We conducted a pre-post study of E-consult implementation for positive ANA referrals. Our outcomes included wait times, diagnostic tests ordered, and patients’ final diagnoses.
The Michael E. DeBakey VA Medical Center is a tertiary health care center consisting of inpatient and outpatient medical services caring for 113,000 Veterans in Southeast Texas. An EHR is used by all providers throughout this system and any provider within the system can order a referral for specialty care. The referring provider places an order for a referral to rheumatology in the EHR; reason for consult is entered into a free text box within the referral order. Starting in August 2015, the referring provider had the option of selecting either “E-consult” or “in-person visit” when placing a referral to rheumatology.
The referral review process was completed by one faculty rheumatologist who reviewed all referral requests and determined if the type of referral selected by the referring clinician (in-person visit or E-consult) was appropriate. The reviewer had the option to switch the type of consult if needed. For E-consults, the reviewer electronically replied through the EHR to the referring clinician with recommendations after reviewing the patient’s electronic chart. Rheumatology staff scheduled clinic appointments for in-person referrals.
We retrospectively reviewed positive ANA referrals to outpatient rheumatology from January 1, 2015, to March 31, 2017. We defined a positive ANA as a result with a titer greater than or equal to 1:40 (our lab reference range) by indirect immunofluorescence. Through chart review, we collected demographic data, referral information, wait times, labs, and imaging ordered during the first rheumatology evaluation and final diagnoses. Chart review was done using a standard data abstraction form with standard definitions of every type of extracted data and standard locations for identifying this data from the EHR.
We defined wait time for an in-person visit as the time from referral placement to the rheumatology clinic appointment. E-consult wait time was defined as the time from referral placement to the rheumatologist’s initial electronic response. We calculated the average monthly wait time for a positive ANA in-person visit and graphed the results using an XmR statistical process control chart to assess for special cause variation [18]. An unpaired T-test was used to compare wait times and resource utilization between visit types in total, and for each final diagnosis category.
Resource utilization was defined as rheumatologic labs and imaging ordered during the first rheumatology evaluation. The following labs were included in data collection: rheumatoid factor, anti-cyclic citrullinated peptide (anti-CCP), anti-Ro (SS-A), anti-La (SS-B), anti-Smith, anti-nRNP, anti-double stranded DNA (dsDNA), complement C3 and C4, Scl-70, sedimentation rate, C-reactive protein, antiphospholipid antibody panel, antineutrophilic cytoplasmic antibodies, cryoglobulins, aldolase, HLA-B27, uric acid, and anti-Jo1. Imaging studies recorded included joint X-Rays, body or joint computed tomography (CT) scans, and joint magnetic resonance imaging (MRI) scans. Resource utilization was calculated as the mean per person and for each final diagnosis category.
At the time of review, patients’ final diagnoses were recorded from the assessment and plan section of the rheumatologist’s most recent clinic note in the EHR. Diagnoses were organized into the following categories: ANA-associated rheumatic disease (AARD), other rheumatic disease (ORD), no rheumatic disease, or no diagnosis at the time of review. AARD included the following diagnoses: systemic lupus erythematosus (SLE), Sjogren’s syndrome, scleroderma, mixed connective tissue disease (MCTD), polymyositis (PM), dermatomyositis (DM), undifferentiated connective tissue disease (UCTD), and drug-induced lupus [15]. ORD included diseases that would require routine rheumatology follow-up, but in which an ANA is not used for the diagnosis.
This study was reviewed by the Institutional Review Board (IRB) and the local Veterans Affairs Research and Development Committee and designated as a quality improvement project which did not require formal IRB approval.