(USA TODAY) -- A review of the imaging system at the Central Alabama Veterans Health Care System prompted by 900 lost X-rays revealed there were an additional 1,146 unread patient exams going back to 2011.
According to a statement from the Central Alabama system, the organization conducted a "broader review" of the imaging system but didn't specify what the review involved. The health care system generated a report dating back to 2001, when the imaging software was installed, and didn't find any unread exams from before 2009.
Of the latest 1,146 images discovered, there were about 176 requiring interpretation that staff "took immediate action to complete," and 227 that were a combination of complete and incomplete X-ray orders that are being assessed to determine if further clinical action is needed.
There were about 559 orders that were summarized as group reports instead of individually and 184 fluoroscopy guided images — all of which didn't require clinical action.
In April, a Central Alabama VA doctor who couldn't find an unread X-ray notified IT staff, who discovered that X-rays that haven't been read in the first eight days "fall off" the system, according to an updated version of a CAVHCS Veterans Health Administration Issue Brief. About 900 unread patient images going back to 2009 were found.
Documents obtained by the Montgomery Advertiser showed that CAVHCS Director James Talton and staff members from the VA Southeast network found out about the imaging problem in October 2012.
Talton notified the VA Southeast regional chief medical officer, who is in charge of the VA systems in Alabama, Georgia and South Carolina, that unread imaging exams were intermittently falling off the "unread list" in the system, according to the brief.
Regional administrators determined there wasn't enough memory on the radiologists' workstations and recommended the memory be increased, according to emails obtained by the Advertiser. However, X-rays continued to disappear, and staff — anticipating a new imaging system that would be purchased — did not pursue the problem further, the brief said.
Emails between Stephen Holt, the regional chief medical officer, and CAVHCS staff show he had all references to knowledge of the problem in 2012 eliminated from the final version of the issue brief that would go on record at the regional VA. The brief also indicates that clinical and institutional disclosure of the problem was not needed.
The email said the reference to workstation issues in 2012 is "unrelated and begs unnecessary and unrelated questions."
According to the statement, CAVHCS has hired two new radiologists — one who started in July and one who hasn't started yet. They've also been actively recruiting a clinical administrator who will monitor the image processing.
A permanent software fix was done to ensure that every pending exam remains on the list until it is properly read and interpreted, the statement said.
CAVHCS also has entered into an agreement with the VA in Birmingham and Charleston, South Carolina, to make sure X-rays and other images are processed in a timely manner.
According to a statement from July 15 about the lost X-rays, the VA's goal is to have 90 percent of all X-ray studies done within 48 hours.
Talton could not be reached for comment.