IOWA CITY, Iowa – Radiology technologist Jeff Dettbarn said he knew something was wrong at the Department of Veterans Affairs hospital in Iowa City, Iowa, when a patient arrived in February 2017 for a CT scan, but the doctor’s order for it had been canceled.
“To have a patient show up for a scan and not have an order – you’re like, ‘What the heck is going on?’ ” he told USA TODAY in an interview.
Dettbarn started collecting cancellation notices for diagnostic procedures such as CT scans, MRIs and ultrasounds.
“I knew something was not right,” he said. “Because none of them were canceled by a physician.”
Cancellations of more than 250,000 radiology orders at VA hospitals across the country since 2016 have raised questions about whether – in a rush to clear out outdated and duplicate diagnostic orders – some facilities failed to follow correct procedures. At issue is a concern over whether some medically necessary orders for CT scans and other imaging tests were canceled improperly.
The VA inspector general is auditing mass cancellations at eight VA medical centers “to determine whether VA processed radiology requests in a timely manner and appropriately managed canceled requests,” VA Inspector General Michael Missal said.
Those hospitals are in Tampa and Bay Pines, Florida; Salisbury, North Carolina; Cleveland; Dallas; Denver; Las Vegas; and Los Angeles.
After receiving inquiries from USA TODAY, a ninth was added – Iowa City.
In Iowa City, Dettbarn alerted the hospital’s compliance officer about his concerns. He is now facing disciplinary proceedings and contends they are an effort to retaliate against him.
The VA declined to comment on disciplinary proceedings without Dettbarn’s written consent to discuss personnel matters, which he did not provide.
This much is clear: in sworn testimony in the disciplinary proceedings against Dettbarn, Iowa City administrative staffer Lisa Bickford saidshe and other employees were told by the hospital’s chief radiologist that they needed to “clean” up a backlog of incomplete diagnostic orders, some dating back years.
The staff responded by “annihilating” thousands of orders in a matter of weeks, Bickford said.
Bryan Clark, a spokesman for the Iowa City hospital, acknowledged the facility failed to follow national VA guidelines for diagnostic order cancellations but said that happened in only a “small number of instances” and “anything closed improperly was reviewed” and actions were taken to try to ensure Veterans received any needed exams. He said the process was intended to “ensure the quality and safety of the care delivered to Veteran patients.”
The VA said many of the orders were outdated or duplicated. The agency said it welcomes the oversight and is working with the inspector general to improve cancellation guidelines. VA officials said efforts to close the loop on test orders with physicians and Veterans surpass private-sector practices.
Laurence Meyer, the chief doctor overseeing specialty care for the national VA, told USA TODAY he didn’t want to comment on how individual VA hospitals handled cancellations, but he acknowledged “we’ve received word that a few places haven’t been following the directive as intended.”
“We’ve sent out teams and have reviewed and are aggressively working to fix that,” he said.
The VA’s guidelines on order cancellations have undergone revisions in the past few years.
In 2016, hospitals were told to try contacting patients multiple times before cancellations. Last year, the rules required review by a radiologist or the ordering provider before canceling. If the tests were still needed, patients should be contacted to schedule them. Since last year, hospitals have been required to establish a fail-safe "triage" process, such as written verification of review by providers.
Concerns about diagnostic test order cancellations have also been raised at the VA hospital in Tampa. Employees estimated they canceled thousands of radiology orders without checking first with doctors or patients, according to depositions in a discrimination lawsuit brought by four ultrasound technicians.
Those technicians told USA TODAY they worry Veterans may have gone months, if not a year or longer, before they or their doctors realized tests weren’t performed – if they realized at all. Technologist Erin Tonkyro noted that risk factors for many Veterans are higher than for other patients.
“Cancer grows very quickly, and our patients are not like those patients on the outside – it doesn’t mean that cancer doesn’t happen in private practice. But our Veterans have been exposed to such a large amount of toxic environments like Agent Orange; now we’re talking about the burn pits that have happened overseas,” Tonkyro said.
‘We knew it was bad’
At the Tampa facility, radiology managers began tackling outstanding orders in fall 2016.
As many as 10 people were tasked with the job, one administrative staffer testified in a deposition in the technicians’ lawsuit. Multiple employees testified they canceled orders by date and did not consult any doctors before doing so, nor was there patient contact.
They disabled office printers because of the volume of cancellations – one employee estimated they canceled thousands of radiology orders, according to testimony.
“That’s when we really started getting worried,” said Tonkyro, who attended the depositions with her co-plaintiffs, ultrasound technologists Yenny Hernandez, Kara Mitchell-Davis and Dana Strauser. “We knew it was bad, but we had no idea the magnitude of how bad it was.”
Strauser told USA TODAY that administrators went beyond past orders and canceled future ones. Those could have been follow-up scans for Veterans who might have been at risk of developing medical conditions, such as cancer recurrence.
“Doctors will put an order in for six months in advance and sometimes even a year in advance, and we were getting cancellations of those future orders,” she said.
In a statement issued by VA spokesman Curt Cashour, the VA declined to comment on what happened in Tampa, citing the litigation. “However, we are confident the James A. Haley Veterans’ Hospital has processes and procedures in place to provide the best care possible for our patients,” the statement said.
