to look at a subset of the sample of
veterans currently included in its performance measure. For example, when
we excluded veterans from the sample who were tested for hepatitis C prior
to fiscal year 2002, and included in the performance measurement sample
only those veterans who were seen by VA in fiscal year 2002 and needed to
be tested for hepatitis C, we found Network 5 tested 38 percent of these
veterans as compared to Network 5's cumulative performance measurement
result of 60 percent.

We identified three factors that impeded the process used by our case
study network, VA's Network 5 (Baltimore), for testing veterans identified
as at risk for hepatitis C. The factors were tests not being ordered by
the provider, ordered tests not being completed, and providers being
unaware that needed tests had not been ordered or completed. More than
twothirds of the time, veterans identified as at risk were not tested
because providers did not order the test, a crucial step in the process.
The remainder of these untested veterans had tests ordered by providers,
but the actual laboratory testing process was not completed. Moreover,
veterans in need of hepatitis C testing had not been tested because
providers did not always recognize during subsequent clinic visits that
the hepatitis C testing process had not been completed. These factors are
similar to those we identified and reported in our testimony in June
2001.14

  Several Factors Impeded One Network's Efforts to Test Veterans Identified as
  At Risk

    Hepatitis C Tests Were Not Always Ordered for Veterans Identified as At Risk

Primary care providers and clinicians in Network 5's three facilities
offered two reasons that hepatitis C tests were not ordered for over
twothirds of the veterans identified as at risk but not tested for
hepatitis C in the Network 5 fiscal year 2002 performance measurement
sample. First, facilities lacked a method for clear communication between
nurses who identified veterans' risk factors and providers who ordered
hepatitis C tests. For example, in two facilities, nurses identified
veterans' need for testing but providers were not alerted through a
reminder in the computerized medical record to order a hepatitis C test.
In one of these

14GAO-01-807T.

facilities, because nursing staff were at times delayed in entering a note
in the computerized medical record after screening a veteran for hepatitis
C risk factors, the provider was unaware of the need to order a test for a
veteran identified as at risk. The three network facilities have changed
their practices for ordering tests, and as of late 2002, nursing staff in
each of the facilities are ordering hepatitis C tests for at-risk
veterans. The second reason for tests not being ordered, which was offered
by a clinician in another one of the three Network 5 facilities, was that
nursing staff did not properly complete the ordering procedure in the
computer. Although nurses identified at-risk veterans using the hepatitis
C screening clinical reminder in the medical record, they sometimes
overlooked the chance the reminder gave them to place a test order. To
correct this, nursing staff were retrained on the proper use of the
reminder.

    Hepatitis C Test Orders Were Not Always Completed

For the remaining 30 percent of untested veterans in Network 5, tests were
not completed for veterans who visited laboratories to have blood drawn
after hepatitis C tests were ordered. One reason that laboratory staff did
not obtain blood samples for tests was because more than two-thirds of the
veterans' test orders had expired by the time they visited the laboratory.
VA medical facilities consider an ordered test to be expired or inactive
if the veteran's visit to the laboratory falls outside the number of days
designated by the facility. For example, at two Network 5 facilities,
laboratory staff considered a test order to be expired or inactive if the
date of the order was more than 30 days before or after the veteran
visited the laboratory. If the veteran's hepatitis C test was ordered and
the veteran visited the laboratory to have the test completed 31 days
later, the test would not be completed because the order would have
exceeded the 30day period and would have expired. Providers can also
select future dates as effective dates. If the provider had designated a
future date for the order and the veteran visited the laboratory within 30
days of that future date, the order would be considered active.

Another reason for incomplete tests was that laboratory staff overlooked
some active test orders when veterans visited the laboratory. VA facility
officials told us that laboratory staff could miss test orders, given the
many test orders some veterans have in their computerized medical records.
The computer package used by laboratory staff to identify active test
orders differs from the computer package used by providers to order tests.
The laboratory package does not allow staff to easily identify all active
test orders for a specific veteran by creating a summary of active test
orders. According to a laboratory supervisor at one facility, the process
for identifying active test orders is cumbersome because staff must scroll

back and forth through a list of orders to find active laboratory test
orders. Further complicating the identification of active orders for
laboratory staff, veterans may have multiple laboratory test orders
submitted on different dates from several providers. As a result, when the
veteran visits the laboratory to have tests completed, instead of having a
summary of active test orders, staff must scroll through a daily list of
ordered testsin two facilities up to 60 days of ordersto
identify the laboratory tests that need to be completed. Network and
facility officials are aware of, but have not successfully addressed, this
problem. VA plans to upgrade the computer package used by laboratory staff
during fiscal year 2005.

