eConsult

1. eConsult How to Guide for Specialty eConsultants Delthia Mckinney Program Manager February 2014

2. What You Will Learn • eConsult Workflow • Guideline for eConsults • Responding to an eConsult request • eConsult Examples

3. eConsult Workflow

4. Guideline for eConsults • Re-State the Question • Define the parameters to address based on the clinical question • Explain Rationale • Indicate the clinical and or evidence-based reasons for recommendation • Provides recommendations for ongoing monitoring • Collaborates with PCP regarding the care plan

5. Responding to an eConsult Request • e-Consults will arrive in the Referral Message Folder. • Copy the Referral Smartphrase text from the referring physician. • Click “New Enc.”

6. Responding to an eConsult Request 5. Open the progress note and paste the PCP’s Referral text. 6. The dot phrase ‘.econsult response’ will insert a graphic division below the PCP’s text. 4. Use the “eConsult Response” Encounter Type.

7. Responding to an eConsult Request 8. Route to the PCP and the eConsult Accounting pool 7. Compose your response

8. Responding to an eConsult Request 9. Click the High Priority button. Do not close the encounter; Simply Close the Tab

9. eConsult Examples My Clinical Question: Thispatient has never been seen by a GI doctor, she believes she contracted hepatitis B with a blood transfusion as a child, has elevated alpha lipoprotein level and heterogeneous liver on ultrasound. Please advise when liver biopsy is indicated, when treatment will be indicated. Based on her lab data, she has chronic HBV infection and may well have significant liver disease. There is no evidence of cirrhosis or HCC on ultrasound from 8-2012. The AFP is minimally elevated and not consistent with HCC (although 30% of patient with HCC have normal AFP). Her HBV DNA is low on one test 8-2012. I would recommend ALT, AST and HBV DNA every 3 months for one year. If elevation in any test, she will need a liver biopsy to determine if she has HBV and/ or fatty liver disease with significant fibrosis -- and this would be the indication for therapy.

10. eConsult Examples My clinical question: Advise on recent TTE findings of abnormal septal motion consistent with abnormal electrical activation in setting of LBBB. Does he need further work up or management?  BRIEF SUMMARY OF PT'S DATA  --Pt has EKG on 7/17 showing new left bundle branch block, prior ECG was on 11/17/2006 which had normal QRS.  --Pt has h/o hypothyroidism, HTN not on meds, morbid obesity.  --Echo 8/22/12:  1. Normal biventricular size and systolic function. The left ventricular volume is normal. Left ventricular systolic function is normal. The left ventricular ejection fraction is estimated to be 55 to 60%. No segmental wall motion abnormalities present. There is abnormal septal motion consistent with abnormal electrical activation  present.   ECONSULT RECOMMENDATIONS:  -- For a new LBBB, I would recommend a stress test to r/o ischemic heart disease. Even if the pt can exercise, vasodilator nuclear stress testing is always preferred for LBBB because there can be exercise induced artifact with LBBB that can mimic ischemia. Thus a pharmacologic NM stress test (such as P-MIBI) would be appropriate.  -- The abnormal septal motion seen on echo just reflects the discoordinate contraction that can occur with left bundle branch block, and does not in and of itself have any other implication.  -- If the stress test is NORMAL, and he has no symptoms of CHF, cardiology f/u is not absolutely necessary but would leave to your discretion. He should have a repeat ECG in 6 mo to make sure he does not have some sort of progressive conduction disease. A repeat echo in 3-5 years may be reasonable as some pts w/ LBBB do progress on to developing cardiomyopathy.  --The etiology of his LBBB may be due to obesity, htn-heart disease, or unknown. The main goal would be to exclude ischemia.