264 Consult Management

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264Consult Management

• Anthony Zollo MD (Lufkin, Texas)
• Philip B. Irwin, PA-C (Gainesville, Florida)Ako
  D. Bradford, M.D. (Amarillo, Texas)Harold D.
  Bonds MT (ASCP) SC (Jackson, Mississippi)

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Consult Management A Tool for Improved
Performance

• Anthony Zollo, MD
• Chief Medical Officer
• Charles Wilson Outpatient Clinic
• Lufkin, Texas
• Michael E. DeBakey VAMC
• Houston, Texas
• South Central VA Health Care Network

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Physicians who meet in consultation must never
quarrel or jeer at one another

• Hippocrates
• Precepts VIII

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A Primary Care Visit A to-do list
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Before seeing the patient

• Review vital signs and todays nursing assessment
• Review recent lab, x-ray, other results
• Review all notes from other clinicians since last
  visit
• Review any outside records

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During the visit with the patient

• Greet the patient
• Take a focused history and review of systems
• Perform focused physical exam
• Satisfy all due clinical reminders
• Review medications and renew, change, add, delete
  as needed
• Communicate and provide patient education on
  diagnoses, prognosis, key issues and changes in
  therapy, medications or instructions
• Elicit from the patient and address remaining
  unaddressed questions or issues
• Discuss plans for future visits

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After the patient leaves

• Order future testing and visits
• Write as detailed a progress note as possible
• Request needed consultation visits in CPRS
• Return calls, review abnormal labs, process view
  alerts, etc, etc, etc

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And, by the way, do it all in 20 minutes or less!!
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That leaves about 0.75 minutes to enter a
consultation request. Anything more and the next
patient will not be seen within the 20 minute
time of the performance measure, and patient
satisfaction will suffer.
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Factors for a best practice consult request

• Provides easy way for communication of main
  questions/reason for consult
• Utilizes pick lists, templates, etc. to minimize
  the need for typing on the part of the requestor
• Does not ask the requestor to retype information
  that is available elsewhere in the CPRS chart
• Clearly communicates the specialtys preferences
  for prerequisites (testing, etc.)
• Is flexible with prerequisites and scheduling
  depending on patients unique situation

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Consultant Factors for a best practice consult
reply

• Do not repeat (especially cut and paste)
  extensive information that is not critical to
  answering the reason for the consult
• Provide clear-cut, specific, reasonable
  recommendations in the assessment and plan
• Explain how to obtain any unusual tests or
  treatments recommended
• Clearly communicate what the consultants role
  will be in the future (if any)

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Requestor Factors for best practice consult
requests

• Clearly communicate reason for consult
• Clearly communicate urgency of consult
• Clearly communicate any unusual patient factors
  (i.e., travel restrictions, location,
  preferences)
• Clearly define whether the requestor would like
  ongoing follow-up by the consultant (co-managed
  care) or a one-time visit

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Requestor behaviors to avoid

• Not being explicit and clear with the questions
  or reason for consult
• Not providing information that is not available
  to the consultant in the CPRS chart (i.e.
  outside records)

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The 10 Commandments of Consultation

• Determine and communicate the question
• Establish the urgency of the consultation
• Personally assess the patient (do not rely on
  others)
• Be as brief as appropriate
• Be specific (in questions and recommendations)

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The 10 Commandments of Consultation

• Provide contingency plans
• Honor thy turf
• Teach with tact
• Talk is cheap and effective
• Follow-up is essential
• (Goldman, L et al, Arch Int Med, 1983)

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1. Determine the Question

• Study showed in 15 of cases the requestor and
  consultant had totally different impressions of
  the reason for the consult
• Another study in diabetics reported no specific
  question was asked in 24 of cases and
  consultants ignored the question being asked in
  another 12
• Requestor should communicate the question clearly
• Consultant should communicate back to the
  requestor if there are any doubts or confusion
• Studies have shown that consult requestors who
  clearly communicate the reasons for the consult
  are more likely to be satisfied with the result
• Requests to evaluate and treat are too vague,
  inappropriate and unlikely to lead to the best
  outcome for either party
• CPRS consult templates can facilitate or impede
  this communication depending on design

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2. Establish Urgency

• Facilitated by CPRS
• Emergent or truly urgent requests should be
  accompanied by direct clinician to clinician
  communication
• Communication from the consultant should explain
  any unusual issues or anticipated delays in
  completing a consult

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3. Personally assess the patient (do not rely on
others)

