In the U.S., the prevalence of diabetes continues to escalate at alarming rates. From 1980-2010 the incidence of diabetes increased by 200% for people aged < 45 years, 124% for people 45 to 64 years, and 126% for people 65 to 74 years. Furthermore, based on the National Institute of Health, diabetes currently affects 25.8 million people in the U.S.1,2 Glycemic control has been demonstrated to reduce the risk of microvascular disease in patients with diabetes.3 Most patients with diabetes are managed by primary care practitioners (PCPs), and as the number of patients with diabetes continues to increase, there is an increasing demand on PCPs to achieve recommended glycemic targets.4
The Veterans Health Administration (VHA) VISN 16 has a notably higher prevalence of diabetes compared with that of the national rate. Failure to achieve glycemic targets continues to impose an escalating economic burden.3 Endocrine assistance is often sought by PCPs, but due to a scarcity of endocrinologists, patients commonly wait weeks or months before being seen. Furthermore, rural patients often must travel for several hours before they can reach a specialty center.
The Office of Specialty Care Transformation has provided a unique opportunity for PCPs to gain greater access to specialty advice via electronic consultations. This initiative allows PCPs and specialists to communicate promptly, to institute definitive solutions for patient care, and to augment the clinical and academic aims of primary and specialty care providers. The Michael E. DeBakey VAMC (MEDVAMC) in Houston, Texas, was chosen to initiate a VISN 16-wide diabetes management e-consult service (DMECS).
Endocrinologists at MEDVAMC developed DMECS to serve as a multifunctional tool to reach as many veterans as possible throughout VISN 16, broaden the scope of the existing diabetes endocrine practice, and engender a collaborative spirit between PCPs and specialty care providers. Initiation of this service has been particularly useful for patients with physical disabilities or financial constraints whose care is managed at the community-based outpatient clinics (CBOCs). The purpose of this article is to discuss the concept and initiation of the DMECS, the structure of the consult note, the implementation process, early provider feedback on the project, and future plans.
The DMECS Process
The DMECS allows endocrinologists to provide advice to PCPs to help improve diabetes care while minimizing travel to specialty centers. The advice generated by the DMECS is electronically conveyed to the referring physician (usually the PCP), not to the patient. The requesting physician is then responsible for implementing the recommendations. The DMECS does not comanage patients with diabetes but rather provides support to the PCP in complex cases that would otherwise require an outside referral.
The diabetes management e-consult team has 1 administrator and 3 health care providers (HCPs). Promotion of the service consisted of electronic distribution of flyers to all primary care teams, posters in the main lobby of the hospital, and electronic distribution of a letter to all VISN 16 HCPs. The DMECS team contacted the chiefs of primary care and CBOC directors to promote the service. Communication was augmented by scheduling videoconferencing with all interested facilities. Presentations were given to the VISN-wide transformational care collaborative and women’s health groups.
Any specialties that assist in diabetes management, including ophthalmology and vascular medicine, were encouraged to refer consults to DMECS if clinically indicated. The recommendation is that PCPs submit an e-consult for any patient with a hemoglobin A1C (A1C) > 9%. The only prerequisite to placing the e-consult order is an A1C > 7.5% within the preceding 3 months. Any patient with reported or objective evidence of hypoglycemia is eligible for an e-consult, regardless of the A1C value. Women who are pregnant and patients on an insulin pump are excluded from the program.
All diabetes e-consults are supervised by a board-certified endocrinologist and are resolved within 2 to 3 business days. On receipt of the consult request, the DMECS provider reviews the chart, including active medication lists, blood glucose levels documented in progress notes, care and coordination of home telehealth data regarding blood glucose levels and changes in diabetes medication management, laboratory results and pharmacy refill patterns.
Recommendations are completed and the DMECS provider alerts the requesting physician by adding them as a cosigner to the note in the Computerized Patient Record System (CPRS). When possible, the patient’s nurse manager is also added to the note. For interfacility consults, the DMECS provider contacts the requesting provider directly via email or telephone. Consistent communication with the requesting physician ensures clarity of understanding between specialist and PCP.
The e-consult recommendations are consolidated into 3 distinct sections. The Impression section provides an explanation to the provider about the specialist’s impression of current diabetes control and the reasoning behind the recommendations. The Recommendation section lists in medical terminology the recommended changes to diabetes medications. A unique component to the e-consult is the Instructions to Patient section, which summarizes both oral and insulin medications that can be provided to the patient. Every note includes a Diabetes Surveillance section and several web links to diabetes education that can be downloaded through the MyHealtheVet website.