    Providers Often Unaware That Hepatitis C Tests Were Not Ordered or Completed

Hepatitis C tests that were not ordered or completed sometimes went
undetected for long periods in Network 5, even though veterans often made
multiple visits to primary care providers after their hepatitis C risk
factors were identified. Our review of medical records showed that nearly
two-thirds of the at-risk veterans in Network 5's performance measurement
sample who did not have ordered or completed hepatitis C tests had risk
factors identified primarily in fiscal years 2002 and 2001.

All veterans identified as at risk but who did not have hepatitis C test
orders visited VA primary care providers at least once after having a risk
factor identified during a previous primary care visit, including nearly
70 percent who visited more than three times. Further, almost all of the
atrisk veterans who had hepatitis C tests ordered but not completed
returned for follow-up visits for medical care. Even when the first
followup visits were made to the same providers who originally identified
these veterans as being at risk for hepatitis C, providers did not
recognize that hepatitis C tests had not been ordered or completed.
Providers did not follow up by checking for hepatitis C test results in
the computerized medical records of these veterans. Most of these veterans
subsequently visited the laboratory to have blood drawn for other tests
and, therefore, could have had the hepatitis C test completed if the
providers had recognized that test results were not available and
reordered the hepatitis C tests.

Some VA Networks Steps intended to improve the testing rate of veterans
identified as at risk

for hepatitis C have been taken in three of VA's 21 health care networks.
and Facilities Have VA network and facility officials in the three
networks we reviewed- Taken Action Network 5 (Baltimore), Network 2
(Albany), and Network 9 (Nashville)-

identified similar factors that impede hepatitis C testing and most
oftenIntended to Improve focused on getting tests ordered immediately
following risk factor Hepatitis C Testing of identification. Officials in
two networks modified VA's required hepatitis C

testing clinical reminder, which is satisfied when a hepatitis C test
isVeterans Identified as ordered, to continue to alert the provider until
a hepatitis C test result is in At Risk the medical record. Officials at
two facilitiesone in Network 5 and the

other in Network 9created a safety net for veterans at risk for
hepatitis C who remain untested by developing a method that looks back
through computerized medical records to identify these veterans. The
method has been adopted in all six facilities in Network 9; the other two
facilities in Network 5 have not adopted it.

Some Networks and VA network and facility managers in two networks we
reviewed Facilities Took Steps Networks 2 and 9instituted
networkwide changes intended to improve Intended to Improve the ordering
of hepatitis C tests for veterans identified as at risk. Facility

officials recognized that VA's enhanced clinical reminder that
facilitiesHepatitis C Test Ordering were required to install by the end of
fiscal year 2002 only alertedand Completion providers to veterans without
ordered hepatitis C tests and did not alert

providers to veterans with ordered but incomplete tests.

These two networks independently changed this reminder to improve
compliance with the testing of veterans at risk for hepatitis C. In both
networks, the clinical reminder was modified to continue to alert the
provider, even after a hepatitis C test was ordered. Thus, if the
laboratory has not completed the order, the reminder is intended to act as
a backup system to alert the provider that a hepatitis C test still needs
to be completed. Providers continue to receive alerts until a hepatitis C
test result is placed in the medical record, ensuring that providers are
aware that a hepatitis C test might need to be reordered. The new clinical
reminder was implemented in Network 2 in January 2002, and Network 9
piloted the reminder at one facility and then implemented it in all six
network facilities in November 2002.

    Some Facilities Developed a Safety Net for Veterans Identified as At Risk
    Who Have Not Been Tested

  Conclusions

Officials at two facilities in our review searched all records in their
facilities' computerized medical record systems and found several thousand
untested veterans identified as at risk for hepatitis C. The process,
referred to as a "look back," involves searching all medical records to
identify veterans who have risk factors for hepatitis C but have not been
tested either because the providers did not order the tests or ordered
tests were not completed. The look back serves as a safety net for these
veterans. The network or facility can perform the look back with any
chosen frequency and over any period of time. The population searched in a
look back includes all veteran users of the VA facility and is more
inclusive than the population that is sampled monthly in VA's performance
measurement process.

