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 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. 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. 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.