VA HEALTH CARE

Management and 

Oversight of Consult 

Process Need 

Improvement to Help 

Ensure Veterans 

Receive Timely 

Outpatient Specialty 

Care

Report to the Chairman, Subcommittee 

on Oversight & Investigations, 

Committee on Veterans’ Affairs, House 

of Representatives

September 2014

GAO-14-808

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-808, a report to the 

Chairman, Subcommittee on Oversight & 

Investigations, Committee on Veterans’ 

Affairs, House of Representatives

September 2014

VA HEALTH CARE

Management and Oversight of Consult Process Need 

Improvement to Help Ensure Veterans Receive Timely 

Outpatient Specialty Care

Why GAO Did This Study

There have been numerous reports of 

VAMCs failing to provide timely care to 

veterans, including specialty care. In 

some cases, delays have reportedly 

resulted in harm to patients. In 2012, 

VHA found that its consult data were 

not adequate to determine the extent 

to which veterans received timely 

outpatient specialty care. In May 2013, 

VHA launched an initiative to 

standardize aspects of the consult 

process at its 151 VAMCs and improve 

its ability to oversee consults.

GAO was asked to evaluate VHA’s 

management of the consult process. 

This report evaluates (1) the extent to 

which VHA’s consult process has 

ensured veterans’ timely access to 

outpatient specialty care, and (2) how 

VHA oversees the consult process to 

ensure veterans are receiving 

outpatient specialty care in accordance 

with its timeliness guidelines. GAO 

reviewed documents and interviewed 

officials from VHA and from five 

VAMCs that varied based on size and 

location. GAO also reviewed a nongeneralizeable sample of 150 consults 

requested across the five VAMCs.

What GAO Recommends

GAO recommends that VHA take 

actions to improve its oversight of 

consults, including (1) routinely assess 

VAMCs’ local consult processes, 

(2) require VAMCs to document 

rationales for closing unresolved 

consults, (3) develop a formal process 

for VAMCs to share consult 

management best practices, and 

(4) develop a policy for managing 

patient no-shows and cancelled 

appointments. VA concurred with all of 

GAO’s recommendations and identified 

actions it is taking to implement them.

What GAO Found

Based on its review of a non-generalizable sample of 150 consults requested 

from April 2013 through September 2013, GAO found that the Department of 

Veterans Affairs’ (VA) Veterans Health Administration’s (VHA) management of 

the consult process has not ensured that veterans always receive outpatient 

specialty care in a timely manner, if at all. Specifically, GAO found that for 122 of 

the 150 consults reviewed—requests for evaluation or management of a patient 

for a specific clinical concern—specialty care providers did not provide veterans 

with the requested care in accordance with VHA’s 90-day timeliness guideline. 

For example, for 4 of the 10 physical therapy consults GAO reviewed for one VA 

medical center (VAMC), between 108 and 152 days elapsed with no apparent 

actions taken to schedule an appointment for the veteran. VAMC officials cited 

increased demand for services, and patient no-shows and cancelled 

appointments among the factors that lead to delays and hinder their ability to 

meet VHA’s timeliness guideline. Further, for all but 1 of the 28 consults for which 

VAMCs provided care within 90 days, an extended amount of time elapsed 

before specialty care providers properly documented in the consult system that 

the care was provided. As a result, the consults remained open in the system, 

making them appear as though the requested care was not provided within 

90 days. 

VHA’s limited oversight of consults impedes its ability to ensure VAMCs provide 

timely access to specialty care. VHA officials reported overseeing the consult 

process primarily by reviewing data on the timeliness of consults; however, GAO 

found limitations in VHA’s oversight, including oversight of its initiative designed 

to standardize aspects of the consult process. Specifically:

• VHA does not routinely assess how VAMCs are managing their local consult 

processes, and thus is limited in its ability to identify systemic underlying 

causes of delays. 

• As part of its consult initiative, VHA required VAMCs to review a backlog of 

thousands of unresolved consults—those open more than 90 days—and if 

warranted to close them. However, VHA did not require VAMCs to document 

their rationales for closing them. As a result, questions remain about whether 

VAMCs appropriately closed these consults and if VHA’s consult data 

accurately reflect whether veterans received the care needed in a timely 

manner, if at all. 

• VHA does not have a formal process by which VAMCs can share best 

practices for managing consults. As a result, VAMCs may not be benefitting 

from the challenges and solutions other VAMCs have discovered regarding 

managing the consult process.

• VHA lacks a detailed system-wide policy for how VAMCs should manage 

patient no-shows and cancelled appointments for outpatient specialty care, 

making it difficult to compare timeliness in providing this care system-wide.

Consequently, concerns remain about the reliability of VHA’s consult data, as 

well as VHA’s oversight of the consult process. View GAO-14-808. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-14-808 VA Outpatient Specialty Care

Letter 1 

Background 6

VHA’s Consult Process Has Not Ensured Veterans Always 

Receive Outpatient Specialty Care in a Timely Manner, or at All 11

VHA’s Limited Oversight of Consults Impedes Its Ability to Ensure 

VAMCs Provide Timely Access to Specialty Care 16

Conclusions 22

Recommendations for Executive Action 23

Agency Comments 24

Appendix I Examples of Gastroenterology Consult Request Templates 25

Appendix II Comments from the Department of Veterans Affairs 27

Appendix III GAO Contact and Staff Acknowledgments 31

Tables

Table 1: Timeliness of Initial VA Medical Center (VAMC) Specialty 

Care Consult Reviews 12

Table 2: Timeliness of Care Provided by VA Medical Centers 

(VAMC) to Veterans for Specialty Care Consults 12

Table 3: VA Medical Center (VAMC) Strategies for Managing 

Future Care Consults 19

Figures

Figure 1: Veterans Health Administration’s (VHA) Outpatient 

Consult Process 7

Figure 2: Example of a Gastroenterology Consult Request 

Template for Abdominal Pain 8

Figure 3: Example of a Gastroenterology Consult Request 

Template for Chronic Diarrhea 25

Figure 4: Example of a Gastroenterology Consult Request 

Template for a Liver Condition 26

Contents
Page ii GAO-14-808 VA Outpatient Specialty Care

Abbreviations

VA Department of Veterans Affairs

VAMC VA medical center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VistA Veterans Health Information Systems and Technology 

 Architecture

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-14-808 VA Outpatient Specialty Care

441 G St. N.W.

Washington, DC 20548

September 30, 2014

The Honorable Mike Coffman

Chairman

Subcommittee on Oversight & Investigations

Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Chairman: 

The Veterans Health Administration (VHA), within the Department of 

Veterans Affairs (VA), operates one of the nation’s largest health care 

systems. Its medical facilities include 151 VA medical centers (VAMC), 

which, in addition to providing inpatient care, also provide outpatient care 

through primary and specialty care clinics.1 In recent years, VHA has 

faced a growing demand for providing outpatient medical appointments. 

