264 Consult Management

1. 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)

2. 2 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

3. 3 �Physicians who meet in consultation must never quarrel or jeer at one another� Hippocrates Precepts VIII

4. 4 A Primary Care Visit: A to-do list

5. 5 Before seeing the patient Review vital signs and today�s nursing assessment Review recent lab, x-ray, other results Review all notes from other clinicians since last visit Review any outside records

6. 6 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

7. 7 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�

8. 8 And, by the way, do it all in 20 minutes or less!!

9. 9 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.

10. 10 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 specialty�s preferences for prerequisites (testing, etc.) Is flexible with prerequisites and scheduling depending on patient�s unique situation

11. 11 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 consultant�s role will be in the future (if any)

12. 12 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

13. 13 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)

14. 14 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)

15. 15 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)

16. 16 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

17. 17 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

18. 18 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 patient�s condition Consultants may extract overlooked information by repeating subjective and objective data collection and assessment

19. 19 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

20. 20 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

21. 21 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

22. 22 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 consultant�s 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

23. 23 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

24. 24 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

25. 25 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.)

26. 26 8 Strategies to improve the requestor�s 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)

27. 27 8 Strategies to improve the requestor�s 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

29. 29 What doesn�t work

30. 30 What doesn�t work

31. 31 Getting better

32. 32 Getting better

33. 33

34. 34

38. 38 Key information provided on common diagnoses

39. 39 Key information provided on common diagnoses

40. 40 Less common conditions also covered

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43. 43 Ordering Procedures

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48. 48 Key data requested when ordering a procedure

49. 49

50. 50 SURGICAL SPECIALTY CONSULTS Philip B. Irwin, PA-C Vascular Surgery North Florida/South Georgia VAMC Gainesville, Florida

51. 51 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

52. 52 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!)

53. 53 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

54. 54 Methods of contacting a Consultant Phone calls (takes a personal touch) E-mail (takes knowledge) By electronic Consult (the new e-mail)

55. 55 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

56. 56 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

57. 57 Third Generation Use the prerequisite functionality of CPRS to create a DIALOG Initiate consults by PROBLEM

58. Third Generation Problem List

59. 59 AAA by ultrasound

60. Answer a question? (dialog)

61. 61 Immediate Feedback!

62. Larger AAA by U/S

63. 63 Pre-clinical testing is included

64. 64 Procedure and history

65. Urgent/routine pathway

66. 66 After 3 clicks, here is the consult

67. 67 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

68. 68 Prior to change 4/2003

69. 69 Results June 2003

70. 70 Improvements

71. 71 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

72. 72 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

73. 73 Ordering a new consult still begins with the Service�

74. 74 Audiology Problem List

75. 75 Primary care/specialty care contracts enforced by default

76. 76 Established patients screened

77. 77 Contact information provided

78. 78 Pick a problem

79. 79 Ear pain gets re-routed�.

80. 80 � to ENT

81. 81 Dental can include�

82. 82 �service connection triage�

83. 83 �with information

84. 84 ENT problem list�

86. 86 Eye consult first step-urgency�

87. 87 �and routes to Optometry

88. 88 GI Medicine Triage

89. 89 Start with brief guidelines�

90. 90 �initial workup�

91. 91 �and then consult

92. 92 Home health care�

93. 93 �with listed resources

94. 94 Nutrition�

95. 95 �has multiple entries

96. 96 Podiatry Problem List

97. 97 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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115. 115 Things to Avoid The worst thing that can happen is an unnecessary visit Makes the patient mad Wastes clinician�s time Interferes with sicker patients

116. 116 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

117. 117 Conclusion continued Refining the questioning process is a worthwhile task Helps the Sender and the Receiver

118. 118 References �Reducing Wait Times for Cardiac Consultation� Federal Practitioner Feb 2005 pp 24-28 �Why we don�t come: patient perceptions on no-shows� Ann Family Medicine 2004;2:541-545 Advanced Clinic access portal vaww.vccsportal.med.va.gov/aca/

119. 119 Consultations and the Inpatient Provider � A Brief Overview of Placing the Consult AND Being the Consultant Ako D. Bradford, M.D. Internal Medicine / Hospitalist Thomas E. Creek VAMC Amarillo, TX Southwest VA Health Care Network (VISN 18) Thank you to Dr. Anthony Zollo, Mr. Phillip Irwin and Harold Bonds for allowing a few minutes of this talk to be dedicated to scratching the surface of consultations from the inpatient perspective. This topic could be a full lecture unto itself.Thank you to Dr. Anthony Zollo, Mr. Phillip Irwin and Harold Bonds for allowing a few minutes of this talk to be dedicated to scratching the surface of consultations from the inpatient perspective. This topic could be a full lecture unto itself.

