E-Consults in Gastroenterology: A Quality Improvement Project

Another speculation concerned the prep instruction sheet. Although all patients received the same sheet, e-consult patients received it in the mail and read it themselves, while it was directly reviewed face-to-face with the appointment patients. Questions remain whether a face-to-face review increases the likelihood for a better prep and how to help e-consult patients achieve optimal prep, since they are not seen face-to-face.

Practice Implications and Sustaining Measures

Theoretically, e-consults are a viable alternative to face-to-face appointments. Potential advantages include efficient use of an EMR, avoidance of unnecessary appointments, and improved access to care for patients who require an appointment. Although patient satisfaction was not measured in this project, the literature review revealed that satisfaction was increased through use of various virtual health care modalities, including a preliminary analysis in this facility by the aforementioned 2009 study by K. L. Rodriguez (unpublished data). Based on findings in this project, the following 4 recommendations were made to improve benchmark outcomes and quality of care.

1. Provide dedicated time to complete e-consults and related tasks. In this setting, a full day was recommended. An alternative was to hire a NP whose sole responsibility was e-consults.
2. Develop a selection process to determine which new referrals are best suited for e-consult. This process will increase e-consult efficiency and decrease the time to complete an e-consult. Recommended selection criteria were (A) gastroenterology referrals only for simple symptoms or issues; (B) referrals only for a procedure; and (C) stable patients with uncomplicated medical histories.
3. Sustain the preprocedure reminder phone call. The reminder call helps patients keep appointments and thus reduces a missed opportunity for care.
4. Plan a future QI project or research study on patient colon prep quality for colonoscopy. Such a project might evaluate types of colon prep, how prep quality is measured, patient instructions, and the timing/content of pre-procedure reminder phone calls, particularly for e-consult patients.

Conclusion

This QI project provided outcomes for e-consults in the subspecialty of gastroenterology at the VAPHS. Although some benchmark outcomes were met and favorable, others were less favorable. By conducting this benchmark analysis, the areas of needed improvement are now clear. This analysis provides information so recommendations for process improvements can be made.

Quality of care improvement is an ongoing process at VAPHS. Since completion of this project, several processes have been adjusted so that outcomes will be improved. For example, corrective actions were taken for patients who did not complete their gastroenterology procedure. The process for scheduling gastroenterology procedures was adjusted for appointments and cancellations. Ongoing efforts to sustain the reminder phone call were put in place. Changes in NP staffing and time assigned for both clinical and nonclinical work were proposed and are currently under review.

It is the mission of the VA to provide access to care, patient satisfaction, timely care, and appropriate use of resources. Having the ability to highlight our strengths, as well as the willingness to recognize weaknesses, allows us to create new improved processes to provide the best care possible for our veterans.

Acknowledgments
This project was Elena Swann’s capstone for the Doctor of Nursing Practice Program, University of Pittsburgh School of Nursing in Pennsylvania. Rich Laufer, Larry Priscella, and Janie Fleming assisted with the VA Gastroenterology Clinic and procedure metrics. Dr. Melissa Taylor, VA associate chief nurse for research provided project guidance and manuscript revisions. Dr. Sandra Engberg, University of Pittsburgh School of Nursing faculty, assisted with project and manuscript development.

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.