From fiscal years 2005 through 2013, the number of annual outpatient 

medical appointments VHA provided through its medical facilities 

increased by approximately 50 percent, from 58 million to 86 million.2

Access to timely medical appointments is critical to ensuring that veterans 

obtain needed medical care, and problems with VHA’s scheduling and 

management of outpatient medical appointments may contribute to 

delays in care, or care not being provided at all. Over the past few years, 

there have been numerous reports of VAMCs failing to provide timely 

care, including specialty care, and in some cases, the delays reportedly 

have resulted in harm to veterans.3

 

1

Outpatient primary and specialty care clinics offer services to patients that do not require 

a hospital stay. VAMCs’ primary care clinics address patients’ routine health needs, while 

its specialty care clinics are focused on a specific specialty service such as cardiology.

In December 2012, we reported that 

2

In addition, the number of patients VHA served increased from fiscal years 2005 to 2013 

by approximately 22 percent, from 5.3 million to 6.5 million.

3

See, for example, Department of Veterans Affairs, Office of Inspector General, 

Healthcare Inspection Gastroenterology Consult Delays, William Jennings Bryan Dorn VA 

Medical Center, Columbia, South Carolina, Report No. 12-04631-313. (Washington, D.C.: 

Sept. 6, 2013); and Department of Veterans Affairs, Office of Inspector General, 

Healthcare Inspection Consultation Mismanagement and Care Delays, Spokane VA 

Medical Center, Spokane, Washington, Report No. 12-01731-284. (Washington, D.C.: 

Sept. 25, 2012).
 

Page 2 GAO-14-808 VA Outpatient Specialty Care

VHA’s medical appointment wait times were unreliable and VHA’s 

inadequate oversight of the outpatient medical appointment scheduling 

processes contributed to VHA’s problems with scheduling timely medical 

appointments.4 More recently, a report by VA’s Office of Inspector 

General,5 as well as congressional hearings on VHA’s delivery of medical 

care, have focused on delays in care and improper scheduling practices 

resulting in lengthy wait times at VHA facilities. Furthermore, a recent VA 

system-wide audit to identify the scope and magnitude of these issues 

confirmed questionable scheduling practices and other problems at many 

VHA facilities, and identified strategies, such as expanding outpatient 

clinic hours, VHA needed to implement to address immediate health care 

access issues for veterans.6

The problems identified in these reports include issues regarding VHA’s 

management of consults for outpatient specialty care. When a physician 

or other provider determines that a veteran needs outpatient specialty 

care, the provider refers the veteran to a specialty care provider for an 

outpatient consult—a request for evaluation or management of a patient 

for a specific clinical concern, or for a specialty procedure such as a 

colonoscopy. VAMCs request, review, and manage consults using VHA’s 

clinical consult process and electronic consult system, which retains 

information about each consult request and is part of VHA’s Veterans 

Health Information Systems and Technology Architecture (VistA).7

 

4

GAO, VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait 

Times and Scheduling Oversight Need Improvement, 

One of 

VHA’s timeliness guidelines is that consults should generally be 

GAO-13-130 (Washington, D.C.: 

Dec. 21, 2012).

5

Department of Veterans Affairs, Office of Inspector General, Veterans Health 

Administration Interim Report, Review of Patient Wait Times, Scheduling Practices, and 

Alleged Patient Deaths at the Phoenix Health Care System, Report No. 14-02603-178. 

(Washington, D.C.: May 28, 2014).

6

Department of Veterans Affairs, Access Audit, System-Wide Review of Access, Results 

of Access Audit Conducted May 12, 2014, through June 3, 2014. 

7

VistA is the single, integrated health information system used throughout VHA in all of its 

health care settings. It contains patients’ electronic health records.
 

Page 3 GAO-14-808 VA Outpatient Specialty Care

completed—care provided and documented in the consult system—within 

90 days of being requested.8

Ideally, the consult system would contain timely and reliable information 

on the status and outcomes of consults, and would provide VHA 

information it needs to help VAMCs effectively manage the process. In 

2012, however, VHA found that these system-wide consult data were not 

adequate to determine the extent to which veterans received timely 

outpatient specialty care. Specifically, VHA found at the time, 

approximately 2 million consults in its system were “unresolved” for more 

than 90 days—that is, for those consults, care had not been provided, 

care had been provided but not documented, or it had yet to be 

determined if care was still needed.9

In light of the findings and conclusions raised in recent reports, including 

our December 2012 report on outpatient medical appointment wait times, 

you asked us to evaluate VHA’s management of the consult process. This 

report evaluates (1) the extent to which VHA’s consult process has 

ensured veterans’ timely access to outpatient specialty care, and (2) how 

VHA oversees the consult process to ensure veterans are receiving 

outpatient specialty care in accordance with its timeliness guidelines.

Additionally, VHA determined that its 

consult data were inadequate to identify whether care had been provided 

in a timely manner or at all. In response, in May 2013, VHA launched the 

Consult Management Business Rules Initiative (referred to in this report 

as the “consult business rules initiative”) to standardize aspects of the 

consult process, with the goal of developing consistent and reliable 

consult data across all 151 VAMCs.

To determine the extent to which VHA’s consult process has ensured 

veterans’ timely access to outpatient specialty care, we reviewed 

documents and interviewed VHA central office officials about VHA’s 

 

8

According to the guideline, VAMCs are expected to complete consults within 90 days, but 

VHA officials told us that consults for urgent needs should be completed sooner, while 

other consults may be completed beyond 90 days when clinically appropriate. Also, 

according to VHA guidelines, the specialty care provider is expected to review and 

determine whether to accept a consult within 7 days of the request.

9

Consults may be resolved in VHA’s electronic system by either providing the requested 

care and completing the consult in the electronic system, or by determining the consult is 

no longer needed (e.g., care is not needed, the patient refuses care, or the patient is 

deceased) and closing the consult in the electronic system.
 