120. 120 Inpatient Consults � cont. PLACING THE CONSULT BEING THE CONSULTANT WOMEN�S 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. In the few minutes that I have, allow me to introduce three considerations for inpatient consults within the V.A. system. Tony and Philip have already provided a very detailed and thorough explanation of how CPRS helps us facilitate this process. These processes are used similarly for inpatients, although there may be differences in outcomes that are not readily apparent in the computerized medical record. Maybe one day, these and other issues will be reflected in CPRS.In the few minutes that I have, allow me to introduce three considerations for inpatient consults within the V.A. system. Tony and Philip have already provided a very detailed and thorough explanation of how CPRS helps us facilitate this process. These processes are used similarly for inpatients, although there may be differences in outcomes that are not readily apparent in the computerized medical record. Maybe one day, these and other issues will be reflected in CPRS.

121. 121 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

122. 122 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! For I.D. � �manage antibiotics�: Do you want them to follow vancomycin levels; this may be poor utilization of their time. However, if you believe drotrecogin alfa is needed on a patient; or, if you have a post-stem cell transplant patient w/ neutropenic sepsis who has not responded to 10 days of aggressive, broad-spectrum therapy, you may want to get their assistance. At our hospital, the only involvement our GI docs have w/ inpatients is procedural. Consequently, the only notes from GI relate to the procedure, its consent, etc. However, because we fee-base our dialysis services (although, we are working on changing this in the near future), our Nephrologist is excellent in providing daily notes on our MSOF patients w/ fluid overload issues. Talk is cheap & effective. Whether these nuances are communicated in the consult or (preferably) in person may effect daily vs. periodic documentation by the consultant. For I.D. � �manage antibiotics�: Do you want them to follow vancomycin levels; this may be poor utilization of their time. However, if you believe drotrecogin alfa is needed on a patient; or, if you have a post-stem cell transplant patient w/ neutropenic sepsis who has not responded to 10 days of aggressive, broad-spectrum therapy, you may want to get their assistance. At our hospital, the only involvement our GI docs have w/ inpatients is procedural. Consequently, the only notes from GI relate to the procedure, its consent, etc. However, because we fee-base our dialysis services (although, we are working on changing this in the near future), our Nephrologist is excellent in providing daily notes on our MSOF patients w/ fluid overload issues. Talk is cheap & effective. Whether these nuances are communicated in the consult or (preferably) in person may effect daily vs. periodic documentation by the consultant.

123. 123 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 Sometimes, assistance is needed for coming up with a diagnosis: if a skin or bone marrow bx is needed; or, if a patient has an FUO. Most times, you may want to try to GIVE the consultant a �working diagnosis� from which to start. It also helps to know how much initiative your consultant takes. Who does what? Who makes the patient NPO or changes them to a caffeine-free diet before their stress test? Who gets the consent for blood transfusion when the patient is scheduled for surgery? In the end, though, know your consultant!! Will your consultant become offended if you offer a diagnosis. . . or, is it viewed as a show of collegiality?Sometimes, assistance is needed for coming up with a diagnosis: if a skin or bone marrow bx is needed; or, if a patient has an FUO. Most times, you may want to try to GIVE the consultant a �working diagnosis� from which to start. It also helps to know how much initiative your consultant takes. Who does what? Who makes the patient NPO or changes them to a caffeine-free diet before their stress test? Who gets the consent for blood transfusion when the patient is scheduled for surgery? In the end, though, know your consultant!! Will your consultant become offended if you offer a diagnosis. . . or, is it viewed as a show of collegiality?

124. 124 Inpatient Consults � cont. PLACING THE CONSULT: Establishing hospital follow-up May depend upon extent of consultant involvement 10th Commandment? Follow-up is essential Daily vs. periodic notes. Sometimes, you may have to call the consultant to get permission to schedule the patient with them in their clinic.Daily vs. periodic notes. Sometimes, you may have to call the consultant to get permission to schedule the patient with them in their clinic.

125. 125 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 patient�s care.� Kammerer and Gross� Medical Consultation: The Internist on Surgical, Obstetric, and Psychiatric Services, 3rd ed. (1998). Rarely are inpatient REFERRALS done, except for Interservice transfer, e.g., a patient who is initially being treated medically for acute diverticulitis later develops a bowel perforation w/ peritonitis. This definitely should warrant a phone call between Attending Physicians. As a courtesy, the person who just referred the patient may continue following the patient who is now under the care of another service.Rarely are inpatient REFERRALS done, except for Interservice transfer, e.g., a patient who is initially being treated medically for acute diverticulitis later develops a bowel perforation w/ peritonitis. This definitely should warrant a phone call between Attending Physicians. As a courtesy, the person who just referred the patient may continue following the patient who is now under the care of another service.

126. 126 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 The second topic we will briefly address . . . The second topic we will briefly address . . .

