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Implementation of a Hematology VA-ECHO Program
Purpose/Rationale: Lack of access to a hematology specialist is a barrier to care for veterans in rural and underserved areas. In light of the increasingly short supply of sub-specialists, there is a need to provide hematology education and outreach to primary care providers within the VA system.
Background: The ECHO program (Extension for Community Healthcare Outcomes) is a well-established and successful platform that audibly and visually links an area specialist to primary care providers and interdisciplinary team members, allowing for two-way specialty consultation combined with continuing education. Overall, our service network (VISN 20) has provided specialty education to more than 10 specialties and 171 clinical sites (26% rural or highly rural) through the VA-ECHO program. In fiscal year 2016, VISN 20 estimated that over 280,000 potential patient travel miles saved as a result of VA-ECHO.
Methods/Approach: As we could not identify an existing Hematology VA-ECHO program within VISN 20, nor to our knowledge nationally, we sought to develop and implement a Hematology VA-ECHO program based at the Puget Sound VA (Seattle, WA).
Results: We delivered an introductory 3-part VA-ECHO series to assess demand and solicit feedback about Hematology VA-ECHO. Session topics were iron deficiency anemia, polycythemia, and deep vein thrombosis/pulmonary embolism. We had participation from 17 sites in 9 states; 10 sites within VISN 20. Attendees included pharmacists, MDs, APRNs and RNs. We averaged 20 participants per session and welcomed 43 unique participants over 3 sessions. The vast majority (94%) of respondents (n=34) agreed or strongly agreed that the content in the sessions were relevant to their practice and 80% anticipated changing their practice as a result of session participation
Conclusion/Implications: A successful Hematology VA-ECHO program stands to de-monopolize specialty knowledge and help primary providers evaluate and manage common hematologic abnormalities, especially in underserved areas. We aim to expand Hematology VA-ECHO to include 8-9 sessions over the next calendar year. Uptake of Hematology VA-ECHO at additional VA sites in different geographical areas would help further increase hematology access for primary providers.
Purpose/Rationale: Lack of access to a hematology specialist is a barrier to care for veterans in rural and underserved areas. In light of the increasingly short supply of sub-specialists, there is a need to provide hematology education and outreach to primary care providers within the VA system.
Background: The ECHO program (Extension for Community Healthcare Outcomes) is a well-established and successful platform that audibly and visually links an area specialist to primary care providers and interdisciplinary team members, allowing for two-way specialty consultation combined with continuing education. Overall, our service network (VISN 20) has provided specialty education to more than 10 specialties and 171 clinical sites (26% rural or highly rural) through the VA-ECHO program. In fiscal year 2016, VISN 20 estimated that over 280,000 potential patient travel miles saved as a result of VA-ECHO.
Methods/Approach: As we could not identify an existing Hematology VA-ECHO program within VISN 20, nor to our knowledge nationally, we sought to develop and implement a Hematology VA-ECHO program based at the Puget Sound VA (Seattle, WA).
Results: We delivered an introductory 3-part VA-ECHO series to assess demand and solicit feedback about Hematology VA-ECHO. Session topics were iron deficiency anemia, polycythemia, and deep vein thrombosis/pulmonary embolism. We had participation from 17 sites in 9 states; 10 sites within VISN 20. Attendees included pharmacists, MDs, APRNs and RNs. We averaged 20 participants per session and welcomed 43 unique participants over 3 sessions. The vast majority (94%) of respondents (n=34) agreed or strongly agreed that the content in the sessions were relevant to their practice and 80% anticipated changing their practice as a result of session participation
Conclusion/Implications: A successful Hematology VA-ECHO program stands to de-monopolize specialty knowledge and help primary providers evaluate and manage common hematologic abnormalities, especially in underserved areas. We aim to expand Hematology VA-ECHO to include 8-9 sessions over the next calendar year. Uptake of Hematology VA-ECHO at additional VA sites in different geographical areas would help further increase hematology access for primary providers.
Purpose/Rationale: Lack of access to a hematology specialist is a barrier to care for veterans in rural and underserved areas. In light of the increasingly short supply of sub-specialists, there is a need to provide hematology education and outreach to primary care providers within the VA system.
Background: The ECHO program (Extension for Community Healthcare Outcomes) is a well-established and successful platform that audibly and visually links an area specialist to primary care providers and interdisciplinary team members, allowing for two-way specialty consultation combined with continuing education. Overall, our service network (VISN 20) has provided specialty education to more than 10 specialties and 171 clinical sites (26% rural or highly rural) through the VA-ECHO program. In fiscal year 2016, VISN 20 estimated that over 280,000 potential patient travel miles saved as a result of VA-ECHO.
Methods/Approach: As we could not identify an existing Hematology VA-ECHO program within VISN 20, nor to our knowledge nationally, we sought to develop and implement a Hematology VA-ECHO program based at the Puget Sound VA (Seattle, WA).
Results: We delivered an introductory 3-part VA-ECHO series to assess demand and solicit feedback about Hematology VA-ECHO. Session topics were iron deficiency anemia, polycythemia, and deep vein thrombosis/pulmonary embolism. We had participation from 17 sites in 9 states; 10 sites within VISN 20. Attendees included pharmacists, MDs, APRNs and RNs. We averaged 20 participants per session and welcomed 43 unique participants over 3 sessions. The vast majority (94%) of respondents (n=34) agreed or strongly agreed that the content in the sessions were relevant to their practice and 80% anticipated changing their practice as a result of session participation
Conclusion/Implications: A successful Hematology VA-ECHO program stands to de-monopolize specialty knowledge and help primary providers evaluate and manage common hematologic abnormalities, especially in underserved areas. We aim to expand Hematology VA-ECHO to include 8-9 sessions over the next calendar year. Uptake of Hematology VA-ECHO at additional VA sites in different geographical areas would help further increase hematology access for primary providers.
Managing MGUS Consultations Electronically—A Single Center Experience
Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.
We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.
22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).
Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.
Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.
We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.
22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).
Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.
Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.
We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.
22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).
Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.