VAMC Hematology-Oncology Continuity Clinic
Welcome to the Durham Veterans Affairs Hospital Hematology-Oncology Clinic. This document describes the educational aspects of the Durham VA Outpatient Clinic for Hematology-Oncology fellows. Please see the document entitled “Policies, Procedures and Practices for Hematology and Oncology Providers” that contains essential information needed to successfully practice in the Hematology/Oncology service at the Durham VA Medical Center.
If you have any questions, feel free to ask:
-Your attending in clinic
-To Be Determined, Clinic Manager
-Michael Kelley, MD (Chief, VA Hem/Onc)
-Radhika “Sandy” Shah, MD, Clinic Director
-Hem/Onc NP/PAs
- Jill Duffy, PA-C –Hem/Onc
- Becky Yost PA-C - Hem/Onc
- Kristen Williamson, ANP - Hem/Onc
-Shirley Parker or another Hem/Onc clerk
-Any of the treatment room nurses
-Vicky Cates (for lab, marrow, and miscellaneous issues)
Goals and Objectives:
Patient Care
1. Learn to manage outpatients with a broad spectrum of hematologic and oncologic
diagnoses.
2. Take primary responsibility for managing a panel of patients with cancer and blood
diseases.
3. Learn to administer chemotherapy competently with at least 50 patient encounters.
Fellows achieving this goal will be allowed to write chemotherapy orders without
co-signature during their second and third years of training.
Medical Knowledge
1. Become competent in outpatient management of common solid tumors including head and
neck, lung and GI malignancies.
2. Become competent in outpatient management of chronic leukemias and lymphoma.
3. Become competent in the diagnosis and treatment of anemia, coagulopathies and other
benign hematologic conditions.
Practice Based Learning and Improvement
1. Identify and evaluate evidence from clinical and scientific studies relevant to patients seen
in the clinic.
2. Present case discussions and literature reviews at the weekly conferences.
Interpersonal and Communication skills
- Communicate effectively with patients and ancillary clinic staff.
Professionalism
1. Demonstrate respect, compassion and integrity.
2. Answer pages and patient calls in a timely manner.
3. Demonstrate a commitment to excellence and ongoing professional development.
System Based Practices
1. Practice cost-effective utilization of laboratory and imaging studies, blood products and
chemotherapy.
2. Follow VAMC policies and procedures as outlined below.
3. Participate in a quality improvement activity, such as ASCO’s QOPI.
Clinic Schedules (first year fellows):
Tuesday
8:15 am-Noon
Thursday
8:15 am – Noon
.
Duties and Responsibilities:
• Clinic is structured with patient appointments from 8:15 to 12:00 on Tuesday and Thursday. New patient slots are for one hour and follow-up slots are for 30 minutes. Full day clinics have patient appointments scheduled until 3:30 pm, 1 new patient at either 9:15 or 10:00 and one at 1:00 pm.
• Approximately 40 patients will be assigned to each new fellow in July 2012. These patients will be seen as follow-up patients. Use the "Interval Note" in CPRS for follow-up patients. Clinic notes must be completed within 24 hours of the visit. Send the note to the attending with whom you discussed the patient for co-signature.
• New patients seen in the clinic should have a consult request and thus you should use the "Consult Note" in CPRS. If there is no consult – enter it yourself or ask the referring provider to complete it.
• Patients coming to clinic should check in at the designated check-in location. They should have any blood tests and radiographs ordered for that day obtained prior to seeing the provider. If a patient may be receiving chemotherapy, assure that blood counts and chem 7s were ordered stat and drawn to prevent delays in administering chemotherapy. If patients need procedures like injections, instruction in collection of specimens, or for planned procedures, send to the Clinic Nurses for implementation of orders at checkout.
• A clinic note should be written within 24 hours for each patient visit. Ideally, this is completed at the time you see the patient but if that is not possible it can be finished later the same day.
• Each patient must be discussed with an attending prior to the patient leaving the clinic. Identify the attending with which you discussed the patient as an expected co-signer of your note.
• Electronic Encounter form. This form must be completed prior to the patient leaving the clinic. Mark the primary and (optional) secondary diagnoses and the appropriate E&M "code". Be sure to mark if procedures were done such as examination of peripheral blood smear (found under other procedure) or bone marrow asp and bx. Be sure to include the attending physician as the Primary provider as only the attending can bill patient insurance. For an outpatient consult and the patient is NEW TO DURHAM VA code this as a CONSULT not a new patient. The appropriate E&M code is 99244 or 99245 depending upon the complexity of the encounter. For patients new to you but have been followed by a prior hem/onc provider, this is an established patient and the code would be 99212-99215 depending upon the complexity. When you see a patient and are writing chemotherapy orders during that encounter it should be coded at minimum as 99214. Some veterans are entitled to receive travel benefits and are reimbursed for mileage to and from their homes to the VA. Therefore, when completing the encounter form for a visit, it is important to indicate whether a patient is being seen for a service-connected condition. Do not check the service connected box unless the condition for which you are seeing the patient is listed (in the left pain pane of the encounter form) as being service-connected. Doing so may be considered fraud. ENCOUNTER FORMS MUST BE COMPLETED BEFORE THE PATIENT LEAVES THE CLINIC.