Page 4 GAO-14-808 VA Outpatient Specialty Care

policies and guidance for VAMCs to send, receive, and complete 

outpatient consults.10 We also reviewed VHA’s policies for scheduling 

outpatient specialty care medical appointments, including VHA’s 

timeliness guidelines for managing consults. As part of our review, we 

interviewed officials from five VAMCs selected for variation in volume of

outpatient consults, complexity,11

Additionally, for each of the five VAMCs, we obtained data on outpatient 

consults that were requested by providers for the three specialties 

included in our review during the period April 1, 2013, through 

September 30, 2013. From these data, we identified those consults that 

took more than 90 days to complete or had been in process for more than 

90 days at the time of our review, and selected a random sample of 150 

outpatient consults, 30 from each VAMC included in our review (10 from 

each of the three specialties). We selected our sample of consults from 

those open for more than 90 days to identify factors that affected VAMCs’ 

ability to meet VHA’s timeliness guideline for consults to be completed 

within 90 days. For each of the 150 consults, we examined veterans’ 

medical records to determine the history of actions taken on each of the 

outpatient consults included in our sample. From the consults data VHA 

originally provided, we asked VHA to identify those that were requested 

for veterans who were deceased as of March 2014. We then selected a 

and location. These five VAMCs were 

located in Augusta, Maine; Denver, Colorado; Gainesville, Florida; 

Oklahoma City, Oklahoma; and Palo Alto, California. At each VAMC, we 

interviewed leadership, specialty care service chiefs, administrative staff, 

and providers from three high-volume, specialty care services—

cardiology, gastroenterology, and physical therapy—regarding how they 

implemented the consult process at their respective VAMCs. Although 

VHA found that its consult data could not be used to determine the 

timeliness of outpatient specialty care system-wide, through interviews 

with VHA officials knowledgeable about the data, we determined that the 

data were sufficiently reliable for our use in selecting individual VAMCs

and specialties to include in our review. We also obtained and reviewed 

any local policies or procedures governing the consult process.

 

10Although VHA uses consults for both inpatient and outpatient specialty care, the scope 

of our review was limited to outpatient consults.

11VHA categorizes VAMCs according to complexity level, which is determined on the 

basis of the characteristics of the patient population, clinical services offered, educational 

and research missions, and administrative complexity.
 

Page 5 GAO-14-808 VA Outpatient Specialty Care

separate random sample of 50 of these consults (10 from each VAMC 

included in our review) to determine if veterans experienced any delays in 

care, and to identify the reported causes of their deaths. For all 200 of the 

consults we examined, we reviewed key data elements from the patients’ 

medical records—such as dates the consults were requested, and dates 

they were completed, if applicable. Due to the small sample size and 

focus on consults open for more than 90 days, the results from our 

examination cannot be generalized to all consults at the VAMCs in our 

review, or to other VAMCs.

To determine how VHA oversees the consult process to ensure veterans 

are receiving outpatient specialty care in accordance with its timeliness 

guidelines, we reviewed documents and interviewed VHA central office 

officials about their efforts to oversee implementation of VHA’s consult 

policies system-wide. We focused our review on VHA’s oversight of the 

consult business rules initiative, as this initiative was specifically intended 

to help improve VHA’s ability to oversee the consult process. We also 

interviewed officials at each of the five VAMCs we selected to identify the 

processes and mechanisms they have used to oversee consults at their 

facilities, and the extent to which they have implemented the tasks 

outlined in the consult business rules initiative. Further, we interviewed 

officials from each of the five Veterans Integrated Service Networks 

(VISN)12 responsible for overseeing the VAMCs included in our review 

about the processes they have used to oversee consults and VAMCs’ 

implementation of the consult business rules initiative. Finally, we 

assessed VHA’s efforts to oversee consults within the context of federal 

internal control standards.13

We conducted this performance audit from July 2013 to September 2014 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

 

12VHA’s health care system is divided into 21 health care networks, referred to as VISNs, 

which serve as the basic budgetary and decision-making units for providing health care 

services to veterans within a given geographical area.

13GAO, Internal Control: Standards for Internal Control in the Federal Government, 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).
 

Page 6 GAO-14-808 VA Outpatient Specialty Care

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

VHA’s outpatient consult process is governed by a national policy14 that 

outlines the use of an electronic system for requesting and managing 

consults and delineates oversight responsibilities at the national, VISN, 

and VAMC level.

Outpatient consults include requests by physicians or other providers for 

both clinical consultations and procedures. A clinical consultation is a

request seeking an opinion, advice, or expertise regarding evaluation or 

management of a patient’s specific clinical concern, whereas a procedure 

request is for a specialty care procedure, such as a colonoscopy. The 

consult process—displayed in figure 1—is governed by VHA’s national 

consult policy, which requires VAMCs to manage consults using a 

national electronic consult system, and to provide timely and appropriate 

care to veterans.

 

14Department of Veterans Affairs, Veterans Health Administration, VHA Consult Policy, 

VHA Directive 2008-056, (Washington, D.C.: Sept. 16, 2008).

Background

Outpatient Consult 

Process
 

Page 7 GAO-14-808 VA Outpatient Specialty Care

Figure 1: Veterans Health Administration’s (VHA) Outpatient Consult Process

Note: According to VHA’s consult policy, each step of the consult process is to be documented in the 

electronic consult system.

a

If the specialty care clinic does not accept the consult, the consult is either closed or sent back to the 

requesting provider to obtain additional information for resubmission.

b

Outpatient consults typically are requested by a veteran’s primary care 

provider using VHA’s electronic consult system. To send a consult 

request, providers log on to the system and complete an electronic 

consult request template that may be customized by the VAMC’s 

applicable specialty care clinic. The template requires the requesting 

provider to provide specific information, such as a diagnosis and a reason 

why the specialty care is needed, and may require additional information 

as determined by the specialty care clinic.

Some consults, referred to as “e-consults,” do not require in-person appointments with patients; and 

instead may be addressed electronically through the consult system. In these cases, an appointment 

would not be scheduled; instead, the specialty care clinic would review the information submitted in 

the patient's medical record by the requesting provider and document recommendations in the 

consult system.

15

 

15According to VA, information can automatically be pulled into consult request templates, 

and thus providers do not always have to input information.

For example, a 

gastroenterology template for abdominal pain used at one VAMC asked 

the requesting provider whether the treatment should be provided in 

person, reminded the provider about specific lab tests to be completed, 

and asked the provider to provide a brief history of the patient’s 

symptoms. (See fig. 2.) This specialty care clinic had specific templates 

depending on the patient’s symptoms. (See appendix I for examples of 

other templates used by the gastroenterology clinic at this VAMC.) After 

completing the template, the requesting provider electronically submits 

the consult for the specialty care provider to review.
 

Page 8 GAO-14-808 VA Outpatient Specialty Care

Figure 2: Example of a Gastroenterology Consult Request Template for Abdominal 

Pain 

According to VHA’s guideline, the specialty care provider is to review and 

determine whether to accept a consult within 7 days of the request. 

Typically, the provider’s review involves determining whether to accept 

the consult—that the consult is needed and appropriate—and if the 

consult is accepted, determining its relative urgency—a process known 

as triaging. When reviewing a consult request, a specialty care provider 

may decide not to accept it, and will send the consult back to the 

requesting provider. This is referred to as discontinuing the consult, which 

a specialty care provider may decide to do for several reasons, including 

that the care is not needed, the patient refuses care, or the patient is 

deceased.16

 

16When a provider discontinues a consult, action on the consult is stopped, and a new 

consult request must be initiated by the requesting provider for the veteran to obtain the 

specialty care.

In other cases the specialty care provider may determine that 

additional information is needed before accepting the consult; in such 

cases, the specialty care provider will send the consult back to the 

requesting provider, who can resubmit it with the needed information.
 

