E-Consults in Gastroenterology: A Quality Improvement Project

To complete an e-consult, the EMR was reviewed for medical diagnoses, medications, diagnostics, and recent physical exam. A summary note outlining an impression, treatment recommendations, and follow-up was entered in the EMR and communicated to the PCP. In most cases, no discussion with the patient occurred. The encounter form was completed, and information was entered into the tracking database. The database was installed on each provider’s computer who processed e-consults. If EGD or colonoscopy was indicated, the scheduler was notified to call the patient. Once a procedure date was established, procedure orders were completed in the EMR, and instructions were mailed to the patient.

Project Description and Evaluation

The project was reviewed by the Institutional Review Board and determined to be a QI project. VA organizational policies were followed for data collection and security. Benchmarks were identified from the e-consult program and from the GD, where available. Process variables were determined to measure benchmark outcomes. (Table)

To identify participants, a retrospective chart review was performed. A total of 203 potential patients were identified from the e-consult program database for the 6-month period between January and July 2012. For comparison, 50 patients who attended an appointment during the same time frame were systematically identified in the EMR. Although this comparison group was eligible for e-consults, they were triaged to in-person appointments and subsequently had colonoscopies completed.

Outcome data were extracted from the e-consult program database and the EMR. The data analysis was descriptive. Summary aggregate data were compared with the benchmarks and comparison patient outcomes. The Table summarizes the process variables, how they were measured, where they came from, and what the comparisons were.

Discussion

Figure 1 illustrates the volume of completed e-consults from January to July 2012. A gastroenterology procedure was not indicated in 43 patients. A procedure was indicated for 160 patients and completed in 116 patients (72%). One hundred procedures were colonoscopies, and 16 were EGDs. Figure 2 provides reasons why procedures were not completed in 44 patients (27%). Group comparisons of colon prep quality and preprocedure reminder calls are displayed in Figures 3 and 4, respectively.

This project sought to evaluate VAPHS GD e-consults beginning in January 2012. Process variables were established to measure benchmarks in the e-consult program and in the GD. Some benchmarks were met with outcomes that were comparable between the groups, while others were not. To our knowledge, this project is the first to evaluate e-consults in the subspecialty of gastroenterology.

Volume of Completed E-Consults

The benchmark for 20% e-consults was not met (Figure 1). For weeks 1 through 8, the volume was between 10% and 20%. Lower volume in weeks 9 through 15 (late March and April) may have been due to staff vacations. Not only do the outcomes show a downward trend in e-consult volume, they also show a precipitous fall in volume at week 15 to almost no e-consults for the remainder of the project. To explore reasons for this outcome, the workflow process of new referral triage and e-consults was reviewed.

Two providers (1 NP, 1 physician) were assigned to new referral triage and e-consults from weeks 1 through 14. At week 15, the physician was reassigned to perform procedures. From this point, only 1 NP worked on e-consults and referral triage. Competing time demands included an e-consult encounter form, tracking database entry, procedure orders, patient instructions, appointment changes, phone calls, and resolution of medications issues for procedures. The triage NP was also required to see patients in the clinic. Each day, only a half-day was allotted to complete e-consults, new referral triage (25-35/day), and the aforementioned tasks.

Therefore, it became clear that a half-day was not sufficient to meet the 20% benchmark for e-consults. Horner and colleagues also found that dedicated time in workflow processes was necessary to allow for e-consult completion.⁵

E-Consults vs Appointment Groups

All patients in both groups were offered the choice of e-consult or appointment; this benchmark was met. Of the 203 e-consult patients, 70% requested an appointment, but their evaluation was completed as an e-consult. By design, the appointment group patients chose e-consult but were triaged to appointment due to time constraints and the high volume of new referrals.

Evaluations via e-consult were completed within 2 to 3 days, whereas the mean for appointments was 19 days, with the longest time frame of 44 days. Thus, e-consult evaluations were completed sooner. Rapid access to care was also found by Zanaboni and colleagues.²

When appointments are delayed, patient complaints or status may change, which in turn may affect treatment plans. In addition, the reason for referral may have already resolved by the actual appointment, rendering the appointment unnecessary. This can be viewed as a missed opportunity for another patient to be seen. Ideally, it is best for a patient to be evaluated soon after a new referral is made.