D.19 SOP for Mammography at Salem VAMC.pdf

D.19 SOP for Mammography at Salem VAMC 36C24621R0068

MAMMOGRAPHY SCHEDULING AND PROCESSING

Salem VA Medical Center SOP 658-11-001

Salem, VA 24153

Signatory Authority: Effective Date:

Special Program Assistant to the Chief of Staff October 7, 2020

Responsible Owner: Recertification Date:

Women’s Veteran Program Manager October 7, 2025

Service Line(s):

Chief of Staff, Primary Care Service Line, Community Care

1. Purpose To define a process for ordering, scheduling, processing and tracking mammography. The goal of Community Care (CITC), Radiology, VHA practitioners, and the Women’s Health (WH) Program at Salem VAMC is to ensure Veterans receive recommended imaging studies; Results are reported and communicated in a timely manner (within 7 and 14 day reporting guidelines); and Veterans receive appropriate follow up and treatment.

2. Service Provision

The imaging and surgical departments of Salem VAMC, at present, do not have capability to complete breast cancer screenings, diagnostic imaging or breast-related procedures. Thus, all requests for breast imaging, evaluation and treatment will be provided through Community Care referrals.

3. Roles and Responsibilities

a. Women’s Health Mammogram Coordinator (WHMC)

b. Community Care

c. Ordering Provider

d. Salem VA Imaging Department

e. Community Imaging Centers

October 7, 2020 SOP 658-11-001

4. Screening and Diagnostic Procedures and Guidelines The mammogram clinical reminder has been revised to follow the American Cancer Society breast cancer screening guidelines of annual screening between the ages of 40-74 (After age 74, provider and patient may decide to continue mammogram screening if the patient is in good health and has life expectancy greater than 10 years).

a. The Mammogram Coordinator will run the “mammogram reminders due report” at the beginning of the month and divide the number of patients due by the number of weeks in the month. The Mammogram Coordinator will then place the number of mammogram screening consults due per week so workload can be evenly distributed to Community Care staff for authorizing and scheduling (The MC reviews all patients due for clinical accuracy; the clinical reminder is adjusted for anyone who is not due).

b. All primary care providers and Gynecologists will also evaluate female Veterans for appropriate breast cancer screening and order mammogram when clinically indicated.

c. The Mammogram Coordinator will enter a COMMUNITY CARE-

MAMMOGRAPHY SCREENING Consult which automatically links to a radiology order and hold for signature by provider (Of note, the initial screening consult standard episode of care (SEOC) covers screening mammography of bilateral breasts, additional views, supplemental imaging approved, if clinically indicated, for suspicious finding or lesion, diagnostic mammography, breast ultrasound, MRI, fine needle biopsy and stereotactic biopsy).

d. Community Care consults are processed in accordance with VHA Office of

Community Care guidelines as well as VHA Directives for scheduling and consult management.

e. On the next business day following a scheduled mammogram appointment, CITC MSA shall contact the community provider to confirm completion of the planned encounter.

1. If Veteran attended the appointment, copy of results will be requested.

2. If Veteran did not attend the appointment, MSA will perform rescheduling as indicated until mandatory scheduling efforts are fulfilled.

f. Upon receipt of results, CITC MSA will:

1. Document records received on the consult utilizing the Consult Toolbox.

2. Scan records for closure of the consult (All results, including but not limited to, mammography, ultrasound, MRI, biopsy and pathology will be scanned and attached to the appropriate consult).

3. CITC MSAs will notify ordering provider, WHMC, Women’s Health (WH) Nurse Manager and Women’s Veteran Program Manager of any test results subsequent, or in addition to, the initial imaging result via comments on consult and additional signer through CPRS.

g. When mammogram results are made available in CPRS, the ordering provider, the Mammogram Coordinator, and Imaging Department designee will receive a “SMART BREAST IMAGING” alert in CPRS. The Mammogram Coordinator will complete the SMART template for abnormal and normal results with the ordering provider as a co-signer.

h. The community radiologist interpreting the imaging study is responsible for communicating any abnormal findings to Community Care clinical staff and/or the ordering provider within 3 business days.

i. Veterans are notified by the ordering provider via telephone or face-to-face visit within 7 business days of receiving abnormal results (BI-RADS 0, 4, 5, 6). This shall be documented in CPRS using the note title “Abnormal Mammogram

Results Notification”. Mammogram result of BI-RADS 3 will be documented using the note title “BI-RADS 3”. This is a letter sent by the ordering provider to the patient. An “Abnormal Mammogram Results” letter will accompany the telephone or face-to-face notification under note title “abnormal diagnostic review community care.”

j. The ordering provider will ensure the patient receives appropriate diagnostic follow-up as indicated. Services may be rendered through the same in-network community imaging center or other network facility chosen by the Veteran.