Page 9 GAO-14-808 VA Outpatient Specialty Care

If the provider accepts the consult, an attempt is made to contact the 

patient and schedule an appointment.17 Appointments resulting from 

outpatient consults, like other outpatient medical appointments, are 

subject to VHA’s scheduling policy.18

If an appointment resulting from a consult is scheduled and held, VHA’s 

policy requires the specialty care provider to appropriately document the 

results in the consult system, which would then close out the consult as 

completed. To do so, the provider updates the consult with the results of 

the appointment by entering a clinical progress note in the consult 

system. If the provider does not perform this step, or does not perform it 

appropriately, the consult remains open in the consult system. If an 

appointment is not held, specialty care clinic staff members are to 

document why they were unable to complete the consult.

This policy is designed to help 

VAMCs meet their commitment of scheduling medical appointments with 

no undue waits or delays for patients. According to VHA officials, the 

scheduler is to take into account the relative urgency of the consult, that 

is, the result of the reviewing specialty provider’s triage decision, when 

attempting to schedule the appointment.

According to VHA’s national consult policy, VHA central office officials 

have overall oversight responsibility for the consult process, including the 

measurement and monitoring of ongoing performance. The policy also 

requires VISN leadership to oversee the consult processes for VAMCs in 

their networks, and requires each VAMC to manage individual consults 

consistent with VHA’s timeliness guidelines.

To evaluate the timeliness of resolving consults across VAMCs, in 

September 2012, VHA created a national consult database from the 

information contained in its electronic consult system. After reviewing 

these data, VHA determined that they were inadequate for monitoring 

consults, because they had not been entered in the consult system in a 

consistent, standard manner, among other issues. For example, in 

 

17Some consults, referred to as “e-consults,” do not require an in-person appointment with 

the patient and instead may be addressed by the specialty care provider electronically 

through the consult system.

18VHA medical appointment scheduling policy is documented in Department of Veterans 

Affairs, Veterans Health Administration, VHA Outpatient Scheduling Processes and 

Procedures, VHA Directive 2010-027, (Washington, D.C.: June 9, 2010).

VHA National Consult 

Policy and Initiative to 

Improve Consult Data
 

Page 10 GAO-14-808 VA Outpatient Specialty Care

addition to requesting consults for clinical concerns, VHA found that 

VAMCs also were using the consult system to request and manage a 

variety of administrative tasks, such as arranging patient travel to 

appointments. Additionally, VHA could not accurately determine whether 

patients actually received the care they needed, or if they received the 

care in a timely fashion. VHA found that this was due, in part, to the fact 

that data in the consult system included consults for both care that was 

clinically appropriate to be open for more than 90 days—known as future 

care consults19

Subsequently, in October 2012, a task force convened by VA’s Under 

Secretary for Health began addressing several issues, including those 

regarding VHA’s consult system. In response to the task force 

recommendations, in May 2013, VHA launched the consult business rules 

initiative to standardize aspects of the consult process and develop 

consistent and reliable information on consults across all VAMCs. For 

example, the consult business rules initiative required that VAMCs limit 

their use of the consult system to requesting consults for care expected 

within 90 days, and distinguish between administrative and clinical 

consults in the consult system. As part of this initiative, VAMCs were 

required to complete four tasks between July 1, 2013, and May 1, 2014:

—as well as those for care that was needed within 

90 days. At the time of the database’s creation, according to VHA 

officials, approximately 2 million consults (both clinical and administrative) 

were unresolved for more than 90 days.

• Review and properly assign codes to consistently record consult 

requests in the consult system.

• Assign distinct identifiers in the electronic consult system to 

differentiate between clinical and administrative consults.

• Develop and implement strategies for managing requests for future 

care consults that are not needed within 90 days.

• Conduct a clinical review, as warranted, to determine if care has been 

provided or is still needed for unresolved consults—those open more 

than 90 days.

 

19According to VHA officials, it is clinically appropriate to request future care consults for 

certain types of care that will not be needed for more than 90 days, such as a routine, 

follow-up colonoscopy.
 

Page 11 GAO-14-808 VA Outpatient Specialty Care

After the initial implementation of these tasks, VHA required VAMCs to 

maintain adherence to the consult business rules initiative when 

processing consults. VHA was updating its national consult policy to 

incorporate aspects of the consult business rules initiative and expected 

to have a draft policy by September 2014.

Our review of a sample of consults at five VAMCs found that veterans did 

not always receive outpatient specialty care in a timely manner, if at all. 

We found consults that were not processed in accordance with VHA 

timeliness guidelines—for example, consults that were not reviewed 

within 7 days or not completed within 90 days. We also found consults for 

which veterans did not receive the outpatient specialty care requested—

64 of the 150 consults in our sample (43 percent)20

We found that specialty care providers at the five VAMCs we examined 

were not always able to make their initial consult reviews within VHA’s 

7-day guideline. Specifically, we found that for 31 of the150 consults in 

our sample (21 percent), specialty care providers did not meet the 7-day 

guideline, but they were able to meet the guideline for 119 of the consults 

(79 percent). (See table 1.) For one VAMC, nearly half the consults were 

not reviewed and triaged within 7 days, and for some consults, we found 

it took several weeks before the specialty care providers took action. 

Officials at this VAMC cited a shortage of providers needed to review and 

triage the consults in a timely manner.

—and those for which 

the requested specialty care was provided, but the consults were not 

properly closed in the consult system.

 

20In these cases, the veterans did not receive care related to the specific consults in our 

review, but may have received the care requested under a separate consult at a later 

date.

VHA’s Consult 

Process Has Not 

Ensured Veterans 

Always Receive 

Outpatient Specialty 

Care in a Timely 

Manner, or at All
 

Page 12 GAO-14-808 VA Outpatient Specialty Care

Table 1: Timeliness of Initial VA Medical Center (VAMC) Specialty Care Consult 

Reviews

VAMC

Total consults 

in sample

Number for which 

specialty care providers did 

not review within 7 days

(percentage of total)

Number for which 

specialty care providers 

reviewed within 7 days

(percentage of total)

A 30 3 (10%) 27 (90%)

B 30 4 (13) 26 (87)

C 30 6 (20) 24 (80)

D 30 14 (47) 16 (53)

E 30 4 (13) 26 (87)

Total 150 31 (21%) 119 (79%)

Source: Sample of patient medical records from the five VAMCs in our review. │ GAO-14-808

Note: The Veterans Health Administration’s guideline is for specialty care providers to review and 

determine whether to accept a consult within 7 days.

We also found that for the majority of the 150 consults in our sample, 

veterans did not receive care within 90 days of the date the consult was 

requested, in accordance with VHA’s guideline. Specifically, veterans did 

not receive care within 90 days for 122 of the 150 consults we examined 

(81 percent). (See table 2.) 

