E-Consults in Gastroenterology: A Quality Improvement Project

The VA encounter form for an e-consult had only one 5-digit code, which allotted only 15 minutes of work credit. Encounter form codes were established by the Center for Medicare and Medicaid Services (CMS) for billing purposes in the private sector, with coding levels based on information documented in a chart note: review of systems, physical exam, and diagnoses decision making. Because all criteria could not be met in an e-consult, only 1 code was assigned for VAPHS e-consults. The CMS has specific telemedicine codes; it was unknown why they were not used for e-consults.

E-consults took an average of 19 minutes to complete, with 91 completed in ≤ 15 minutes and over half (112) having taken > 15 minutes. Therefore, the actual workload was not captured, and more work was done than was credited. To speculate, e-consults were in their infancy; a learning curve may have existed as staff became accustomed to this new process.

The EMRs were reviewed for the 7 e-consults that took > 30 minutes to complete. Two were in the early stage of e-consult implementation, but the remainder were scattered throughout. Patients in these e-consults had complicated medical histories and perhaps should not have been triaged to e-consult. Theoretically, only uncomplicated patients with simple reasons for gastroenterology referral should be triaged to e-consult, allowing for a shorter time frame and higher volume.

The wait times to procedure were 58 days for the e-consult group and 39 days in the appointment group. Although wait time was originally identified as an outcome, its relevance is questionable after looking at the outcome data. The procedure appointment date was a subjective decision by the patient; many factors affected what date the patient established, including weekday preference, time off from work, caretaker availability, season, and staffing. Many patients rescheduled their initial procedure dates, often several times. These factors are reflected in the variable ranges of wait times.

Colon Prep Quality

Colon prep refers to patient instructions on the day before the procedure and includes a clear liquid diet, drinking a liquid solution to empty bowel contents, and no food or liquid after midnight. Prep quality is stated in the colonoscopy report. During the procedure, the physician makes a visual decision based on presence or absence of stool inside the colon. Prep quality is important, because retained stool can preclude thorough visualization of the colon wall for polyps or abnormalities. In the event of fair and poor preps, the colonoscopy might be aborted and rescheduled or completed, but with the recommendation for another colonoscopy in a short time frame, such as 1 to 3 years.

Forty-four percent of the e-consult group and 62% of the appointment group had good or adequate preps. Thus, more patients in the appointment group achieved good and adequate preps, and far fewer achieved fair or poor preps. One important point was that almost half (47%) of the e-consult group had only a fair prep (Figure 3).

A number of reasons have been identified in the literature, which might help us understand these findings. First, patients may not fully understand or adhere to prep instructions.^8-10 Furthermore, certain medical diagnoses are known to affect prep quality (ie, diabetes, thyroid disease, constipation).^11,12 Another potential factor is the manner in which prep quality is determined.^13,14 However, due to the focus of this QI study, the influential drivers of prep quality can only be inferred from the literature; thus, a future research or QI study is warranted to ascertain the underlying mechanism of colon prep quality in our specific veteran population.

Preprocedure Reminder Calls

Outcomes were essentially reversed between the 2 groups (Figure 4). Between 50% and 60% of the e-consult group received a call, while the same percentage of appointment patients did not. All patients did attend their procedure appointment. A GD goal was to call every patient before their procedure, but the ability to make the calls was staffing-dependent, which may explain these findings.

Most Relevant Findings

Although this project provides a thorough analysis of various benchmarks within this recently implemented e-consult gastroenterology program, 3 findings emerged that were identified as most relevant. First, the benchmark of 20% volume of completed e-consults was not met. A review of the workflow processes revealed that a daily allotment of only a half-day was not sufficient to complete e-consults, referral triage, and related tasks.

Second, outcomes for colon prep quality and preprocedure reminder calls were also relevant. Although beyond the scope of this project, the question arose of a relationship between prep quality and the reminder call: Does the reminder call affect prep quality? The goal of colon prep is to achieve a good or adequate prep. The purpose of the reminder call was to confirm the appointment and to review the colon prep. Among patients in both groups who achieved only a fair prep, 62% in the e-consult group did receive the reminder call; thus, the call seemed to have failed in helping these patients achieve an adequate or good prep. The actual content of colon prep review during the call was unknown, but certainly bears improvement.