S02 - Attachment 21 - VA Outpatient Radiology Scheduling Policy and Guidance.pdf

DEPARTMENT OF

VETERANS AFFAIRS

Memorandum

Date:

rAUG 1 2 2016

From: Assistant Deputy Under Secretary for Health for Clinical Operations (1 ONC) subject: Veterans Health Administration (VHA) Outpatient Radiology Scheduling Policy and Interim Guidance (UPDATED) (VAIQ 7722255)

To: Network Directors (10N1-23)

1. The purpose of this memorandum is to notify networks that VHA's Outpatient Radiology Scheduling Policy and Procedures Interim Guidance was updated to reflect some of the changes contained in VHA Directive 1230, Outpatient Scheduling Process and Procedures are directed towards Primary Care and Specialty Care Clinics. Radiology and nuclear medicine studies are requested using "orders" and not "consults"; therefore, specific guidance for radiology orders is necessary. Please reference UPDATED Outpatient Scheduling Procedures for Radiology and Nuclear Medicine (Attachment A).

2 . In summary, the attached guidance was updated in the following areas:

a. Future orders can be placed as much as 390 days in advance.

b. Clarified the first attempt to contact the patient should be made within seven calendar days of the Date/Time the order is entered.

c. Scheduling process: Radiology will make two documented attempts to contact the patient. One of the attempts must be a letter or through MyHealtheVet.

d. No Shows that cannot be explained by inclement weather or other circumstances should be canceled with the reason "NO SHOW." Facilities to work with their Clinical Applications Coordinator to ensure provider Computerized Patient Record System Notifications for Imaging Request Cancel/Held are turned on.

3. For additi nal in rmation, please contact Dr. Robert Sherrier, Chief Consultant fo Diag ostic Services, by e-mail at Robert.Sherrier@va.gov .

VA FORM

MAR 1989 2105

.D.

Attachment 21

Attachment A

UPDATED Outpatient Scheduling Standard Operating Procedures for Radiology and Nuclear Medicine

1. PURPOSE: This Procedure provides guidance for scheduling Radiology and Nuclear Medicine exams, including those performed by the Choice program.

2. BACKGROUND: VHA Directive 1230, "Outpatient Scheduling Processes and Procedures" defines the process for scheduling outpatient clinic appointments that are requested by consult, but does not discuss Radiology exams requested by an order.

The process for scheduling Rad iology orders is similar to consults, but differs in several important ways.

3. RESPONSIBILITIES:

a. VA Medical Facility Center Director: Responsible for ensuring this guidance is distributed to appropriate staff and the scheduling process for Radiology/ Nuclear Medicine exams adhered to and provides resources to adequately perform scheduling tasks to meet the needs of Veterans.

b. Chief of Staff: Responsible for ensuring providers enter the correct Clinically Indicated Date (CID) for exams and discontinue orders when the study is no longer clinically indicated.

c. Radiology/Nuclear Medicine Service Chief: Responsible for developing local policies which:

(1) Identify radiology exams and procedures that require scheduling, as opposed to being performed as walk-in exams;

(2) Identify which radiology and nuclear medicine exams that require a radiologist approval and protocoling;

(3) Identify the approval process for order and delivery of contrast material ;

(4) Specify a set of standard protocols that are available to the technologists in paper and electronic format; and

(5) Define the responsibilities for daily monitoring of the incomplete, pending, hold lists, and retrospective review of the log of scheduled requests, and ensures resolution for these management reports is affected.

A- I and Nuclear Medicine

4. GUIDELINES AND PROCEDURES:

a. Imaging Orders

(1) The Radiology Package of Veterans Health Information Systems and Technology Architecture (VistA) requires entry of an order to track requisitions to completed reports, and to create an index location for the report in the Computerized Patient Record System (CPRS).

(2) When entering an order, the provider should discuss with the Veteran the necessity and benefit/risks of the exam. The ordering provider should discontinue the radiology order, if the imaging study is no longer needed.

(3) The "Clinically Indicated Date" (CID), formerly referred by radiology staff as "Date Desired", is the ordering provider's, and not the Veteran's preferred date. The CID is used to calculate outpatient procedure wait times for radiology exams. If the CID is entered incorrectly, the scheduler should ask the provider to correct it. The CID cannot be changed by the Scheduling Clerk to match the Veteran 's preferred date. The order cannot be canceled and re-entered by the Radiology Service to improve the wait time metric. Orders can be placed as much as one year in advance of the CID. From order entry date, the CID may not exceed 390 days into the future.

(4) The CID is entered by the ordering provider based on the Veteran's healthcare needs which determines the "Urgency" of the exam.

a. STAT is defined as an "immediate" exam and should be completed in 24 hours unless otherwise indicated. The sender of a STAT order is required to:

.1. Contact the Radiology Service to notify them that a STAT order has placed.

£.Enter 'Today" as the CID

3. Enter "STAT" in the urgency field of the order.

b. ASAP is defined as completing the study within 14 days of the CID. For exams ordered as ASAP, which corresponds to the Urgent status in CPRS, the ordering provider is to communicate with the Radiology Service at the time order entry or at patient check out from the ordering provider's clinic. This is

A- 2 and Nuclear Medicine done to ensure an appointment is scheduled in a timely manner to meet patient care needs.

c. Routine exams should be completed within 30 days of the clinicians CID.

b. Scheduling

(1) For radiology exams that must be scheduled, the appointment is entered in the Scheduling Software, and the order is scheduled with the same date into the Radiology package. The appointment date must be manually entered in the Radiology package because the two software systems do not exchange information. The radiology scheduled date entry changes the order status in CPRS from Pending to Scheduled.