• One study showed that only 9 of consults were
  requested to obtain assistance in interpreting
  data already in the chart
• Consultants bring a unique expertise and a
  different view of a patients condition
• Consultants may extract overlooked information by
  repeating subjective and objective data
  collection and assessment

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4. Be as brief as appropriate

• Requestors and Consultants should not pull
  available data from other parts of CPRS into the
  consult request or response
• Separate the wheat from the chaff

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5. Be specific (in questions and recommendations)

• Except for the purpose of facilitating academic
  training, consultation reports should be brief
  and goal oriented
• Otherwise, key points and recommendations can be
  lost in a sea of less important musings
• Suggestions that follow should be explicit and
  clearly related to the matter at hand
• Studies have shown that leaving a long list of
  suggestions decreased the likelihood that any of
  them would be followed
• Consultants should resist the temptation to
  suggest tests that are not crucial to the case

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6. Provide contingency plans

• Consultants should remember that patient
  situations change and initial recommendations
  might prove irrelevant with time
• Try to anticipate potential problems or changes
• Try to offer diagnostic and therapeutic options
  for contingencies

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7. Honor thy turf

• Less of a problem in VHA than in private sector
• Requestor should communicate any desire or
  expectation for ongoing follow-up
• Avoid comments (and especially arguments) in the
  notes regarding other subjects or areas outside
  the consultants area of expertise
• Often more than one strategy will likely succeed.
  If a strategy chosen by the requestor is as
  likely to succeed as one favored by the
  consultant, agreement is more appropriate than
  steadfast insistence on an alternate but
  equivalent strategy

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8. Teach with tact

• Although brevity and clarity is important,
  sharing expertise without condescension is often
  appreciated
• References to key articles may be appreciated but
  should not replace focused discussion of the
  recommendations in the case

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9. Talk is cheap- and effective

• There is no substitute for direct
  person-to-person communication
• This is especially the case if there are unusual
  circumstances before, during or after the consult

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10. Follow-up is essential

• Consultant should recognize the appropriate time
  to sign off on a case
• Available mechanisms for communication down the
  road should be explained (telephone extension,
  email, new consult, etc.)

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8 Strategies to improve the requestors
compliance with recommendations

• Perform the consult within 24 hours of the
  request
• Frequent, regular follow-up, with notes in the
  chart
• Verbal contact and a positive, professional
  interaction with the referring physician/service
• Limit recommendations to no more than five (if
  possible)

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8 Strategies to improve the requestors
compliance with recommendations

• Recommendations should be directly related to the
  reason for the consultation
• Phrase recommendations as definitive statements
• Assert the importance of the recommendations
• Give precise information about how to order the
  recommended diagnostic test and how to administer
  any recommended treatment
• Kammerer Gross Medical Consultation, 1988

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Examples in CPRS
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What doesnt work
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What doesnt work
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Getting better
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Getting better
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A Success Cardiology
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Key information provided on common diagnoses
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Key information provided on common diagnoses
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Less common conditions also covered
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For simpler questions not requiring a patient
visit, no more curbside consults, but
recommendations will be documented in the CPRS
chart
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Ordering Procedures
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Key data requested when ordering a procedure
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Consultation success!
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SURGICAL SPECIALTY CONSULTS
Consult Management for Success Part 2

• Philip B. Irwin, PA-C
• Vascular Surgery
• North Florida/South Georgia VAMC
• Gainesville, Florida

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Process ImprovementIdentification of the problem

• Surgical specialty care has seen a dramatic
  increase in requests for service as primary care
  has expanded
• There are limited resources to address the
  consults (providers, space, OR utilization)
• Feedback loop was lacking

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Reviewing Consults

• With a high initial rejection rate
• Makes the primary care referring provider look
  foolish (they were just asking for help!)
• Makes the specialty care service look stingy (we
  are refusing to help!)
• Confuses the patient (they just want help!)

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Specialty Care Council Charge 2002

• Charged with developing service contracts
• Open door communication between primary care and
  specialty care
• CBOCs included in process
• Broad applications
• Limited impact on actual requests

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Methods of contacting a Consultant

• Phone calls (takes a personal touch)
• E-mail (takes knowledge)
• By electronic Consult (the new e-mail)

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Consults

• Request exists apart from the clinic referral
  guidelines
• Generally are blank pieces of paper
• Current use of the prerequisite field is too
  large and gets ignored

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Fundament Change the Process was needed

• Current process Service Specific
• New Process Problem Specific
• Create a dialog between the services via the
  Prerequisite Fields of CPRS

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Third Generation

• Use the prerequisite functionality of CPRS to
  create a DIALOG
• Initiate consults by PROBLEM

