VA Health Care: Management and Oversight of Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty Care
Released: 2014-10-30T00:00:00

Letter

Background

VHA’s outpatient consult process is governed by a national policyoutlines the use of an electronic system for requesting and managing consults and delineates oversight responsibilities at the national, VISN, and VAMC level.

Outpatient Consult Process

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.

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. 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.

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. 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.

If the provider accepts the consult, an attempt is made to contact the patient and schedule an appointment. Appointments resulting from outpatient consults, like other outpatient medical appointments, are subject to VHA’s scheduling policy. 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.

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.

VHA National Consult Policy and Initiative to Improve Consult Data

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 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 consults—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.

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:

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.

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.

VHA’s Consult Process Has Not Ensured Veterans Always Receive Outpatient Specialty Care in a Timely Manner, or at All

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)—and those for which the requested specialty care was provided, but the consults were not properly closed in the consult system.

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.

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.)

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 due to resource constraints, the clinic was not accepting consults for For 1 of these non-service-connected physical therapy evaluations.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.

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.

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 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.

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.

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.

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.

VHA’s Limited Oversight of Consults Impedes Its Ability to Ensure VAMCs Provide Timely Access to 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.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.

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 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 non- administrative 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 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.

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. 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.

VHA 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.

VAMCs 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. 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.

According to federal internal control standards, managers should perform ongoing monitoring, including independent assessments of performance. However, because VHA officials relied on self- certifications 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.

Furthermore, VHA does not have a formal process by which VAMCs could share best practices system-wide. control standards, identifying and sharing information is an essential part of ensuring effective and efficient use of resources. 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.

Officials from VAMCs in our review described sharing best practices with colleagues at other VAMCs in their VISN on an ad hoc basis. 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.

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 VHA officials told us that they allow each VAMC to appointment. 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.

See VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures (June 9, 2010) and VHA Directive 2008-056, VHA Consult Policy (Sept. 16, 2008). varied in its requirements.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).

Conclusions

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.

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.

Recommendations for Executive Action

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 system- wide 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.

Agency Comments

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.

Appendix I: Examples of Gastroenterology Consult Request Templates

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.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.