Report Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to assess allegations that a lack of care coordination and a lack of hepatocellular carcinoma (HCC) surveillance led to a delay in a patient being diagnosed with HCC.

The OIG substantiated that a lack of care coordination occurred when the patient transferred between primary care providers, which contributed to a lack of HCC surveillance and varices monitoring. Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.

The OIG determined that the patient’s providers, and facility providers in general, did not maintain an accurate problem list, creating another missed opportunity to conduct necessary HCC surveillance. Furthermore, facility providers did not consistently comply with the recommended HCC surveillance for other patients with a similar diagnosis. Surveillance, if done correctly, could have led to an earlier diagnosis of HCC in the patient.

The OIG made six recommendations to the Facility Director related to care coordination, developing and updating patient problem lists, reviewing an established patient’s medical record, conducting a clinical review of the care of the patients discussed in the report and determining if adverse events occurred, and ensuring that patients receive HCC surveillance and varices monitoring.