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Third Generation Problem List
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AAA by ultrasound
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Answer a question? (dialog)
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Immediate Feedback!
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Larger AAA by U/S
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Pre-clinical testing is included
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Procedure and history
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Urgent/routine pathway
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After 3 clicks, here is the consult
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Results for Vascular

• Electronic consult evaluated May 20, 2003
• Turnkey process transparent to requestor
• Now allowed for urgent and routine consults to be
  handled differently

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Prior to change 4/2003
DC 14 Comp 53 Sched 17 Denied 15
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Results June 2003
DC 15 Comp 32 Sched 36 Denied 17
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Improvements
DC 11 Complete 43 Scheduled 33 Denied 12
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Results

• Saw a 20 reduction in total consults requested
  per month (208 160)
• Saw a 10 reduction in the number of consults
  denied or discontinued (32 to 23)
• Easy to use, broad application

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Results (part 2)

• Reduction in the need for a second visit
• Increase in the number of patients being
  appropriately followed in primary care
• Reduce the number of inadequate studies (i.e. CT
  scans in wrong format)
• Ultimately improves access to specialty care

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Ordering a new consult still begins with the
Service
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Audiology Problem List
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Primary care/specialty care contracts enforced by
default
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Established patients screened
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Contact information provided
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Pick a problem
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Ear pain gets re-routed.
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to ENT
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Dental can include
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service connection triage
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with information
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ENT problem list
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Eye consult first step-urgency
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and routes to Optometry
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GI Medicine Triage
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Start with brief guidelines
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initial workup
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and then consult
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Home health care
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with listed resources
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Nutrition
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has multiple entries
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Podiatry Problem List
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Decision Tree

• Nuclear medicine stress testing was being over
  utilized
• Unable to meet demand
• Cardiology presented in-service training on
  workup, had limited change in practice pattern
• Used CPRS to help manage stress testing

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Things to Avoid

• The worst thing that can happen is an unnecessary
  visit
• Makes the patient mad
• Wastes clinicians time
• Interferes with sicker patients

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In conclusion

• Problem-oriented patient diagnosis best fit into
  a problem-oriented consultation system
• CPRS with the use of the prerequisite fields is
  aptly suited to facilitate the process
• Groundwork must be set out by the service
  handling the consult

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Conclusion continued

• Refining the questioning process is a worthwhile
  task
• Helps the Sender and the Receiver

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References

• Reducing Wait Times for Cardiac Consultation
  Federal Practitioner Feb 2005 pp 24-28
• Why we dont come patient perceptions on
  no-shows Ann Family Medicine 20042541-545
• Advanced Clinic access portal vaww.vccsportal.med.
  va.gov/aca/

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Consultations and the Inpatient Provider A
Brief Overview of Placing the Consult AND Being
the Consultant
Consult Management for Success Part 3

• Ako D. Bradford, M.D.
• Internal Medicine / Hospitalist
• Thomas E. Creek VAMC
• Amarillo, TX
• Southwest VA Health Care Network (VISN 18)

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Inpatient Consults cont.

• PLACING THE CONSULT
• BEING THE CONSULTANT
• WOMENS HEALTH CONSULTS
• An excellent reference text Kammerer and Gross
  Medical Consultation The Internist on Surgical,
  Obstetric, and Psychiatric Services, 3rd ed.
  (1998). Gross and Caputo, Ed.

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Inpatient Consults cont.

• PLACING THE CONSULT
• Daily vs. periodic involvement
• Expectations of the Consultant what do you want
  them to do?
• Establishing follow-up after discharge
• Consult vs. Referral

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Inpatient Consults cont.

• PLACING THE CONSULT Daily vs. periodic
  involvement
• May be affected by how the problem is stated
• May be affected by how your hospital provides
  more specialized / invasive services
• Is this addressed in the service agreement?
• Remember the 9th Consult Commandment?
• Talk is cheap and effective!

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Inpatient Consults cont.

• PLACING THE CONSULT Whaddaya want?!?
• Do you want them to do something... to make the
  diagnosis... or, to support / refute the
  diagnosis that YOU have already made?
• How aggressive / proactive is your consultant?
• Is this addressed in the service agreement?
• But, remember the 7th Commandment?
• Honor thy turf

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Inpatient Consults cont.

• PLACING THE CONSULT Establishing hospital
  follow-up
• May depend upon extent of consultant involvement
• 10th Commandment?
• Follow-up is essential

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Inpatient Consults cont.