Table 2: Timeliness of Care Provided by VA Medical Centers (VAMC) to Veterans for 

Specialty Care Consults 

VAMC

Total consults 

in sample

Number of consults for 

which veterans did not 

receive care within 90 days

(percentage of total)

Number of consults for 

which veterans received 

care within 90 days

(percentage of total)

A 30 26 (87%) 4 (13%)

B 30 27 (90) 3 (10)

C 30 17 (57) 13 (43)

D 30 24 (80) 6 (20)

E 30 28 (93) 2 (7)

Total 150 122 (81%) 28 (19%)

Source: Sample of patient medical records from the five VAMCs in our review. │ GAO-14-808

Note: According to the Veterans Health Administration’s (VHA) timeliness guideline, VAMCs are 

expected to complete consults within 90 days of being requested. However, consults for urgent needs 

should be completed sooner, while other consults may be completed beyond 90 days when clinically 

appropriate, according to VHA officials.
 

Page 13 GAO-14-808 VA Outpatient Specialty Care

We also found that for the 28 consults in our sample for which VAMCs 

provided care to veterans within 90 days, an extended amount of time 

elapsed before specialty care providers completed all but 1 of them in the 

consult system. As a result, the consults remained open in the system, 

making them appear as though the requested care was not provided 

within 90 days. Although 1 consult remained open for only 8 days from 

when the care was provided, for the remaining 27 consults, it took 

between 29 and 149 days from the time care was provided until the 

consults were completed in the system. In addition, of the 28 consults, we 

found that specialty care providers at one VAMC did not properly 

document the results of all 10 cardiology consults we reviewed, in order 

to close them in the system.

Officials from four of the five VAMCs told us that specialty care providers 

often do not properly document that consults are complete, which 

requires the selection of the correct clinical progress note that 

corresponds to the patient’s consult. Officials attributed this ongoing issue 

in part to the use of medical residents who rotate in and out of specialty 

care clinics after a few months, and lack experience with completing 

consults. Officials from one VAMC told us such rotations require VAMC 

leadership to ensure new residents are continually trained on how to 

properly complete consults. To help ensure that specialty care providers 

consistently choose the correct clinical progress note, this VAMC 

activated a technical solution consisting of a prompt in its consult system 

that instructs providers to choose the correct clinical progress note 

needed to complete consults. Officials stated that this has resulted in 

providers more frequently choosing the correct notes needed to complete 

consults.

Examples of consults that were not completed in 90 days, or were closed 

without the veterans being seen, included:

• For 3 of 10 gastroenterology consults we examined for one VAMC, we 

found that between 140 and 210 days elapsed from the dates the 

consults were requested to when the veterans received care. For the 

consult that took 210 days, an appointment was not available and the 

veteran was placed on a waiting list before having a screening 

colonoscopy.

• For 4 of the 10 physical therapy consults we examined for one VAMC, 

we found that between 108 and 152 days elapsed, with no apparent 

actions taken to schedule appointments for the veterans for whom 

consults were requested. The veterans’ medical records indicated that 
 

Page 14 GAO-14-808 VA Outpatient Specialty Care

due to resource constraints, the clinic was not accepting consults for 

non-service-connected physical therapy evaluations.21

• For all 10 of the cardiology consults we examined for one VAMC, we 

found that staff initially scheduled veterans for appointments between 

33 and 90 days after the request, but medical records for those 

patients indicated that the veterans either cancelled or did not show 

for their initial appointments. In several instances, medical records 

indicated the veterans cancelled multiple times. For 4 of the consults, 

VAMC staff closed the consults without the veterans being seen; for 

the other 6 consults, VAMC staff rescheduled the appointments for 

times that exceeded VHA’s 90-day guideline.

For 1 of these 

consults, several months passed before the veteran was referred to 

non-VA care, and was seen 252 days after the initial consult request. 

The other 3 consults were sent back to the requesting providers 

without the veterans receiving care.

22

VAMC officials cited increased demand for services, patient no-shows, 

and cancelled appointments, among the factors that hinder specialty care 

providers’ ability to meet VHA’s guideline for completing consults within 

90 days. Several VAMC officials also noted a growing demand for both 

gastroenterology procedures, such as colonoscopies, as well as 

consultations for physical therapy evaluations, combined with a difficulty 

in hiring and retaining specialty care providers for these two clinical areas, 

as causes of periodic backlogs in providing these services. Officials at 

these VAMCs indicated that they try to mitigate backlogs by referring 

veterans to non-VA providers for care.

Although officials indicated that use of non-VA care can help mitigate 

backlogs, several officials also indicated that this requires more 

coordination between the VAMC, the patient, and the non-VA provider; 

can require additional approvals for the care; and also may increase the 

 

21A non-service-connected disability is an injury or illness that was not incurred or 

aggravated during active military service. According to VHA’s medical appointment 

scheduling policy (VHA Directive 2010-027), VHA is mandated to provide priority, nonemergent care for veterans with certain service-connected disabilities and certain serviceconnected conditions.

22As we previously reported, scheduling practices at some VAMCs could result in 

miscommunication with veterans, which causes or contributes to them missing medical 

appointments. In addition, outdated or incorrect veteran contact information may also 

affect patient no-shows and cancelled appointments. See GAO-13-130. 
 

Page 15 GAO-14-808 VA Outpatient Specialty Care

amount of time it takes a VAMC specialty care provider to obtain the 

results (such as diagnoses, clinical findings and treatment plans) of 

medical appointments or procedures. Officials acknowledged that using 

non-VA care does not always prevent delays in veterans receiving timely 

care or in specialty care providers completing consults.23

Additionally, we identified one consult for which the patient experienced 

delays in obtaining non-VA care and died prior to obtaining needed care. 

In this case, the patient needed endovascular surgery to repair two 

aneurysms—an abdominal aortic aneurysm and an iliac aneurysm. 

According to the patient’s medical record, the timeline of events 

surrounding this consult was:

• September 2013 – Patient was diagnosed with two aneurysms.

• October 2013 – VAMC scheduled patient for surgery in November, 

but subsequently cancelled the scheduled surgery due to staffing 

issues.24

• December 2013 – VAMC approved non-VA care and referred the 

patient to a local hospital for surgery.

• Late December 2013 – After the patient followed up with the specialty 

care clinic, it was discovered that the non-VA provider lost the 

patient’s information. The specialty care clinic staff resubmitted the 

patient’s information to the non-VA provider.

• February 2014 – The consult was closed because the patient died 

prior to the surgery scheduled by the non-VA provider.25

According to VAMC officials, they conducted an investigation of this case. 

They found that the non-VA provider planned to perform the surgery on 

February 14, 2014, but the patient died the previous day. Additionally, 

they stated that according to the coroner, the patient died of cardiac 

disease and hypertension, and that the aneurysms remained intact.