127. 127 Inpatient Consults � cont. BEING THE CONSULTANT: To admit or to consult? (A.K.A. �To be, or not to be��) What is the patient�s primary issue? How is this issue best addressed for their safety? Communication and collegiality are essential! You talk about the ultimate �turf war!� And, unfortunately, many times the patient is stuck in the middle down in the E.D. while this is being figured out. What if the patient likely needs surgery soon� but, not RIGHT NOW? The patient w/ the abscess and fever; does Internal Medicine consult while Surgery admits for drainage? Or, does Medicine admit to �treat the fever�? The patient who presents w/ severe HTN and has a broken hip. Does Ortho admit to fix the hip; or, does Medicine admit because the severe HTN �probably caused the patient to get dizzy, fall, and break their hip�?You talk about the ultimate �turf war!� And, unfortunately, many times the patient is stuck in the middle down in the E.D. while this is being figured out. What if the patient likely needs surgery soon� but, not RIGHT NOW? The patient w/ the abscess and fever; does Internal Medicine consult while Surgery admits for drainage? Or, does Medicine admit to �treat the fever�? The patient who presents w/ severe HTN and has a broken hip. Does Ortho admit to fix the hip; or, does Medicine admit because the severe HTN �probably caused the patient to get dizzy, fall, and break their hip�?

128. 128 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? Because of our patient population w/ their diverse co-morbidities, it is essential to address what you specifically want to have done. This may also be the time to establish how frequently the patient will be seen, etc. Determine what your level of involvement is. A few things are suggested: (1) state WHO consulted you and WHY (�Consult placed by Surgery for post-operative ventilator management� (2) your SOAP note moreso identifies a �Recommendation� instead of a �Plan�. (3) To this end, determine whether your are expected to act on the Recommendations or notBecause of our patient population w/ their diverse co-morbidities, it is essential to address what you specifically want to have done. This may also be the time to establish how frequently the patient will be seen, etc. Determine what your level of involvement is. A few things are suggested: (1) state WHO consulted you and WHY (�Consult placed by Surgery for post-operative ventilator management� (2) your SOAP note moreso identifies a �Recommendation� instead of a �Plan�. (3) To this end, determine whether your are expected to act on the Recommendations or not

129. 129 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 18;144(8):575-80. Although many facilities have a Pre-Operative Clinic that is managed by Anesthesiology, this is a bread-and-butter aspect of inpatient management. YOU DO NOT CLEAR A PATIENT. You assess, and then modify (when able) their risks while disclosing to the patient what these risks are. It is recommended that the physician performing the procedure be responsible for identifying the risks OF THE PROCEDURE. Your responsibility is to address their risk of complications before, during and/or after the procedure. The �gold standard� paper to which many Residency training programs (and, practicing physicians) still refer even today is colloquially referred to as the Goldman Criteria, as per its primary author. A more recent paper published looks at pulmonary operative risks.Although many facilities have a Pre-Operative Clinic that is managed by Anesthesiology, this is a bread-and-butter aspect of inpatient management. YOU DO NOT CLEAR A PATIENT. You assess, and then modify (when able) their risks while disclosing to the patient what these risks are. It is recommended that the physician performing the procedure be responsible for identifying the risks OF THE PROCEDURE. Your responsibility is to address their risk of complications before, during and/or after the procedure. The �gold standard� paper to which many Residency training programs (and, practicing physicians) still refer even today is colloquially referred to as the Goldman Criteria, as per its primary author. A more recent paper published looks at pulmonary operative risks.

130. 130 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� By having a warm body �in house� at all times, you can have your patient seen promptly. Also, get the full benefit of a full evaluation and not just someone�s �off-the-cuff gestalt� However, this can be a mixed blessing, since some services will try to abuse this availability by asking the Nursing staff (@ �0-dark-thirty�) to call the Resident for a consult in the middle of the night. Unfortunately, this does NOT lend itself to the degree of carefulness and detail that all patients require and deserve. However, when wee-hour consults are needed, a telephone call is the best way to get the Resident into actionBy having a warm body �in house� at all times, you can have your patient seen promptly. Also, get the full benefit of a full evaluation and not just someone�s �off-the-cuff gestalt� However, this can be a mixed blessing, since some services will try to abuse this availability by asking the Nursing staff (@ �0-dark-thirty�) to call the Resident for a consult in the middle of the night. Unfortunately, this does NOT lend itself to the degree of carefulness and detail that all patients require and deserve. However, when wee-hour consults are needed, a telephone call is the best way to get the Resident into action

131. 131 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 it�s for the same thing as before? It lets the primary physician know that you�re no longer following (or are responsible for) the patient. Again, this should be clearly communicated at least in the chart if not in person. Clearly define your recommendations (if there are any) before signing-offIt lets the primary physician know that you�re no longer following (or are responsible for) the patient. Again, this should be clearly communicated at least in the chart if not in person. Clearly define your recommendations (if there are any) before signing-off