As a result of a look back, one facility manager in Network 5 identified
2,000 veterans who had hepatitis C risk factors identified since January
2001 but had not been tested as of August 2002. Facility staff began
contacting the identified veterans in October 2002 to offer them the
opportunity to be tested. Although officials in the other two Network 5
facilities have the technical capability to identify and contact all
untested veterans determined to be at risk for hepatitis C, they have not
done so. An official at one facility not currently conducting look back
searches stated that the facility would need support from those with
computer expertise to conduct a look back search.

A facility manager in Network 9 identified, through a look back, more than
1,500 veterans who had identified risk factors for hepatitis C but were
not tested from January 2001 to September 2002. The manager in this
facility began identifying untested, at-risk veterans in late March 2003
and providers subsequently began contacting these veterans to arrange
testing opportunities. Other Network 9 facility managers have also begun
to identify untested, at-risk veterans. Given that two facilities in our
review have identified over 3,000 at-risk veterans in need of testing
through look back searches, it is likely that similar situations exist at
other VA facilities.

Although VA met its goal for fiscal year 2002, thousands of veterans at
risk for hepatitis C remained untested. Problems persisted with obtaining
and completing hepatitis C test orders. As a result, many veterans
identified as at risk did not know if they have hepatitis C. These
undiagnosed veterans risk unknowingly transmitting the disease as well as
potentially developing complications resulting from delayed treatment.

Some networks and facilities have upgraded VA's required hepatitis C
clinical reminder to continue to alert providers until a hepatitis C test
result is present in the medical record. Such a system appears to have
merit, but neither the networks nor VA has evaluated its effectiveness.
Network and facility managers would benefit from knowing, in addition to
the cumulative results, current fiscal year performance results for
hepatitis C testing to determine the effectiveness of actions taken to
improve hepatitis C testing rates. Some facilities have compensated for
weaknesses in hepatitis C test ordering and completion processes by
conducting look backs through computerized medical record systems to
identify all at-risk veterans in need of testing. If all facilities were
to conduct look back searches, potentially thousands more untested,
at-risk veterans would be identified.

Recommendations for To improve VA's testing of veterans identified as at
risk of hepatitis C infection, we recommend that the Secretary of Veterans
Affairs direct the Executive Action Under Secretary for Health to

o  	determine the effectiveness of actions taken by networks and
facilities to improve the hepatitis C testing rates for veterans and,
where actions have been successful, consider applying these improvements
systemwide and

o  provide local managers with information on current fiscal year

  Agency Comments
  and Our Evaluation

performance results using a subset of the performance measurement sample
of veterans in order for them to determine the effectiveness of actions
taken to improve hepatitis C testing processes.

In commenting on a draft of this report VA concurred with our
recommendations. VA said its agreement with the report's findings was
somewhat qualified because it was based on fiscal year 2002 performance
measurement results. VA stated that the use of fiscal year 2002 results
does not accurately reflect the significant improvement in VA's hepatitis
C testing performanceup from 62 percent in fiscal year 2002 to 86
percent in fiscal year 2003, results that became available recently. VA,
however, did not include its fiscal year 2003 hepatitis C testing
performance results by individual network, and as a result, we do not know
if the wide variation in network results, which we found in fiscal year
2002, still exists in fiscal year 2003. We incorporated updated
performance information provided by VA where appropriate.

VA did report that it has, as part of its fiscal year 2003 hepatitis C
performance measurement system, provided local facility managers with a
tool to assess real-time performance in addition to cumulative
performance. Because this tool was not available at the time we conducted
our audit work, we were unable to assess its effectiveness. VA's written
comments are reprinted in appendix II.

We are sending copies of this report to the Secretary of Veterans Affairs
and other interested parties. We also will make copies available to others
upon request. In addition, the report is available at no charge on the GAO
Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at (202) 512-7101. Another contact and key contributors are listed in
appendix III.

Sincerely yours,

Cynthia A. Bascetta Director, Health Care-Veterans' Health and Benefits
Issues

                       Appendix I: Scope and Methodology

To follow up on the Department of Veterans Affairs' (VA) implementation of
performance measures for hepatitis C we (1) reviewed VA's fiscal year 2002
performance measurement results of testing veterans it identified as at
risk for hepatitis C, (2) identified factors that impede VA's efforts to
test veterans for hepatitis C in one VA health care network, and (3)
identified actions taken by VA networks and medical facilities intended to
improve the testing rate of veterans identified as at risk for hepatitis
C.