• PLACING THE CONSULT Consult vs. Referral
• A consultation is strictly defined as requesting
  another physician to give his or her opinion on
  diagnosis or management. A referral means to
  request another physician to assume direct
  responsibility for a portion or for all of the
  patients care.
• Kammerer and Gross Medical Consultation The
  Internist on Surgical, Obstetric, and Psychiatric
  Services, 3rd ed. (1998).

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Inpatient Consults cont.

• BEING THE CONSULTANT
• To admit or to consult?
• What do they want you to do?
• Pre-op evaluation
• Resident-managed Consultation Service
• Signing Off

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Inpatient Consults cont.

• BEING THE CONSULTANT To admit or to consult?
  (A.K.A. To be, or not to be)
• What is the patients primary issue? How is this
  issue best addressed for their safety?
• Communication and collegiality are essential!

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Inpatient Consults cont.

• BEING THE CONSULTANT Whaddaya want?!?
• The 1st Commandment?
• Determine and communicate the question
• Medical issues or follow along are
  inappropriate
• How aggressive / proactive do they want you to
  be?

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Inpatient Consults cont.

• BEING THE CONSULTANT Pre-op Evaluation
• You do not clear a patient you assess their
  peri- / intra- / post-operative risks.
• Goldman Criteria
• L Goldman et. al. Multifactorial index of
  cardiac risk in noncardiac surgical procedures
  NEJM 297 (16)845-850. October 20, 1977.
• Qaseem A et. al. Risk assessment for and
  strategies to reduce perioperative pulmonary
  complications for patients undergoing
  noncardiothoracic surgery A guideline from the
  American College of Physicians. Ann Intern Med.
  2006 Apr 18144(8)575-80.

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Inpatient Consults cont.

• BEING THE CONSULTANT Resident-managed Consult
  Service
• One of the greatest benefits availability
• 3rd Commandment?
• Personally assess the patient (do not rely on
  others)
• Less likely to request a curbside consult

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Inpatient Consults cont.

• BEING THE CONSULTANT Signing off (or, Like Nike
  Just do it!)
• Professionally courteous.
• Consults can always be re-requested but, what if
  its for the same thing as before?

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Inpatient Consults cont.

• WOMENS HEALTH CONSULTS
• In the Military . .
• 212,000 Total number of active duty women in the
  military, as of Sept. 30, 2004. Of that total,
  35,100 women were officers and 177,000 were
  enlisted.(Source Statistical Abstract of the
  United States 2006, Table 501.)
• 15 Proportion of members of the armed forces
  who were women, as of Sept. 30, 2004. In 1950,
  women comprised fewer than 2 percent.(Source
  Statistical Abstract of the United States 2006,
  Table 501.)
• 1.7 million The number of military veterans who
  are women. (Source Statistical Abstract of the
  United States 2006, Table 510.)

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Inpatient Consults cont.

• So, whats the bottom line?
• The success of many inpatient consultations
  depends upon your relationship with your
  consultants.
• Dont be afraid to pick up the phone
• Remember the 10 Consult Commandments

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264 Consult Management Monitoring for
Performance improvement
Consult Management for Success Part 4
Harold D. Bonds MT (ASCP) SC Health Systems
SpecialistG. V. Montgomery VAMC Jackson,
Mississippi
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264 Consult Management Monitoring for
Performance improvement

• Reasons for monitoring consult from a referring
  service perspective
• Provider Utilization
• Appropriateness of request (consult reason for
  request)
• Provider training needs (over utilization vs.
  underutilization)
• Timeliness of Response by Consultant for quality
  patient care

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264 Consult Management Monitoring for
Performance improvement

• Reasons for monitoring consult requests from a
  consultant perspective
• Provider Utilization
• Appropriateness of request (consult reason for
  request)
• Provider utilization (over utilization vs. under
  utilization)
• Monitor Supply and Demand
• Demand for services
• Timeliness of Care
• Clinic Capacity and Utilization
• Staffing effectiveness and utilization

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264 Consult Management Monitoring for
Performance improvement

• Data for Monitoring may be collected from several
  sources
• VistA Consult Package Reporting Options
• Care Management Query Tool
• VistA Fileman templates (requires some
  programming knowledge for obtaining information
  from the files)
• VistA Ambulatory Care Reporting Package Options
• National Reports called KLF reports from the
  Austin Automation Center generated with software
  created by Kathie Lee Frisbee.