 

23We have previously reported on VA’s use of non-VA providers for care. See GAO, VA 

Health Care: Management and Oversight of Fee Basis Care Need Improvement, 

GAO-13-441 (Washington, D.C.: May 31, 2013).

24Officials indicated that, in October 2013, the VAMC temporarily suspended the 

endovascular surgeon that conducts these surgeries.

25We have referred this case to VA’s Office of Inspector General for further review.
 

Page 16 GAO-14-808 VA Outpatient Specialty Care

Since launching the consult business rules initiative in May 2013, VHA 

officials reported overseeing the consult process system-wide primarily by 

reviewing consult reports created from its national database to monitor 

VAMCs’ progress in meeting VHA’s timeliness guidelines. However, we 

found limitations in VHA’s system-wide oversight, as well as in the 

oversight provided by the five VISNs included in our review. These 

limitations have affected the reliability of VHA’s consult data and 

consequently VHA’s ability to effectively assess VAMC performance in 

managing consults.

VHA and VISNs do not routinely assess VAMCs’ management of 

consults. Although VHA officials reported using system-wide consult 

data to help ensure that VAMCs are meeting VHA timeliness guidelines, 

and the five VISNs included in our review reported using consult data to 

monitor VAMCs they oversee, neither routinely assesses how VAMCs are 

actually managing consults. According to federal internal control 

standards, managers should perform ongoing monitoring, including 

independent assessments of performance.26

Although VHA and the five VISNs included in our review do not routinely 

conduct such assessments, our work at five VAMCs found such reviews 

may help provide insights into the underlying causes of delays. Our 

examination of a sample of consults revealed several issues with VAMCs’ 

specialty care clinics’ management of consults, including delays in 

reviewing and scheduling consults, incorrectly discontinuing consults, and 

Such assessments are 

important to help VHA identify the underlying causes of delays and to 

help ensure that its consult data reliably reflects the number of, and 

length of time, veterans are waiting for care. VHA and VISN officials 

reported that they do not routinely audit consults to assess whether 

VAMC providers have been appropriately requesting, reviewing, and 

resolving consults in accordance with VHA’s consult policy. Instead, VHA 

and VISN officials reported their oversight primarily relies on monitoring 

reports that track VAMCs’ progress in reducing the number of consults 

unresolved for more than 90 days. VHA officials stated that they delegate 

oversight of unresolved consults to VAMCs and as such, do not conduct 

assessments of individual consults. Further, several VISN officials stated 

that they did not see the need for such assessments and that ongoing 

monitoring of consult data has been sufficient.

 

26See GAO/AIMD-00-21.3.1.

VHA’s Limited 

Oversight of Consults 

Impedes Its Ability to 

Ensure VAMCs 

Provide Timely 

Access to Specialty 

Care
 

Page 17 GAO-14-808 VA Outpatient Specialty Care

in some cases incorrectly closing a consult as complete even though care 

had not been provided. We discussed these issues with officials at the 

five VAMCs included in our review. Officials from two VAMCs stated that 

in responding to our questions, they researched the actions taken on 

each consult and learned about some of the root causes contributing to 

consult delays. For example, one VAMC found that its process for 

managing consults requested from other VAMCs was not clear to 

providers and needed to be improved to mitigate delays in processing 

such consults. Additionally, for a few of the consults for which we 

identified that care had not been provided, VAMC officials stated that, as 

a result of our findings, they contacted the veterans to schedule 

appointments when care was still needed. In addition, VHA officials stated 

that independent assessments of consults may be helpful and that they 

would consider conducting them in the future. By primarily relying on 

reviewing data and not routinely conducting an assessment of VAMCs’ 

management of consults, VHA and VISN officials may be limited in 

identifying systemic issues affecting VAMCs’ ability to provide veterans 

with timely access to care.

VHA lacks documentation of how VAMCs addressed unresolved 

consults. One task under the consult business rules initiative required 

VAMCs to resolve consults that had been open for more than 90 days. 

VHA provided system-wide guidance outlining how to appropriately 

complete this task. VAMCs were to conduct clinical reviews of all nonadministrative consults and determine whether the consult should be 

completed or discontinued—thus closing them in the consult system. 

However, VHA did not require VAMCs to document these decisions or the 

processes by which they were made, only to self-certify the task had been 

completed. Further, VHA did not require VISNs to independently verify 

that the task was completed appropriately. VAMC officials told us their 

reviews indicated that for many of the consults, care had been provided, 

but an incorrect clinical progress note was used. Therefore, officials had 

to select the correct note that corresponded to each consult, which 

completed the consult in the system. In addition, officials also told us that 

they discontinued many other consults because they found that patients 

were deceased or that patients had repeatedly cancelled appointments 

and thus, they determined that care was no longer needed. However, 

none of the five VAMCs in our review were able to provide us with 

specific documentation of these decisions and rationales. At one VAMC, 

for example, we found that a specialty care clinic discontinued 18 

consults the same day that a task for addressing unresolved consults was 

due. Three of these 18 consults were part of our random sample, and we 

found no indication that a clinical review was conducted prior to the 
 

Page 18 GAO-14-808 VA Outpatient Specialty Care

consults being discontinued. The lack of documentation is not consistent 

with federal internal control standards, which indicate that all transactions 

and other significant events need to be clearly documented and stress the 

importance of the creation and maintenance of related records, which 

provide evidence of execution of these activities.27

In addition to monitoring VAMC performance in completing the consult 

business rules initiative tasks, VHA officials told us they are continuing to 

monitor VAMCs’ performance in addressing unresolved consults. In 2012, 

VHA estimated that approximately 2 million consults in its system were 

unresolved for more than 90 days. According to a VHA June 2014 consult 

tracking report, 285,877 consults were unresolved.28

VHA has not independently verified VAMCs’ strategies for managing 

future care consults. Another task under the consult business rules 

initiative required VAMCs to develop and implement strategies for 

managing future care consults—those that are not needed within 

90 days.

VHA officials 

attributed this reduction in the number of unresolved consults to 

implementation of the consult business rules initiative and their continued 

monitoring of VAMC performance in meeting VHA’s consult timeliness 

guideline. Given the thousands of consults that have been closed by 

VAMCs, the lack of documentation and independent verification of how 

VAMCs addressed these unresolved consults raises questions about the 

reliability of VHA consult data and whether the data accurately reflects 

whether patients received the care needed in a timely manner, if at all.

29

 

27See 

Similar to the other tasks, VHA relied on self-certification with 

no independent verification that this task was completed. VHA approved 

specific strategies for VAMCs to use to manage future care consults—

namely that they could develop markers to identify them in the consult 

system, or use existing mechanisms outside of the consult system such 

as electronic wait lists. Although each VAMC in our review self-certified 

GAO/AIMD-00-21.3.1.

28VHA officials told us that this number changes daily and expects it to continue to decline 

as VAMCs continue to resolve consults open more than 90 days.