We reviewed VA's fiscal year 2002 hepatitis C testing performance results,
the most recently available data at the time we conducted our work, for a
sample of 8,501 veterans identified as at risk and compared VA's national
and network results for fiscal year 2002 against VA's performance goal for
hepatitis C testing. The sample of veterans identified as at risk for
hepatitis C was selected from VA's performance measurement process-also
referred to as the External Peer Review Process-that is based on data
abstracted from medical records by a contractor. In addition, we looked at
one VA health care network's testing rate for at-risk veterans visiting
its clinics in fiscal year 2002. To test the reliability of VA's hepatitis
C performance measurement data, we reviewed 288 medical records in Network
5 (Baltimore) and compared the results against the contractor's results
for the same medical records and found that VA's data were sufficiently
reliable for our purposes.1 To augment our understanding of VA's
performance measurement process for hepatitis C testing, we reviewed VA
documents and interviewed officials in VA's Office of Quality and
Performance and Public Health Strategic Health Care Group.

To identify the factors that impede VA's efforts to test veterans for
hepatitis C, we conducted a case study of the three medical facilities
located in VA's Network 5Martinsburg, West Virginia; Washington,
D.C.; and the VA Maryland Health Care System. We chose Network 5 for our
case study because its hepatitis C testing performance, at 60 percent, was
comparable to VA's national performance of 62 percent.

1In May 2003, VA's Office of Inspector General reported that differences
in VA's performance measurement results collected by its contractor and
the results found by the Inspector General were immaterial. See U.S.
Department of Veterans Affairs, Office of Inspector General, Accuracy of
Data Used to Compute VA's Chronic Disease Care and Prevention Indices for
FY 2001, 01-01544-88 (Washington, D.C.: May 1, 2003).

Appendix I: Scope and Methodology

As part of the case study of Network 5, we reviewed medical records for
all 288 veterans identified as at risk for hepatitis C who were included
in that network's sample for VA's fiscal year 2002 performance measurement
process. Of the 288 veterans identified as at risk who needed hepatitis C
testing, VA's performance results found that 115 veterans in VA's Network
5 were untested. We reviewed the medical records for these 115 veterans
and found hepatitis C testing results or indications that the veterans
refused testing in 21 cases. Eleven veterans had hepatitis C tests
performed subsequent to VA's fiscal year 2002 performance measurement data
collection. Hepatitis C test results or test refusals for 10 veterans were
overlooked during VA's data collection.2 As such, we consider hepatitis C
testing opportunities to have been missed for 94 veterans.

On the basis of our medical record review, we determined if the provider
ordered a hepatitis C test and, if the test was ordered, why the test was
not completed. For example, if a hepatitis C test had been ordered but a
test result was not available in the computerized medical record, we
determined whether the veteran visited the laboratory after the test was
ordered. If the veteran had visited the laboratory, we determined if the
test order was active at the time of the visit and was overlooked by
laboratory staff. Based on interviews with providers, we identified the
reason why hepatitis C tests were not ordered. We also analyzed medical
records to determine how many times veterans with identified risk factors
and no hepatitis C test orders returned for primary care visits.

To determine actions taken by networks and medical facilities intended to
improve the testing rate of veterans identified as at risk for hepatitis
C, we expanded our review beyond Network 5 to include Network 2 and
Network 9. We reviewed network and facility documents and conducted
interviews with network quality managers and medical facility staff-
primary care providers, nurses, quality managers, laboratory chiefs and
supervisors, and information management staff. Our review was conducted
from April 2002 through November 2003 in accordance with generally
accepted government auditing standards.

2Our review for hepatitis C test results was extended to November 30,
2002, in order to allow time for testing of veterans who had tests ordered
in September 2002.

Appendix II: Comments from the Department of Veterans Affairs

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact Marcia A. Mann, (202) 512-9526

Acknowledgments 	In addition to the contact named above, Carl S. Barden,
Irene J. Barnett, Martha A. Fisher, Daniel M. Montinez, and Paul R.
Reynolds made key contributions to this report.

Related GAO Products

VA Health Care: Improvements Needed in Hepatitis C Disease Management
Practices. GAO-03-136. Washington, D.C.: January 31, 2003.

Major Management Challenges and Program Risks: Department of Veterans
Affairs. GAO-03-110. Washington, D.C.: January 2003.

Veterans' Health Care: Standards and Accountability Could Improve
Hepatitis C Screening and Testing Performance. GAO-01-807T. Washington,
D.C.: June 14, 2001.

Veterans' Health Care: Observations on VA's Assessment of Hepatitis C
Budgeting and Funding. GAO-01-661T. Washington, D.C.: April 25, 2001.

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