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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Reports option
• ST Completion Time Statistics
• PC Service Consults Pending Resolution
• SH Service Consults Schedule-Management
  Report
• CC Service Consults Completed
• CP Service Consults Completed or Pending
  Resolution
• IFC Interfacility (IFC) Requests
• IP Interfacility (IFC) Requests By Patient
• IR Interfacility (IFC) Requests by Remote
  Ordering Provider
• NU Service Consults with Consults Numbers
• PI Print Interfacility (IFC) Requests
• PL Print Consults by Provider, Location, or
  Procedure
• PM Consult Performance Monitor Report
• PR Print Service Consults by Status
• SC Service Consults By Status
• TS Print Completion Time Statistics Report

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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Reports option
• SH Service Consults Schedule-Management
  Report
• Benefits of this option are
• Status of the consults
• Service Connection Percentage (Priority
  Scheduling)
• Total consult numbers at a single glance
• Patient appointment linked with consult
• Pitfalls of this option
• Ordering Provider not listed
• Reason for Request not indicated
• Completion, Cancellation, and Discontinued data
  not available

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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Reports option
• IFC Interfacility (IFC) Requests
• Benefits of this option
• List consults by Requesting or Consulting
  facility
• List status of consults by Requesting or
  Consulting facility
• Provides totals for each consult service by
  facility and overall totals by facility
• Provides basic status of consults
• Pitfalls of this option
• Does not indicate Ordering Provider
• Does not indicate Reason for Request
• Does not indicate Completion, Cancellation, or
  Discontinue data
• No appointment data not available

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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Reports option
• PL Print Consults by Provider, Location, or
  Procedure
• Benefits of this option
• Consult Statistics by Ordering Provider, Location
  or Procedure
• Individually
• System wide
• Pitfalls of this option
• Reason for Request not indicated
• Completion, Cancellation, or Discontinue data not
  available
• No appointment data not available

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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Reports option
• PM Consult Performance Monitor Report
• Benefit of this option
• Gives Consult Completion Statistics with
  Percentages
• Pitfalls of this option
• No Individual consult information available
• No appointment data available

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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Reports option
• PR Print Service Consults by Status
• Benefits of this option
• Allows each status to be reviewed/printed
  separately or together
• Provides numbers of consults in each status
• Provides patient information with ordering
  location
• Pitfalls of this option
• No Ordering provider information
• No Reason for Request available
• No Completion, Cancellation, or Discontinue data
  available
• No Appointment data available

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264 Consult Management Monitoring for
Performance improvement

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264 Consult Management Monitoring for
Performance improvement

• VistA System Consult Tracking Options
• There is no one option in the VistA Consult
  Package that will provide all the information
  that may be obtained from all five of the
  reporting options described.
• There is not an option in the VistA Consult
  Package that will provide the Reason for Request
• There is not an option in the VistA Consult
  Package that will provide the Completion,
  Cancellation or Discontinued consult information.

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264 Consult Management Monitoring for
Performance improvement

• Consult cancellation reasons can be retrieved by
  two methods
• Manually looking at each patients Electronic
  Medical Record from a list generated with one of
  the VistA Consult Tracking Options.
• Searching and printing the cancelled consults
  with the reason for cancellation from the consult
  files.

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264 Consult Management Monitoring for
Performance improvement

• Consult completion information can be retrieved
  by two methods
• Manually looking at each patients Electronic
  Medical Record from a list generated with one of
  the VistA Consult Tracking Options.
• Searching and printing a list of the completed
  consults from the consult files with the
  associated results field populated.

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264 Consult Management Monitoring for
Performance improvement

• Care Management Query Tool
• Benefits
• Provides report with differing criteria defined
  by user
• Consult Service
• Ordering Provider
• Ordering Location
• Date Range
• Directly exportable report to Microsoft Excel
  Spreadsheet
• Pitfalls
• Requires specific patient list for search
• No Appointment data available
• No Reason for Request
• No Completion, Cancellation, or Discontinue data
  available

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264 Consult Management Monitoring for
Performance improvement
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264 Consult Management Monitoring for
Performance improvement

• Ambulatory Care Reporting Package Options
• Benefits
• Provides statistical data on patient appointments
  that may be compared to Consult data obtained
  from the VistA Consult Package
• Pitfalls
• Provides no direct consult data

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264 Consult Management Monitoring for
Performance improvement

• VHA Service Support Center Reports
• Benefits
• Provides statistical data on patient
  appointments, wait times, delays, and missed
  opportunities that may be compared to Consult
  data obtained from the VistA Consult Package and
  utilized for performance improvement.
• Pitfalls
• Provides no direct consult data at this time
• 5 week lag time before monthly data is available

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264 Consult Management Monitoring for
Performance improvement
VSSC KLF Data
Ambulatory Care Option Reports
Consult Data
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3 x 5 cards please