132. 132 Inpatient Consults � cont. WOMEN�S 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.) Kammerer and Gross discuss medical mgmnt. during pregnancy. Are we prepared for the 20- and 30-something females who are redeploying who will want to either start or extend their families? What about gynecologic issues? Where, in your hospital, is an adequate place for doing a pelvic exam? In the E.R.? In your Women�s Center? If you need to get an x-ray on a female veteran of childbearing age, can your lab quickly do a urine beta-HCG; or, is it a send-out? Do you have to send out for GC/Chlamydia or can your lab accommodate these tests? What about our female veteran with atrial fibrillation who now wants to have a child; what do we do with her warfarin with its known teratogenicity? Serving our female veterans efficiently and respectfully in the hospital will have to continue being a priority. Saying that �we just don�t have the facilities for that� is unacceptable. Even if a pregnant veteran is eventually transferred out of your facility to one where he Ob/Gyn can manage her, we will need to be able to safely manage and stabilize her until the transfer occurs.Kammerer and Gross discuss medical mgmnt. during pregnancy. Are we prepared for the 20- and 30-something females who are redeploying who will want to either start or extend their families? What about gynecologic issues? Where, in your hospital, is an adequate place for doing a pelvic exam? In the E.R.? In your Women�s Center? If you need to get an x-ray on a female veteran of childbearing age, can your lab quickly do a urine beta-HCG; or, is it a send-out? Do you have to send out for GC/Chlamydia or can your lab accommodate these tests? What about our female veteran with atrial fibrillation who now wants to have a child; what do we do with her warfarin with its known teratogenicity? Serving our female veterans efficiently and respectfully in the hospital will have to continue being a priority. Saying that �we just don�t have the facilities for that� is unacceptable. Even if a pregnant veteran is eventually transferred out of your facility to one where he Ob/Gyn can manage her, we will need to be able to safely manage and stabilize her until the transfer occurs.

133. 133 Inpatient Consults � cont. So, what�s the bottom line? The success of many inpatient consultations depends upon your relationship with your consultants. Don�t be afraid to pick up the phone Remember the 10 Consult Commandments

134. 134 264 Consult Management: Monitoring for Performance improvement

135. 135 #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

136. 136 #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

137. 137 #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. Since there is no one reporting mechanism for collecting all of the data in one report, data for monitoring the effectiveness of the Consult process must be collected from several sources and then compiled into workable programs such as Microsoft Excel, Microsoft Access, or some other database program. What sources you use to collect the data will be determined by the information you wish to compile into your reports. Data is available in all of the options listed here.Since there is no one reporting mechanism for collecting all of the data in one report, data for monitoring the effectiveness of the Consult process must be collected from several sources and then compiled into workable programs such as Microsoft Excel, Microsoft Access, or some other database program. What sources you use to collect the data will be determined by the information you wish to compile into your reports. Data is available in all of the options listed here.

138. 138 #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 In the VistA Consult Package, I have used these five options highlighted in bold to pull statistics on consults. The most frequently used option is the �Print Service Consults by Status�. However, this option does not include the ordering provider in the report. When the ordering provider is needed, I have used the option �Print Consults by Provider, Location, or Procedure�. In the VistA Consult Package, I have used these five options highlighted in bold to pull statistics on consults. The most frequently used option is the �Print Service Consults by Status�. However, this option does not include the ordering provider in the report. When the ordering provider is needed, I have used the option �Print Consults by Provider, Location, or Procedure�.

139. 139 #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

140. #264 � Consult Management Monitoring for Performance improvement

141. #264 � Consult Management Monitoring for Performance improvement

142. #264 � Consult Management Monitoring for Performance improvement

143. 143 #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

144. #264 � Consult Management Monitoring for Performance improvement

145. #264 � Consult Management Monitoring for Performance improvement

146. 146 #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

147. #264 � Consult Management Monitoring for Performance improvement

148. #264 � Consult Management Monitoring for Performance improvement

149. 149 #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

150. 150 #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

151. #264 � Consult Management Monitoring for Performance improvement VistA Consult Package Print Consults by Status Report.VistA Consult Package Print Consults by Status Report.

152. 152 #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.

153. 153 #264 � Consult Management Monitoring for Performance improvement Consult cancellation reasons can be retrieved by two methods: Manually looking at each patient�s 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.

154. 154 #264 � Consult Management Monitoring for Performance improvement Consult completion information can be retrieved by two methods: Manually looking at each patient�s 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.

155. 155 #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

156. #264 � Consult Management Monitoring for Performance improvement

157. 157 #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

158. 158 #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

159. #264 � Consult Management Monitoring for Performance improvement

160. 160 3 x 5 cards please