• We are attempting to cap the clinic load at 6 follow-up patients and 1 new patient per provider per day, or 8 follow-up patients and no new patient. This is not always possible (or necessary), especially for upper level fellows. The providers in each clinic should help balance the patient load with the leadership or the clinic director. Talk with the clinic director or Chief of Hem/Onc at the VA if you are routinely not able to complete your clinic in a timely fashion or have other concerns about the operation of the clinic.
Clinic Cancellation:
If you will not be in clinic on any of your scheduled clinic days, notify ShirleyParker (x 6944) 30 days in advance (this is a VA mandatory policy) so she may cancel your clinic and reschedule any patients already scheduled for that day. You must complete the Fellows Request to Cancel VA Clinics form and have this approved by Dr. Kelley 30 days in advance of the day you are cancelling clinic. This form needs to be given to Shirley Parker after you have obtained written authorization from Dr. Kelley.
• Cyber Security: USB ports on VA computer have been deactivated. Use only limited identifying information in unencrypted electronic communications (first three letters of last name, last 4 of SSN, and first initial; e.g., Kel1234M)
• Dual Care Policy: There are instances when patients are being cared for by non-VA hematologists oncologists and are seeking VA assistance with prescriptions. Before these patients are seen in clinic a Dual Care Letter is mailed to the patient. These patients must have ongoing appointments at the VA Hem/Onc clinic for management. Just providing the prescription benefit w/o ongoing management by the VA is not permitted.
Department of Veterans Affairs
Medical Center
Hematology/Oncology (111G)
508 Fulton Street
Durham NC 27705
Michael J. Kelley, MD
Chief, Hematology/Oncology
6/27/11
Clinic phone:919-286-6944
Clinic FAX: 919-286-6896
Dear Patient,
You are receiving this letter because you recently requested that the VA provide care and or medication for cancer or a blood disorder that is currently being treated or was treated by a non-VA physician. Before considering the specific request, VA providers must see you in consultation, review the results of your prior studies and procedures, and independently make decisions regarding which medications or treatments to recommend to you. The recommendations may or may not be the same as those recommended by your non-VA physician.
Because most medications used to treat cancer and blood disorders can cause significant and sometimes life-threatening side effects, it is imperative that the VA provider follow internal policies as outlined in VHA Directive 2002-074:
“The VA provider assumes medical and legal responsibility for and has the final authority for decisions regarding any medications and supplies the VA provider prescribes. As such, the VA provider is under no obligation to order medications or diagnostic testing for any condition for which the veteran does not allow the VA provider to adequately manage.”
If you are willing to transfer care, you will be required to have regular follow-up in Hematology/Oncology at Durham VA. It is the goal of the Hematology/Oncology Clinic at the Durham VA Hospital to provide excellent care to all eligible veterans with cancer or blood disorders. If you wish to be seen in our clinic, please contact our office at 919-286-6944 to schedule an appointment. You will also need to have records mailed or faxed to the above address or fax number prior to having an appointment scheduled. No further action will be taken on this request until we have heard from you indicating your willingness to transfer care of your oncologic or hematologic problem.
Sincerely,
Michael J. Kelley, MD, FACP
“
Bisphosphonates:
For IV administration of bisphosphonates, use the VA formulary agent zoledronic acid (Zometa). The typical dose is 4 mg IV over 20 minutes (adjusted for renal insufficiency if needed). A STAT chem 7 must be ordered prior to each infusion. Doses may need to be adjusted if the patient develops an elevation of creatinine from baseline.
Bone Marrow Aspirates and Biopsies (should be done in the AM if possible):
• The performance of BM aspirates and/or biopsies are usually discussed with the attending prior to the performance of the procedure. If "special" studies including flow cytometry and cytogenetics are to be performed, you must discuss this with the attending prior to performing the procedure
• A time for the procedure should be scheduled with Vicky Cates (pager 0565) in the BM lab.
Bone marrows should be scheduled as early as possible in the morning since cytogenetics and flow cytometry samples must be sent to the 3rd floor laboratory by 12:00 noon. The samples
have to be processed in fee basis before the courier arrives at 1:00 pm.
• The bone marrow procedure consent is done electronically in CPRS under the “tools” tab
and iMed Consent. Hand written non-electronic consents are not permitted.
• Enter a procedure note on the day of the procedure using the Bone Marrow Procedure
template in CPRS.
• To order cytogenetics or flow cytometry: Please first discuss with an attending the appropriate studies to be ordered as these are very expensive tests that VA has to outsource to labs outside VA. Enter an electronic order and complete appropriate paperwork prior to arriving with the patient in the bone marrow room. This will save valuable time, especially when several marrows are scheduled, and will prevent having to reschedule the patient for the procedure.
