Report to the Chairman, Subcommittee 

on National Security, Emerging 

Threats, and International Relations, 

Committee on Government Reform, 

House of Representatives 

United States General Accounting Office 

GAO 

December 2003 VA HEALTH CARE

Further Efforts 

Needed to Improve 

Hepatitis C Testing for 

At-Risk Veterans 

GAO-04-106 
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. 

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 

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. 

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. 
Page i GAO-04-106 VA Hepatitis C Testing Performance 

Letter 1

Results in Brief 3

Background 5

Thousands of Veterans Identified as At Risk Remain Untested for 

Hepatitis C Despite VA Exceeding Its Testing Goal 8

Several Factors Impeded One Network’s Efforts to Test Veterans 

Identified as At Risk 10

Some VA Networks and Facilities Have Taken Action Intended to 

Improve Hepatitis C Testing of Veterans Identified as At Risk 13

Conclusions 14

Recommendations for Executive Action 15

Agency Comments and Our Evaluation 15

Appendix I Scope and Methodology 17 

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 22 

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

Contents 
Page ii GAO-04-106 VA Hepatitis C Testing Performance 

Abbreviations 

NIH National Institutes of Health 

VA Department of Veterans Affairs 

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Page 1 GAO-04-106 VA Hepatitis C Testing Performance 

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 

 1

VA 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. 

2

U.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). 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-106 VA Hepatitis C Testing Performance 

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 

 3

VA’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. 

4

VA’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. 
Page 3 GAO-04-106 VA Hepatitis C Testing Performance 

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 

Results in Brief 
Page 4 GAO-04-106 VA Hepatitis C Testing Performance 

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 
Page 5 GAO-04-106 VA Hepatitis C Testing Performance 

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 

 5

W. 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). 

Background 
Page 6 GAO-04-106 VA Hepatitis C Testing Performance 

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 

 6

Ramsey C. Cheung, MD, “Epidemiology of Hepatitis C Virus Infection in American 

Veterans,” The American Journal of Gastroenterology, vol. 95, no. 3 (March 2000). 

7

See Samuel B. Ho, MD, “Managing the HCV Veteran,” The HCV Advocate Medical Writers’ 

Circle (April 2002), and GAO-01-807T. 

8

NIH 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. 
Page 7 GAO-04-106 VA Hepatitis C Testing Performance 

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 

 9

U.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. 
Page 8 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

Thousands of 

Veterans Identified 

as At Risk Remain 

Untested for 

Hepatitis C Despite 

VA Exceeding Its 

Testing Goal 
Page 9 GAO-04-106 VA Hepatitis C Testing Performance 

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 

VA network 

(location) 

Number of 

veterans

identified as at risk 

for hepatitis C

Number of at-risk 

veterans tested for 

hepatitis Ca

Percentage of 

veterans identified 

as at risk tested 

for hepatitis Cb

1 (Boston) 548 381 69

2 (Albany) 308 181 59

3 (Bronx) 284 226 80

4 (Pittsburgh) 528 315 60

5 (Baltimore) 288 173 60

6 (Durham) 424 288 68

7 (Atlanta) 539 289 54

8 (Bay Pines) 375 214 57

9 (Nashville) 436 219 50

10 (Cincinnati) 277 165 60

11 (Ann Arbor) 429 229 53

12 (Chicago) 327 169 52

15 (Kansas City) 392 231 59

16 (Jackson) 566 348 61

17 (Dallas) 198 90 45

18 (Phoenix) 428 224 52

19 (Denver) 303 208 69

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. 

a

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

b

These 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 
Page 10 GAO-04-106 VA Hepatitis C Testing Performance 

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

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. 

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 
Page 11 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

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 30-

day 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 

Hepatitis C Test Orders 

Were Not Always 

Completed 
Page 12 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

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. 

Providers Often Unaware 

That Hepatitis C Tests 

Were Not Ordered or 

Completed 
Page 13 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

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 most often 

focused on getting tests ordered immediately following risk factor 

identification. Officials in two networks modified VA’s required hepatitis C 

testing clinical reminder, which is satisfied when a hepatitis C test is 

ordered, to continue to alert the provider until a hepatitis C test result is in 

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. 

VA network and facility managers in two networks we reviewed

Networks 2 and 9instituted networkwide changes 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 facilities 

were required to install by the end of fiscal year 2002 only alerted 

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 VA Networks 

and Facilities Have 

Taken Action 

Intended to Improve 

Hepatitis C Testing of 

Veterans Identified as 

At Risk 

Some Networks and 

Facilities Took Steps 

Intended to Improve 

Hepatitis C Test Ordering 

and Completion 
Page 14 GAO-04-106 VA Hepatitis C Testing Performance 

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 Facilities Developed 

a Safety Net for Veterans 

Identified as At Risk Who 

Have Not Been Tested 

Conclusions 
Page 15 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

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 

Under Secretary for Health to 

• 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 

• provide local managers with information on current fiscal year 

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. 

Recommendations for 

Executive Action 

Agency Comments 

and Our Evaluation 
Page 16 GAO-04-106 VA Hepatitis C Testing Performance 

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 

Page 17 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

 1

In 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 
Appendix I: Scope and Methodology 

Page 18 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

 2

Our 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 

Page 19 GAO-04-106 VA Hepatitis C Testing Performance 

Appendix II: Comments from the Department 

of Veterans Affairs 
Appendix II: Comments from the Department of Veterans Affairs 

Page 20 GAO-04-106 VA Hepatitis C Testing Performance 
Appendix III: GAO Contact and Staff 

Acknowledgments 

Page 21 GAO-04-106 VA Hepatitis C Testing Performance 

Marcia A. Mann, (202) 512-9526 

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. 

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 
Related GAO Products 

Page 22 GAO-04-106 VA Hepatitis C Testing Performance 

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. 

Related GAO Products 

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