Services may include diagnostic mammography, breast ultrasound, fine needle biopsy, or stereotactic biopsy. The type of service/procedure needed will be detailed in the screening imaging results under impression/recommendations.

k. The Mammogram Coordinator is responsible for sending a “Mammogram

Normal Results Notification” letter within 14-business-days of receiving normal results, BI-RADS 1 or 2.

l. Imaging Department designee will document the BI-RADS code in the radiology package. Imaging reports must be incorporated into VISTA by scanning a copy of the paper report into VISTA Imaging and associating it with the outside radiology procedure order.

m. The clinical reminder is resolved when the SMART follow-up note template is completed.

n. The Mammogram Coordinator at Salem VAMC will receive CPRS alerts on all mammogram consults placed and will record the following information on a secure spreadsheet: patient’s name, date of birth, social security number, ordering provider, type of procedure, appointment date. Data will be entered into to the Breast Imaging QI spreadsheet as exams are completed including, but not limited to, date exam completed, BIRADS score and follow up recommendations (Tracking spreadsheets will be utilized and located in a secure file on Salem Shared Drive).

o. If further diagnostic testing is recommended by community radiologist, the

Mammogram Coordinator will request the ordering provider review and order subsequent diagnostic follow-up as indicated. If follow-up care is not ordered after two requests, the Women’s Health Medical Director will be notified to review the case and order care as deemed appropriate.

p. Provider places COMMUNITY CARE-MAMMOGRAPHY DIAGNOSTIC consult

(male or female) (Of note, the diagnostic consult SEOC covers supplemental imaging, if clinically indicated, for suspicious finding or lesion. Services may include breast ultrasound, MRI, fine needle biopsy or stereotactic biopsy).

q. The ordering provider obtains and documents additional information from the patient as needed, such as the presence of breast implants, family & personal history of breast cancer and any history of breast surgery.

r. As required by certain outside imaging centers, the provider completes a

Mammogram order for Diagnostic Mammogram (CPRS note title Mammogram

Diagnostic Order), utilizing information from patient inquiry to complete order, and then faxes the order to CITC to have the appointment authorized and scheduled. Verification of this is documented in CPRS.

s. All previously outlined procedures for screening mammogram apply to diagnostic mammograms with regard to authorizing, scheduling, patient notification and tracking of results. The Mammogram Coordinator will send a certified letter to all patients who miss their diagnostic mammogram appointment. Documentation will be performed in CPRS using the “Missed

Diagnostic Mammogram” note title.

t. The Mammogram Coordinator will review all open diagnostic consults on a weekly basis. If results have not been returned, the mammogram coordinator will contact imaging centers to request results. Status update will be documented on the consult utilizing the Consult Toolbox.

u. The WHC Nurse Manager will audit all abnormal results monthly for appropriate documentation of notification and diagnostic follow-up. This data will be reported to the Women’s Health Committee quarterly.

v. Male patients are at low risk for breast cancer. However, any patient with a clinical concern related to breast disease shall be examined by a clinical provider and have diagnostic imaging performed as indicated.

w. Pregnant patients should not have routine mammogram performed.

x. Transgender patients will be evaluated for breast disease as clinically indicated.

y. Veterans requiring treatment for breast pathology will be referred as appropriate for Community Care services. At this time, referrals for mastectomy/lumpectomy will be referred to CITC Surgery and breast reconstruction referred to CITC

Plastic Surgery. Oncology services will be provided at Salem VA Healthcare

System or referred to Community Care based on Veteran eligibility. The

Mammogram Coordinator is responsible for notifying the Oncology RN Care

Coordinator of any Veteran with breast cancer diagnosis.

z. If the provider deems necessary, genetic testing (BRAC-1 and BRAC-2) shall be ordered via inter-facility consult (IFC). Based on the results of the genetic testing, the ordering provider shall request appropriate follow-up such as MRI of the breast(s) or further treatment/chemo-prevention.

5. Quality Metrics

a. The Women’s Health Medical Director, WH Nurse Manager, Women Veterans Program Manager and Quality Manager are responsible for tracking and reporting quality and safety metrics to internal and external governing bodies.

b. Reports are provided quarterly to the Women Veterans Health Committee.

6. Definitions The American College of Radiology (ACR) uses the lexicon known as BIRADS (Breast Imaging Reporting and Database System) to assess and categorize mammogram findings. Each category is associated with an expected follow up plan, shown below in parentheses. Community imaging centers are required to list the BIRADS code and specific follow-up recommendation on the report:

Digitally signed by Eleanor E. Wright

Eleanor E. Wright 181394 181394 Date: 2020.10.14 06:41:56 -04'00'

a. BI-RADS Category 0—Incomplete (Requires additional imaging evaluation)

b. BI-RADS Category 1—Negative (Continue routine screening)

c. BI-RADS Category 2—Benign (Continue routine screening)

d. BI-RADS Category 3—Probably Benign (Short-term follow-up mammogram suggested)

e. BI-RADS Category 4—Suspicious (Biopsy should be considered)

f. BI-RADS Category 5-- Highly Suggestive of Malignancy (Biopsy)

g. BI-RADS Category 6—Known Biopsy Proven Malignancy (Appropriate action should be taken—treatment)

7. References

a. VHA Directive 1330.01, Health Care Services for Women Veterans, June 29, 2020, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5332

b. VHA Directive 1105.03, Mammography Program Procedures and Standards, May 21, 2018, https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=6423

c. American Cancer Society – Recommendations for the Early Detection of Breast Cancer: https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

8. Signature Authority

Digitally signed by Tammy S. Snyder 181419

Date: 2020.10.13 18:07:17 -04'00'

Tammy Snyder Special Program Assistant to the Chief of Staff

SOHEIR S BOSHRA Digitally signed by SOHEIR S

BOSHRA 1440776

1440776 Date: 2020.10.14 08:04:24 -04'00'

Soheir Boshra, MD Women’s Health Medical Director

Eleanor “Beth” Wright, LCSW Women Veterans Program Manager

Tammy S. Snyder 181419 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5332 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=6423 https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs can be found on the Salem SharePoint at:

https://dvagov.sharepoint.com/sites/salem/Salem%20SOPs/Forms/AllItems.aspx https://dvagov.sharepoint.com/sites/salem/Salem%20SOPs/Forms/AllItems.aspx