29VAMCs were instructed to track future care consults either by developing markers so 

such consults could be identified in the consult system, or by using existing mechanisms 

outside of the consult system such as an electronic wait list. The electronic wait list is a 

component of the VistA scheduling system designed for recording, tracking, and reporting 

veterans waiting for medical appointments.
 

Page 19 GAO-14-808 VA Outpatient Specialty Care

completing this task, we found that each of the five VAMCs initially 

implemented strategies for managing future care consults that were, 

wholly or in part, non-approved VHA options. For example, one VAMC 

reported to us that initially its staff entered consult requests for future care 

into the consult system without the use of a future care flag, and 

subsequently discontinued these consults if they reached the 90-day 

threshold. Discontinuing future care consults closed them in the consult 

system, and thus prevented the consults from being monitored, which 

may have increased the risk of the VAMC losing track of these requests

for specialty care. Further, during the course of our work, officials from 

three VAMCs reported revising their initial strategies for managing future 

care consults. (See table 3.) Some of these VAMCs continued to 

implement strategies that were non-approved VHA options and could 

have resulted in consult data that failed to distinguish future care consults 

from those that were truly delayed.

Table 3: VA Medical Center (VAMC) Strategies for Managing Future Care Consults

Initial VAMC strategiesa Updated VAMC strategiesa

Approved strategy

Non-approved 

strategy Approved strategy

Non-approved 

strategy

VAMC

Implement future 

care flags in 

consult system

Use existing 

mechanism 

outside of 

consult system

Enter consults 

in consult 

system without 

future care flags

Implement future 

care flags in 

consult system

Use existing 

mechanism 

outside of 

consult system

Enter consults 

in consult 

system without 

future care flags

A X X 

B X X 

C X Xb X X

D 

b

X X 

E X X X 

Source: Five VAMCs in our review. │ GAO-14-808

Note: To manage future care consults, the Veterans Health Administration approved specific 

strategies for VAMCs to use: either developing markers so they could be identified in the consult 

system, or using existing mechanisms outside of the consult system to keep track of these requests, 

such as an electronic wait list. The electronic wait list is a component of the VistA scheduling system 

designed for recording, tracking, and reporting veterans waiting for medical appointments.

a

VAMCs reported their initial strategies for managing future care consults to us during interviews 

conducted between November 2013 and February 2014. VAMCs reported their updated strategies to 

us during interviews conducted between May and June 2014.

b

Officials from this VAMC stated that they developed future care flags only for those specialty care 

clinics that routinely requested care beyond 90 days. Specialty care clinics that did not routinely 

request consults beyond 90 days entered them into the consult system regardless of when care was 

needed without identifying them as future care consults.
 

Page 20 GAO-14-808 VA Outpatient Specialty Care

According to federal internal control standards, managers should perform 

ongoing monitoring, including independent assessments of 

performance.30

Furthermore, VHA does not have a formal process by which VAMCs 

could share best practices system-wide.

However, because VHA officials relied on selfcertifications submitted by VAMCs, they were not aware of the extent to 

which VAMCs implemented strategies that were not one of VHA’s 

approved options, nor would they be aware of the extent to which VAMCs 

have since changed their strategies. As of June 2014, VHA officials told 

us they did not have detailed information on the various strategies 

VAMCs have implemented to manage future care consults, and they 

acknowledged that they had not conducted a system-wide review of 

VAMCs’ strategies.

31 According to federal internal 

control standards, identifying and sharing information is an essential part 

of ensuring effective and efficient use of resources.32

VHA lacks a detailed system-wide policy for managing patient noshows and cancelled appointments. Although VHA’s consult business 

rules initiative was intended to create consistency in VAMCs’ consult 

data, we found variation in how VAMCs are managing patient no shows 

and cancelled appointments, which could impact VHA’s ability to obtain 

We found that 

VAMCs may not be benefiting from the challenges and solutions other 

VAMCs discovered when implementing strategies for managing future 

care consults. For example, during our review, we found that one VAMC 

revised its initial strategy in a way that another VAMC had already found 

ineffective. Officials at that VAMC stated that they were implementing a 

new strategy to manage future care consults in a separate electronic 

system. However, another VAMC opted not to use a similar electronic 

system it piloted after finding that it confused providers and required 

extensive training; that VAMC opted instead to use future care markers in 

its consult system. A more systematic identification and sharing of best 

practices for managing future care consults would enable VAMCs to more 

efficiently implement effective strategies for managing specialty care 

consults.

 

30See GAO/AIMD-00-21.3.1.

31Officials from VAMCs in our review described sharing best practices with colleagues at 

other VAMCs in their VISN on an ad hoc basis.

32See GAO/AIMD-00-21.3.1.
 

Page 21 GAO-14-808 VA Outpatient Specialty Care

standardized data needed for conducting oversight. Additionally, 

according to federal internal control standards, management is 

responsible for developing the detailed policies, procedures, and 

practices to fit their agency’s operations and to ensure that they are built 

into, and an integral part of, operations.33

However, we found that VHA has not developed a detailed, system-wide 

policy on how to address patient no-shows and cancelled appointments, 

two frequently noted causes of delays in providing care. Instead, VHA 

policies provide general guidance that state that after a patient does not 

show for or cancels an appointment, the specialty care clinic staff should 

review the consult and determine whether or not to reschedule the 

appointment.34

Officials from the five VAMCs in our review stated that they had adopted 

various strategies for managing patient no-shows and cancelled 

appointments. For example, one VAMC developed a rule, referred to as 

the “1-1-30” rule, which states that a patient must receive at least 1 letter 

and 1 phone call, and be granted 30 days to contact the VAMC to 

schedule a specialty care appointment.

VHA officials told us that they allow each VAMC to 

determine its own approach to managing these occurrences. However, 

such variations in no-show and cancellation policies are reflected in the 

consult data, and as a result, this variation may make it difficult to assess 

and compare VAMCs’ performance. For example, if a specialty care clinic 

allows a patient to cancel multiple specialty care appointments, the 

consult would remain open and could inaccurately suggest delays in care 

where none might exist. In contrast, if the specialty care clinic limited the 

number of patient cancellations, the consult would be closed after the 

allowed number and would not appear as a delay in care, even if a delay 

had occurred.

35

 

33See 

In addition, this VAMC’s consult 

policy limits a patient to a combination of two no-shows or cancelled 

appointments after which the specialty care provider may discontinue the 

consult. The other four VAMCs in our review had some type of policy 

addressing patient no-shows and cancelled appointments, each of which 

GAO/AIMD-00-21.3.1.

34See VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures 

(June 9, 2010) and VHA Directive 2008-056, VHA Consult Policy (Sept. 16, 2008).

35According to VAMC officials, the 1-1-30 rule provides a minimum standard for specialty 

care providers to follow in scheduling medical appointments.
 

