April 28, 2014
PCP’S E-CONSULT REQUEST
My clinical question: This 36 year-old woman asked for work up for celiac disease. She had history of chronic diarrhea years ago. She switched to gluten free diet a year ago and her symptom significantly improved. She suspects that she has celiac disease and she would like lab tests to confirm the diagnosis. She has no abdominal pain, nausea, vomiting, diarrhea or constipation now. Tissue Transglutaminase IgA was NEG - see APEX HLA Typing. She is requesting for repeat testing. Is this necessary? What other tests should be ordered?
SPECIALIST'S E-CONSULT RESPONSE (Dr. Fernando Velayos)
As you know, many people feel better when cutting out gluten, so as I am sure you have told her, this is not diagnostic.
She does have one of the HLA types seen with Celiac. I recommend a gluten challenge with retesting tissue transglutaminase along with an IgA level (as a gluten-free diet can cause ttg to be negative, and 10% of people with celiac are IgA deficient).
I would still do the above but if she is insistent, she needs an EGD while on gluten with biopsies of the duodenum to exclude celiac based on histology. Let me know and I can schedule her for an EGD with me or can see her in the office to discuss and work up any symptoms she may have.
PCP’S E-CONSULT REQUEST
I am requesting an eConsult from Endocrinology for my 65 y.o. year-old female patient with thyroid nodule or goiter. The following results are available in Apex: TSH, free T4
Free T4 15 2/4/2014
Thyroid Stimulating Hormone 2.25 2/4/2014
My clinical question: pt has had thyroid nodule for many years. She had FNA in 2002 which was benign. At that time the nodule was described as being 1.5 cm. The ultrasound that was done most recently shows size of 2.2 cm. Should she have another FNA? Should she have any more ultrasounds?
SPECIALIST'S E-CONSULT RESPONSE (Dr. Robert Rushakoff)
Patient with autoimmune thyroid disease and history of thyroid nodule. FNA in 2002 was benign, but now nodule is possibly about 50% enlarged since then. The question is what if anything needs to be done. In general, thyroid nodules initially with benign findings on FNA, do require some f/u as there is a low, but not negligible, false-negative rate (generally 3-5%). This rate is higher with larger nodules (>4cm). These nodules do often increase in size, though generally very slowly. To make this more difficult, the rate of thyroid nodule growth does not appear to distinguish between benign and malignant nodules.
Nevertheless, while growth is not in and of itself an indication of malignancy, this growth is an generally felt to be an indication for repeat biopsy. Many agree that about a 50% increase in volume size would be a cutoff for repeat FNA.
Thyroid Association Recommendations are:
It is recommended that all benign thyroid nodules be followed with serial US examinations 6–18 months after the initial FNA. If nodule size is stable (i.e., nomore than a 50% change in volume or <20% increase in at least two nodule dimensions in solid nodules or in the solid portion of mixed cystic–solid nodules), theinterval before the next follow-up clinical examination or US may be longer, e.g., every 3–5 years
If there is evidence for nodule growth either by palpation or sonographically (more than a 50% change in volume or a 20% increase in at least two nodule dimensions with a minimal increase of 2 mm in solid nodules or in the solid portion of mixed cystic–solid nodules), the FNA should be repeated, preferably with US guidance.
So the bottom line for this patient is that repeat FNA should be done at this point.
New Specialties Go Live on eConsult
This month, the eReferral/eConsult program has expanded to Pain Management and Symptom Management!
As always, the launch of eConsult services by a specialty practice is coupled with the use of the eReferral Smartphrase templates. Please use .REFPAIN… and .REFSYM… for standard referrals to these services.
These help structure the referral data, help the practices triage, and ensure that the patient has what they need in advance of the visit. With the magnifier button on the comment box, the larger workspace makes referral smartphrase use more efficient.
Our Progress- Metrics
% of eConsult Responses Completed Within 3 Business Days
External eConsults Pilot
We have begun to pilot eConsults from PCPs outside UCSF. The system uses the MD-Link web-based portal, which allows community PCPs to place orders, referrals, and eConsults that flow directly into Apex.
eConsultants: You do not need to change your workflow. In the inbasket message, the Department field shows the referring provider’s home clinic. The present pilot includes only Mercy Doctors Medical Group.
Outside PCPs will attach supporting data in one of two ways:
- A link will appear at the end of the eConsult message text
- If no link is present, uploaded data will appear under the Scanned Documents tab in Chart Review.
Closing the Loop
PCPs: After receiving an eConsult response, please make sure to acknowledge the sender. Closing the loop on the message is a great way to inform the eConsultant that the consultations was successfully received.Simply click “Reply" and acknowledge the receipt.
To ask a follow-up question, simply addend the encounter and route to the specialist.
Additionally, remember that eConsult is for patients who are not established in the specialty practice. For established patients, use the Care Coordination encounter so that your exchange with the specialist is preserved in the chart.
eConsultants: Please close the eConsult encounter upon completion (after entering the PCP name and eConsult accounting pool in the Routing section). This is an important change. After responding to an eConsult, press the "Done" button in the specialty pool. This will remove the message out of the pool.
Evangelize the Program!
eConsultants: The new reimbursement rate may allow eConsultants to enlist colleagues in the eConsult work. If you experience high demand, consider asking colleagues if they would like to field specific types of questions.
Additionally, if you have recruited a new eConsultant to your team, please let us know, so that we may orient them to the program.
If you have any questions/comments about this newsletter or the eReferral/eConsult program, please contact:
Delthia Mckinney, MPHH
Nat Gleason, MD
Ralph Gonzales, MD, MSPH