(2) Ideally, the Veteran leaves the referring clinicians office with an appointment for their Radiology exam. This can be accomplished by having the ordering clinician's staff work with the Radiology Schedulers to facilitate making the appointment at the time of check out from the clinic.

(3) If the Veteran does not schedule their radiology exam at the time of the clinic visit, then the first attempt to contact the Veteran should be made within seven (7) calendar days of Daterrime ordered. Proposed or blind scheduling is not allowed .

(4) There must be two (2) documented attempts to contact the Veteran; one of the contacts must be through MyHealthe Vet or a letter to the Veteran .

a. Phone call. If no answer, leave message with instructions to call back and initiate a contact through MyHealthe Vet or send a letter to the Veteran.

b. MyHealthe Vet. Contacting the Veteran using MyHealthe Vet (MHV) is a process where e-mails are sent through the MHV portal which is included in the patients Electronic Medical Record (EMR) Veteran . The message to the Veteran must include contact information telling the Veteran to call or respond through MHV to the Radiology Scheduler within 14 days of the communication.

c. Letter. Contacting the Veteran by mail is a process where it invites the Veteran to call the Radiology Scheduler (proposed or blind scheduling is not allowed). The letter must include contact information so the Veteran can call directly to the Radiology Scheduler, and state Radiology has attempted to contact them, and request them to call Radiology within 14 days.

A - 3 and Nuclear Medicine

(5) If the Veteran cannot be contacted by phone and does not have a mailing address, the order should be canceled using a cancellation reason , "Incorrect Patient Contact Information."

(6) Documentation must be included in the respective Veterans EMR with at least two attempts as outlined above. This can be accomplished by use of progress notes, progress notes with addendums, scanned in paper noted from the printed Radiology order, and/or by the use of the MyHealthe Vet process.

(7) After two attempts and 14 calendar days (from the date of the letter or MHV communication) without a Veteran's response schedule his/her exam, the exam should be canceled. Cancel the exam using a cancellation reason, "Unable to Contact the Veteran. " Cancelling the order alerts the Ordering Provider that Radiology was unable to schedule the exam. Alerting the Ordering Provider is essential so that he/she may adjust the Veteran 's care plan, as necessary.

(8) Providers may enter future orders for follow-up to include semi-annual, annual, or another clinical reason for which the CID is greater than 90 days from the order entry date. These future orders can be handled one of two ways depending on the Veteran's preference and to ensure the Veteran's exam is completed within 30 days of the CID:

a. Scheduled in the clinic or within 7 days of the order entry date using the 2 documented contacts (outlined in (4) above). However, if the patient cannot be contacted to schedule the exam, another 2 contacts should be made at least 45 days before the CID. Exam may then be cancelled as in (7) above.

b. Order may be kept in Pending status until approximately 45 days before the CID at which time two documented attempts (listed in (4), above) are made to contact the patient. Exam may then be cancelled as in (7) above.

(9) For Unscheduled ("walk-ins"), typically x-rays, if the Veteran does not complete the exam within 60 days of the CID, these exams should be cancelled . Cancel the exam using a cancellation reason, "No Show." Cancelling the order alerts the Ordering Provider that the patient did not show up for the exam. Alerting the Ordering Provider is essential so that he/she may adjust the Veteran's care plan, as necessary

A- 4 and Nuclear Medicine

(1 0) If a Veteran calls to reschedule a study and the requested new date delays the study by several weeks, the Veteran should be cautioned that delaying the study might also delay diagnosis and treatment. If the Veteran still requests to reschedule the appointment, the clerk should make a new appointment and notify a designated radiology point of contact. It is not advisable to automatically cancel the order and ask the provider to re-evaluate every Veteran who asks for a later appointment, because this delays the diagnosis further.

(11) The Electronic Wait List (EWL) is not utilized for Radiology services because Radiology patients are established and not new patients.

(12) Use of the Recall Reminder Software (RRS) does not change the status of the radiology order.

c. Disposition of orders for studies that are not performed

(1) Exams that are not performed must be dealt with when identified ; for example, duplicate orders, patient refusals, or change in care plan. Exams should be "cancelled" in the Radiology VistA Package which sends an alert to the ordering provider.

(2) No Shows which cannot be explained by inclement weather or other circumstance should be "cancelled" with "NO SHOW" to alert the Ordering Provider.

Schedulers must enter Veteran No Shows into VistA Scheduling and Radiology packages prior to the end of each workday.

(3) Cancelling the order in the Radiology Package changes the status to "Discontinued" in CPRS. Orders are never deleted or purged but remain visible in CPRS. By alerting the provider, he or she can make provisions to the Veteran 's care plan. The Clinical Applications Coordinator should ensure receipt of imaging cancellation alerts by ordering providers is mandatory.

5. CHOICE Program Veterans may be eligible for the Choice program for various reasons; the service is not offered at the facility; the Veteran cannot be seen with in VHA Wait Time Goals (greater than 30 days of the CID, unusual and/or excessive burden); or the Veteran resides more than 40 miles from a VA facility and must meet basic Choice eligibility criteria. Please coordinate exams for Veterans that fall into these categories through the business office at your respective facility.

A-5 and Nuclear Medicine

6. FOLLOW-UP RESPONSIBILITY: The Radiology Program of the Office of Patient Care Services is responsible for any updates and changes to this guidance.

A-6