The Tampa Bay Times first reported the technicians’ concerns in July, and the hospital’s chief of staff, Colleen Jakey, wrote to providers the following month asking them to review canceled orders, according to a copy of the correspondence obtained by USA TODAY.
“We believe appropriate action was taken,” Jakey wrote, adding that a review of a random sample of cancellations did not turn up any cases of harm to Veterans. “This is a second-level review of these orders to confirm that each of these patients received the appropriate care and/or follow up.”
The technicians told USA TODAY some doctors have since reordered canceled exams but won’t know whether Veteran patients suffered any harm from the delays until they are performed and assessed.
‘An important patient safety issue’
VA hospitals came under increasing pressure to address outstanding diagnostic orders after a conference call that national officials convened with radiology managers across the country in January 2017. More than 325,000 orders for scans of Veteran patients had not been completed nationwide.
The VA’s top radiologist, Robert Sherrier, called it “an important patient safety issue” in a presentation for the call.
“Ordered studies are not being performed on Veterans, and providers may not be aware that the ordered study has not been completed,” he said.
In a dozen states, there were VA medical centers with more than 5,000 outstanding orders, his presentation said. The numbers reached 29,000 in Columbia, S.C.; 21,000 in Cleveland; and 12,000 in Washington.
Some dated back to the 1980s, but others were only months old. VA officials said that in some cases, staff may not have been able to contact Veterans to schedule exams. In other cases, Veterans may not have shown up, possibly because their ailments had gone away. Some orders may have been duplicates ordered by two different doctors.
Others may have been tests that were still needed – to monitor tumors or follow up on emergency room visits, for example.
A panel of medical and ethics specialists conducted thousands of chart reviews, Meyer said, and determined orders for exams due to be performed before June 2015 could be canceled outright without jeopardizing Veteran health.
Orders due after that date required further steps to ensure patient safety.
The national call to action triggered a dramatic reduction in pending exam orders overdue by two months or longer. As of last month, the VA said, there were 31,000 nationwide.
‘We look terrible’
At the Iowa City VA hospital, Bickford said the chief of radiology – who also was the top radiology official in the Midwest for the VA – told her after the conference call in January 2017 that the facility had more outstanding orders than any other VA in the region.
“He came to (us) and said, ‘We’ve got to get this cleaned up now. I mean, we look terrible,’ ” Bickford said. So she and other staff “went through and started annihilating orders,” she testified in the disciplinary proceeding against Dettbarn.
Any radiology orders more than 60 days past due were considered “invalid” and “expired,” Bickford testified. That is at odds with VA guidelines at the time requiring doctor reviews.
Cancellation records reviewed by USA TODAY show that in some instances, she and other staff canceled future orders.
In one case, a nurse practitioner ordered an ultrasound for September 2017 as a six-month follow-up for a Veteran with a history of kidney stones. An X-ray technician canceled it in June 2017, calling it an “expired” order.
That same month, records indicate, Bickford canceled an order for a follow-up CT scan to monitor a Veteran’s lung nodules. The test wasn’t due to be performed until September 2017. Also in June, she canceled a CT to monitor fluid in a patient’s lung not due until November 2017. Records show Bickford selected “patient failed to contact clinic” in both cases. None of the records reviewed by USA TODAY contained personal information identifying patients.
In the disciplinary case against Dettbarn, his supervisors alleged he was “disruptive” and didn’t send one patient’s images to be interpreted – accusations he denied. The investigation was initiated soon after he reported his concerns about the order cancellations.
The Office of Special Counsel, a federal agency tasked with protecting whistle-blowers, is investigating, according to a letter from the office.
Bickford declined to comment and referred questions to the Iowa City VA. In her sworn testimony, she blamed scheduling clerks for not indicating on orders that exams were scheduled. That led employees to assume there was a “dead order” even though a patient had a future appointment, she said, but she estimated that occurred only “maybe a half a dozen times.” When patients arrived for appointments, the errors were discovered, new orders were created and the exams went ahead, she said.
The chief of radiology, Stanley Parker, did not respond to a message seeking comment at a number listed in public records. In his deposition in the case, he testified that he believed physician-review would have been done before canceling.
Clark, the hospital spokesman, said Bickford's testimony about “annihilating” orders was not in context and referred to the “success of the process to right size the number” of outstanding radiology orders at the hospital.
Clark said he doesn’t know how many orders were canceled at the facility because officials didn’t track it, but he said more than 4,000 were canceled in January and February 2017 in the southern part of the Midwest region.
Clark said “most” canceled orders were from before 2015, though he didn’t know how many. He said “some” exam orders were “canceled without following proper policies or procedures.”
In those instances, Clark said, “appropriate personnel actions were taken to correct the behavior, and staff reviewed the cancellations to ensure every order that required action was appropriately reviewed by a radiology provider.”
Dettbarn has been detailed to a job collating VA records since July 2017. He said that whatever happens to him, he wants the public to know about what he called a “horrible shortcut” administrators took to improve the numbers. Dettbarn said Iowa City officials should do a clinical review like the Tampa VA to ensure Veterans weren’t harmed.
“It’s so far beyond wrong what was done,” he said. “This is someone’s health care, this is their body, their life you’re screwing with, and people are playing doctor that aren’t physicians.”