36C25019R0093-023.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM (VANIHCS)

April 2018 POLICY NO. 11-90-18

BREAST IMAGING POLICY

1. PURPOSE: To define the process for ordering, tracking, and completing mammography at the Department of Veterans Affairs Northern Indiana Health Care System (VANIHCS).

2. POLICY: All eligible women Veterans will be offered breast exams and screening in accordance with the Veterans Health Administration (VHA) National Center for Health Promotion and Disease Prevention (NCP). VHA recommends yearly screening for breast cancer with mammography starting at the age 45:

a. Women aged 45 to 54 years should be screened annually.

b. Women 55 years and older should transition to biennial screening or can continue screening annually.

c. The decision to start regular screening mammography prior to the age of 45 should be on an individual case basis, taking into consideration the Veteran’s health history, family history, and other risk factors.

d. Women should continue screening mammography if their overall health is good and they have a life expectancy of 10 years or longer.

e. Male veterans shall have diagnostic mammography when clinically indicated.

3. DEFINITIONS:

a. Breast screening: Physical examination, risk assessment, radiologic exams, and biopsies for the detection of early breast cancer.

b. Clinical breast exam (CBE): Inspection and palpation of all breast tissue including axillary region and lymph nodal basins for the breast.

c. Screening mammography: A radiological examination to detect unsuspected breast cancer at an early stage in asymptomatic women.

d. Diagnostic mammography: A radiographic examination performed to evaluate an existing problem such as mass or nipple discharge.

e. Breast interventional procedures: Stereotactic (mammographic) needle/ core biopsy performed to obtain tissue sampling for detection of breast cancer.

POLICY NO. 11-90-18

f. Positive mammograms: Mammography report final assessment is

"Suspicious" or "Highly Suggestive of Malignancy" (BI-RADS codes "4" or "5", respectively).

h. Incomplete evaluation: Patient needs additional imaging studies to complete the interpretation (BI-RADS code "0").

4. RESPONSIBILITIES:

a. Chief of Staff (COS)

b. Associate COS Patient Aligned Care Team (ACOS PACT)

c. Women Veterans Program Manager (WVPM)

d. Women Veterans Program Support Assistant (PSA) or Women’s Health

Designee

e. Non-VA Care Coordination staff

f. Imaging Services

g. Health Information Management Section (HIMS) staff

5. PROCEDURES:

a. The Provider (MD, DO, or NP) performs a clinical breast exam as needed, orders the appropriate screening/diagnostic breast imaging studies at the appropriate clinical intervals, and follows up on all ordered breast imaging studies:

(1) The provider or designee initiates the ordering process by entering the

Computerized Patient Record System (CPRS) consult for the breast imaging exam; and

(2) The breast imaging type (screening or diagnostic) must be clearly identified in the consult.

b. The WVPM oversees the coordination of care for the breast imaging process and leads change to improve the overall outcomes.

c. Non-VA Care Coordination staff will verify eligibility, approve, and coordinate the scheduling process for the breast imaging examinations that are not generated from the Contract Community-Based Outpatient Clinic (CBOC).

d. The Contract CBOC ensures that the breast imaging consults are acted upon in accordance with Non-VA Care practice standards.

e. Imaging Services ensures that the results of the breast imaging reports are entered into the Veterans Information Systems and Technology Architecture (VistA) Radiology report.

f. The Women Veterans PSA or Women’s Health Designee obtains, tracks, and communicates the availability of the breast imaging reports. The PSA will scan the breast imaging report to the appropriate consult and enter the report into VistA Web.

g. HIMS staff scans the breast imaging report to the appropriate consult and enters the report into VistA Web in the absence of the PSA.

6. REFERENCES:

a. VHA Directive 1330.01(1), Health Care Services for Women Veterans, dated February 15, 2017

b. VHA Handbook 1105.03, Mammography Program Procedures and

Standards, dated April 28, 2011

c. VHA Handbook 1330.02, Women Veterans Program Manager (WVMP), dated May 23, 2012

d. VHA National Center for Health Promotion and Disease Prevention

7. RESCISSIONS: None.

8. REVIEW DATE: April 22, 2021

9. FOLLOW-UP RESPONSIBILITY: Women Veterans Program Manager (WVMP)

X

KASANDRA D. JOHNSON, BSN, RN

Women Veterans Program Manager (WVPM)

AUDREY L. FRISON, DM, MHA, BSN, RN

Associate Director Patient Care Services

WAYNE Z. MCBRIDE, DO, MPH

Chief of Staff

JAY H. MILLER

Associate Director for Operations

JOHN PHILLIP SHEALEY, MBA

Assistant Director

MICHAEL E. HERSHMAN, MHA, FACHE

Director