Page 22 GAO-14-808 VA Outpatient Specialty Care

varied in its requirements.36 For the 150 consults included in our sample, 

we found that specialty care providers had scheduled appointments for 

127 of the consults, and that patient no-shows and cancelled 

appointments were among the factors contributing to delays in providing 

timely care for 66 of these consults (52 percent).

Providing our nation’s veterans with timely access to medical care, 

including outpatient specialty care, is a crucial responsibility of VHA. We 

and others have identified problems with VHA’s consult process used to 

manage the outpatient specialty care needs of veterans. Our review of a 

sample of consults found that VAMCs did not always provide veterans

with requested specialty care in a timely manner, if at all. In other cases, 

VAMCs were able to provide the needed care on a timely basis, but 

specialty care providers failed to properly complete or document the 

consults, making it appear as though care for veterans was delayed, even 

when it was not.

Limitations in VHA’s oversight of the consult process have affected the 

reliability of VHA’s consult data and its usefulness for oversight. Although 

VHA officials cited VAMCs’ progress in reducing the backlog of consults 

unresolved for more than 90 days, they have not independently verified 

that VAMCs appropriately closed these consults, calling into question the 

accuracy of these data. Due to their lack of oversight, VHA officials are 

not aware of the various strategies VAMCs implemented to manage 

future care consults, and thus when monitoring consult data, cannot 

adequately determine if future care consults are distinguishable from 

those that are truly delayed. Additionally, VHA has not developed a 

system-wide process for identifying and sharing VAMCs’ best practices 

for managing future care and other types of consults; thus, VAMCs may 

be implementing strategies that others already have found ineffective or 

may be unaware of strategies that others have successfully implemented. 

Further, VHA’s decentralized approach for handling patient no-shows and 

cancelled appointments, as well as other issues, makes it difficult to 

compare timeliness of providing outpatient specialty care system-wide. 

 

36One of the VAMCs allowed for a maximum of two no-shows for all specialty care 

appointments, with consideration given to the patient’s medical needs. Two of the VAMCs’ 

policies stated that specialty care providers should reassess the patient’s needs after one 

no-show and may or may not reschedule the appointment. Another VAMC’s policy did not 

include a limit to the number of no-shows allowed for specialty care appointments.

Conclusions
 

Page 23 GAO-14-808 VA Outpatient Specialty Care

Ultimately, this decentralized approach may further limit the usefulness of 

the data and VHA’s and VISNs’ ability to assess VAMCs’ performance in 

managing consults and providing timely care to our nation’s veterans.

To improve VHA’s ability to effectively oversee the consult process, and 

help ensure VAMCs are providing veterans with timely access to 

outpatient specialty care, we recommend that the Secretary of Veterans 

Affairs direct the Interim Under Secretary for Health to take the following 

six actions:

• Assess the extent to which specialty care providers across all VAMCs, 

including residents who may be serving on a temporary basis, are 

using the correct clinical progress notes to complete consults in a 

timely manner, and, as warranted, develop and implement systemwide solutions such as technical enhancements, to ensure this is 

done appropriately.

• Enhance oversight of VAMCs by routinely conducting independent 

assessments of how VAMCs are managing the consult process, 

including whether they are appropriately resolving consults. This 

oversight could be accomplished, for example, by VISN officials 

periodically conducting reviews of a random sample of consults as we 

did in the review we conducted.

• Require specialty care providers to clearly document in the electronic 

consult system their rationale for resolving a consult when care has 

not been provided.

• Identify and assess the various strategies that all VAMCs have 

implemented for managing future care consults; including determining 

the potential effects these strategies may have on the reliability of 

consult data; and identifying and implementing measures for 

managing future care consults that will ensure the consistency of 

consult data.

• Establish a system-wide process for identifying and sharing VAMCs’ 

best practices for managing consults that may have broader 

applicability throughout VHA, including future care consults.

• Develop a national policy for VAMCs to manage patient no-shows and 

cancelled appointments that will ensure standardized data needed for 

effective oversight of consults.

Recommendations for 

Executive Action
 

Page 24 GAO-14-808 VA Outpatient Specialty Care

We provided VA with a draft of this report for its review and comment. VA 

provided written comments, which are reprinted in appendix II. In its 

written comments, VA concurred with all six of the report’s 

recommendations. To implement five of the recommendations, VA 

indicated that the VHA Deputy Under Secretary for Health for Operations 

and Management will take a number of actions, such as chartering a 

workgroup to develop clear standard operating procedures for completing 

and managing consults. VA indicated that target completion dates for 

implementing these recommendations range from December 2014 

through December 2015. For the sixth recommendation, VA indicated 

that, by December 2014, VHA will establish a system-wide process that 

facilitates identifying and disseminating VAMC best practices for 

managing consults. VA also provided technical comments, which we have 

incorporated as appropriate.

As arranged with your office, unless you publicly disclose the contents 

earlier, we plan no further distribution of this report until 30 days after the 

date of this letter. At that time, we will send copies of this report to the 

Secretary of Veterans Affairs and interested congressional committees. In 

addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made key contributions to this report 

are listed in appendix III.

Sincerely yours,

Debra A. Draper

Director, Health Care

Agency Comments
Appendix I: Examples of Gastroenterology 

Consult Request Templates

Page 25 GAO-14-808 VA Outpatient Specialty Care

To send a consult request, providers log on to the consult system and 

complete an electronic consult request template developed by the VA 

medical center's specialty care clinic. As shown in figures 3 and 4 below, 

the information requested in these templates may vary depending on the 

patient’s symptoms. After completing the template, the requesting 

provider electronically submits the consult for the specialty care provider 

to review.

Figure 3: Example of a Gastroenterology Consult Request Template for Chronic 

Diarrhea

Appendix I: Examples of Gastroenterology 

Consult Request Templates
Appendix I: Examples of Gastroenterology 

Consult Request Templates

Page 26 GAO-14-808 VA Outpatient Specialty Care

Figure 4: Example of a Gastroenterology Consult Request Template for a Liver 

Condition
Appendix II: Comments from the Department 

of Veterans Affairs

Page 27 GAO-14-808 VA Outpatient Specialty Care

Appendix II: Comments from the Department 

of Veterans Affairs
Appendix II: Comments from the Department 

of Veterans Affairs

Page 28 GAO-14-808 VA Outpatient Specialty Care
Appendix II: Comments from the Department 

of Veterans Affairs

Page 29 GAO-14-808 VA Outpatient Specialty Care
Appendix II: Comments from the Department 

of Veterans Affairs

Page 30 GAO-14-808 VA Outpatient Specialty Care
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 31 GAO-14-808 VA Outpatient Specialty Care

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Janina Austin, Assistant Director; 

Jennie F. Apter; Jacquelyn Hamilton; David Lichtenfeld; Brienne Tierney; 

and Ann Tynan made key contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291154)
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