In addition this will alert the medical technologist to have the correct tubes available for the aspirate. Due to safety and space issues, relatives and other medical personnel as much as possible should remain in the waiting area. Please refrain from teaching residents bone marrow procedures during busy Tues., Wed., and Thurs. morning clinics.
Avoid bone marrows on Friday, as samples cannot be left over the weekend.
Radiology:
• Typical request times for studies are shown below. Orders entered into the computer will typically be scheduled on the date specified only for plain radiographs. You or the radiology clerk will need to schedule the other tests with radiology. You must enter a date you desire the exam to be done and not leave the date an open date. The provider will need to call radiology to request an urgent study.Radiology appointments for scans are scheduled by the Radiology clerk and not the Clinic clerk.
• Plain films - same day. Ordered from third floor radiology (OP Radiology in CPRS)
• Metastatic surveys (OP Radiology in CPRS)—same day.
• CT scans –1-2 weeks, sometimes longer depending on equipment and staffing; call x
5976 to request an earlier time or same day study if needed.
• Nuclear medicine (x 6952)
• Bone scans - within 1 week; sometimes the same day
• MUGA - 1-2 weeks
• MRI - (x 5818) ~1 month. The provider will need to contact the appropriate radiologist to request an urgent MRI.
• PET scans – 1-2 weeks.
• Most radiology studies can be viewed using Stentor PACS (selected from the “tools”menu in CPRS). When selecting patients in Stentor PACS, use an asterisk and the last four digits of the SSN (instead of the initial of the last name and last four), or the patients last and first name. Images can be viewed from studies done at other VA’s within VISN 6 (including Asheville, Fayetteville, and Salisbury). Important outside studies can be uploaded by giving the disk to radiology.
Medical Records:
• The VA has an electronic medical record (CPRS), which is accessible through two programs: CPRS (a GUI) and VISTA (a command line interface). Nearly all providers now use CPRS, which can be accessed outside the VA using a Citrix connection and from the Duke Virtual PIN station (or any PIN station at Duke).
• All notes and orders (labs, radiology, medications, consults), except chemotherapy orders, are entered into the computer record. Paper records are not permitted. Use of the Problem List in the electronic record is encouraged and can be used to document diagnosis, stage, treatments, response, and other items by using the "Annotation" feature. If you make a template for progress notes (or copy one from another provider), the entire problem list can be imported into the progress note along with medications and vital signs.
• The computer will generate "View Alerts" for critical lab results. You may also optionally request to receive View Alerts for other events such as completed Radiology Reports (highly recommended).
• Paper copies of outside records, copies of correspondence, flow cytometry reports from Duke, VA consent forms and other paper records that are not already in the electronic record can be scanned into the record by the clerk. This requires completion of a scanning form attached to the records. You will also need to type a “Non-VA Medical Records” note into CPRS before the records can be scanned. Please send pertinentdocumentation and not the irrelevant data for scanning. Once this is scanned it will be found under Vista Imaging Display under the “Tools‖ tab in CPRS.
Notification of test results to patients:
It is VA policy to notify patients of test results within 14 days. This includes labs, radiologic studies, pathology, etc. This must be documented in the progress note including how the patient was formed (in person during the visit, by phone, by mail). There is a Patient Lettertemplate that is used for Primary Care. It can be modified to apply to our clinic visits. It can be found in CPRS under “notes”. You print the letter to printer C1022. This will print to the secretaries’ office (main Hematology Office) and the secretaries will mail these for you. Also refer to the separate document Ten Strategies Providers Can Use to Improve Management of View AlertNotifications in CPRS.
Admissions:
Due to bed availability and house staff availability elective admissions need to be limited. Please attempt to administer chemotherapy in the outpatient/lodger setting. If this cannot be done as an outpatient the division chief (Dr. Kelley) will need to review the rationale. This will need to be done via email. If there is documentation of the rationale in CPRS, you do not need to duplicate that in the email. This only applies to elective and not emergent admissions.
To admit a patient, place a consult in the consult tab of CPRS to Admission Future Admission or Admission Acute Stay. You will be paged with a team and bed assignment. You will assume primary oncology care for your patient while hospitalized.
Emergency Department:
Patients of the Hem/Onc service who need to be seen outside a regular clinic visit are best managed by our clinic. If a patient needs to be sent to the ED, you should communicate with the ED prior to the patient's arrival. Also, if a patient in the clinic is acutely unstable, transfer to the ED may be appropriate. If you bring a patient to clinic on a day that is normally not your clinic day, please have the clerk schedule the patient to Hema-Overflowclinic.
Cancer Pain Management:
There is an inpatient cancer pain management team that may be consulted during circumstances of difficult pain management. Please generate an electronic consultation to the Cancer Pain Team, which is staffed by the Oncology Clinical Nurse Specialist (Hem/Onc nursing) and Becky Yost, PA-C (Hem/Onc PA). For interventional anesthesiology procedures and the Chronic Pain Team, please generate an electronic consult to Chronic Pain Team, Dr. Joel Goldberg (anesthesia/pain clinic).