eConsult

Provision of Electronic Consultation Scheduling

Angela Waters is a 66 year old TRICARE Prime enrollee living with her husband in Pensacola Florida where she receives her routine care from the Naval Hospital in Pensacola. Over the past 4 months she has noticed increasing sensations of burning in the chest at night and abdominal pain.

Mrs. Waters calls the appointment line at the hospital and makes an appointment to see her primary care provider. Two days later she arrives in the family practice clinic at Pensacola Naval Hospital. During a thorough history and physical examination Doctor Know finds that Mrs. Waters has trace positively for blood in her stool. He reviews her medications and past EKGs in AHLTA. He notes that while her past EKGs have been normal she has recently received a prescription for ibuprofen for right hip degenerative joint disease. Dr. Know performs an EKG in the clinic (that is unchanged from prior EKGs), discontinues the ibuprofen, and orders a gastroenterology consultation.

The consultation is electronically available to Fred Sand the referral management officer for the hospital through the CHCS system. Fred looks at the appointment availability of the GI Clinic at the hospital but notes that the clinic is booked for the next four weeks. He prints the consult request and faxes it to the TRICARE Managed Care Support Contractor (MCSC) so Mrs. Waters can be seen in a timely manner in the purchase care network. Mrs. Waters is informed of the TRICARE phone number to call to make her GI appointment.

Mrs. Waters calls the MCSC and receives the authorization number and contact information for the GI specialist in downtown Pensacola. She calls the clinic and is seen the next day by Dr. Fisher. Dr. Fisher discovers a small non-bleeding antral ulcer of the stomach. He provides her several prescriptions and instructs her to return to her PCM in one week for follow-up.

Dr. Fisher dictates a brief procedure/consultative note and instructs his staff to deliver a final copy to the TRICARE MCSC by fax.

The MCSC receives Dr. Fisher’s fax which is stored electronically as a (PDF, TIFF, GIFF,…) image file. Added to the file are header information including the: DEERS ID, Order number, DMIS ID, ICD-9, CPT, Dr. Fisher’s NPI, and date of service.

Every night a file of that day’s consult results are transmitted by HTTPS to the MHS National Health Information Exchange gateway. The eConsults follow the X12 275 transmission format and the image file is wrapped in a CDA R2 document format.

eConsults are received by the NHIE gateway, checked for completeness, integrity of the fields, and if validated (with date/time stamp) are routed to the CDR. Files not passing validation are returned to the MCSC for reprocessing.

Based on header fields each individual X12 transmission uniquely identifies the beneficiary, ordering provider, and date of service. The clinical document image is stored in the CDR so that: 1) the image is viewable in the past encounters module, 2) a new result message appears in the new results module, and 3) (if possible) the ICD-9 code populates the problem list as ‘unverified’.

The day after Dr. Fisher faxes his procedure/consultative note to the MCSC, Dr. Know is reviewing his new results in AHLTA. He finds Mrs. Waters consultation is completed and double clicks to view the image document. He notes the ulcer diagnosis and switches to her medication list noting that she has started her new meds (purchased at CVS and sent to AHLTA via PDTS) and that she has an appointment with him next week.

Actors: Angela (Patient), Appointment Line Cal Taker, Dr. Know (Primary Care Provider), Fred (Referral Management Officer), Managed Care Support Contractor, Dr. Fisher (GI Specialist), NHIE gateway

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