Name of the Procedure:

Interprofessional Telephone/Internet/Electronic Health Record Assessment and Management Service

Summary

This procedure involves a consultative physician reviewing a patient's case using telephone, internet, or electronic health records (EHR), and then providing a verbal and written report to the patient's primary physician or another healthcare provider. This collaborative process ensures comprehensive patient care.

Purpose

The procedure addresses complex medical conditions that require input from multiple healthcare professionals. The goal is to provide a thorough assessment and management plan to improve patient outcomes.

Indications

• Complex medical cases requiring specialized input
• Coordination of care for patients with multiple health conditions
• Situations requiring timely expert consultation to adjust treatment plans
• Need for a second opinion on diagnosis or management

Preparation

• Ensure all relevant medical records and test results are accessible in the EHR
• The primary physician may need to brief the consultative physician on the patient's current status and specific concerns.
• Patients do not require specific preparation, but be sure all necessary documents and prior treatments are up-to-date in the EHR.

Procedure Description

1. Initiation: The treating/requesting physician contacts the consultative physician via telephone, internet, or through the EHR system.
2. Case Review: The consultative physician reviews the patient's medical records, test results, and any previous treatments.
3. Discussion: A verbal discussion may take place between the doctors to clarify details.
4. Assessment: The consultative physician assesses the patient’s condition based on the information provided.
5. Report: A detailed written report is generated, including recommendations and management strategies.
6. Follow-Up: The consultative physician may follow up if further clarification is needed.

Tools and Equipment:

• Telephone or internet communication tools
• Electronic Health Record (EHR) system

Anesthesia or sedation: Not applicable

Duration

The procedure typically takes 30 minutes to 1 hour, depending on the complexity of the case.

Setting

This is performed remotely, utilizing telehealth platforms or EHR systems.

Personnel

• Consultative Physician (specialist)
• Treating/Requesting Physician
• Administrative staff may assist in coordinating communication

Risks and Complications

• Miscommunication or misunderstanding between providers
• Incomplete or inaccurate patient data in the EHR
• Delays in reporting

Benefits

• Access to expert opinion without the need for patient travel
• Timely updates to the treatment plan based on the latest expert assessment
• Enhanced coordination of care among multiple healthcare providers

Recovery

• No physical recovery needed for the patient
• Implementation of the recommendations may require follow-up appointments and adjustments to the treatment plan

Alternatives

• In-person specialist consultation
  • Pros: Direct examination and interaction with the specialist
  • Cons: Requires patient travel, potentially longer wait times
• Referral to another primary physician
  • Pros: Localized care
  • Cons: May lack specialized expertise

Patient Experience

• Patients should experience minimal disruption, as they do not actively participate in the consultation.
• Improved care coordination and treatment plans should lead to better health outcomes.
• Clear communication between healthcare providers ensures that the patient's primary physician remains updated and involved in care decisions, enhancing patient confidence in their treatment plan.