The End of the Consult Letter as We Know It

The End of the Consult Letter as We Know ItThe end is in sight for the consult letter as we know it today. This has the potential to be a significant benefit delivered by meaningful use standards—physicians will get the clinical information they want and need from other physicians, and they will get it faster and more efficiently. Gone will be the days of lengthy, unstructured notes sent by fax or mail from one provider to another.

In today’s world, specialists report to referring physicians (i.e., primary-care providers) via a dictated consult letter or transcribed exam notes. These tend to be text heavy and contain no discrete or importable data. Others send EHR-generated narratives—lengthy notes that most physicians find difficult to read, if not useless. Finding the impression and care plan buried in massive amounts of verbiage is frequently a frustrating and time-consuming process. Meaningful use addresses this challenge by requiring a discrete data-rich summary of care for transitions from provider to provider. A menu measure in Stage 1, these summaries become a core measure in Stage 2, with more robust and structured content and the requirement that at least some of them be transmitted electronically.

The required Summary of Care provides better-quality information to the receiving provider and is created with less manual effort by the sending physician. The receiving EHR assimilates all of the data, presenting it in a cogent manner. The Summary of Care will contain structured data and a concise, accessible impression and care plan that tells the referring physician exactly what he/she needs to know. The receiving physician will filter the data as desired and the data can then be incorporated into the patient’s chart in his/her EHR, since all certified EHRs will use standard vocabularies.

Ease and speed of communication, along with cost reduction, are significant benefits, too. The Summary of Care can be transmitted as quickly as the data is entered into the patient’s chart. An automated batch process sends the summaries from the specialist’s EHR directly to the PCP’s, eliminating the cost of printing, faxing, or mailing letters. Meaningful use Stage 2 provides for the exchange either directly from provider to provider via secure e-mail (the “Direct” messaging protocol) or through Health Information Exchanges (HIEs).

Meaningful use will mark an end to the transmission of consult letters devoid of discrete data and to the exchange of hard to read exam notes. The impact on physician and practice productivity is undeniable.

15 thoughts on “The End of the Consult Letter as We Know It

  1. I’m not sure.

    When I send someone to the retina doc, I’m happy with “They have a neovascular membrane and we will being treating them with intravitreal injections.

    From the plastics guy, “I removed a basal cell with clean margins. No return appointment does it.

    I think my doctors are happy with, “I agree they have neovascular glaucoma and surgery is scheduled for tomorrow. Expect post op report in 8 weeks”

    Any number of people have been credited with saying, “I would have written you a shorter letter, but I didn’t have the time.

    Brevity is crucial, but I think the doctor is most aware of what is consultant wants.

  2. Consult letters are still valuable. Not every patient has a well defined specific diagnosis. The specialist’s impression and plan in uncertain cases and the nuances of the language used are improtant especially when dealing with the same specialist over time and over many patients. Patients are not just data to be assimulated. Physicians are not just key punch operators. Discrete data and opinions are not mutually exclusive.

  3. You are correct in one assertion. Physicians universally hate EMR driven documentation. This is not progress, and I would like to hear about any credible study that shows how our current systems of documentation and sharing information fails to meet patient needs. I know that HIT systems vendors view this as the new golden age, it is actually the dumbing down of medical documentation, at the same time that artifact and inadvertently captured data elements can now be distributed across multiple databases at the speed of light, there to reside forever. Soon, everyone’s medical records will simply be petabytes of homogenized boiler plate, completely lacking the nuance of the patient narrative that actually helps good physicians treat the individual needs of patients. Your belief however that EMR vendors will magically be able to “assimilate” all manner of disparate data and present it to physicians in a more enlightened way than the mind of a physician reviewing the full patient picture is amusing… oh I forgot, CMS knows what we need to know to care for patients, and they intend to straighten all the doctors out……

  4. I disagree strongly. Consultation letters, ideally based on the time honored history and physical sequence (Chief complaint, history of present illness, etc) wwhen done well, provide a narrative of the patient’s problems which makes sense to the reader. EMR encourages endless repetition and a non-sequential putting down of data, from which a narrative has to be extracted, if it is there at all. EMR is well intentioned, but is impairing the art of diagnosis.

  5. Gone are the days of the two to three paragraph consultant’s report on his or her letterhead. Now I receive three to four pages of useless data, much of which is a product of “cloning.” Somewhere in these pages is a diagnosis and treatment plan. Honestly, when I refer a patient to a retina specialist I really don’t need a recap of all the patient’s medicines, previous surgeries, family history, social history, height, weight and BMI. I am sad to say that “The End of the Consult Letter as we Know It” is truly here.

  6. I have seen only one decent summary report from an EHR. Nothing to date replaces the consult letter which done properly is the best source of information. A hospital dc summary cannot be replaced by an automated summary report. As all above have alluded to, Data without the nuance of the treating MD’s editing is void of much meaning.

  7. I am sorry Mr. Steele, but you and everyone else pushing EMR are very wrong. It is not going to improve anything in health care except the bottom line for EMR vendors. I strongly disagree with nearly everything you said.

    If you don’t understand why this is true you would need to go to medical school and residency and internship to find out why it is true.

    You cannot put down all of a physician’s thoughts with a drop down menu. Much of medicine is not always a cut and dried diagnosis. Every EMR record of patient care that I have read is just so much meaningless dribble that makes it very difficult to read through to get to the important part. All of this garbage is forever entered into a patient’s medical record. This is going to be a real tragedy, and it will not improve anybody’s health care. You are right about one thing and that is the impact on physician practice and productivity will be undeniable. I do agree that it is often difficult to read another physician’s notes if they are not transcribed. I think a better solution than EMR would be to require every physician to transcribe his notes into typewritten form so that everyone else can read them.

  8. Boy, as I read the responses above, it sure is an indictment AGAINST the way EMR vendors have been encouraging physicians to document their patient encounters. When are the vendors going to get the message that clinical relevance and the documentation needed to support the *correct* level of E/M services are not mutually exclusive? And when are doctors going to tell their vendors “thanks for the suggestion but we’re NOT going to use your suggestion to create preloaded templates”?

    But back on the topic of consult letters, don’t forget that for those payers that still accept the 99241-99245 office/outpatient consultation codes, the CPT definition of those services still requires that the consulting physician provide a written report of their findings/advice/recommendations to the requesting physician (CPT 2012; page 18). Unless that “Summary of Care” document (record) contains a clinically meaningful information (rather than “‘meaningful use’ meaningful information), it may not be sufficient to meet this additional documentation requirement for reporting the 99241-99245.

  9. The reality is that physicians unwittingly sold what little autonomy they had left, for a relatively insignificant amount of incentive, or the risk of a relatively insignificant level of fee penalty. They allowed CMS to worm itself into the very heart of how they practice, and they will soon control almost every aspect of how they document and deliver their art and skill. CMS is a pitiless bureaucracy, and now that they have a huge new universe of data to audit, will crush any remaining pleasure out caring for patients. How does Meaningful Use Phase 10 sound to you?

  10. Paid By The Word

    Woe to the resident who performed cataract surgery at the VA in the 1980s without performing a rectal and CXR. We had to be “complete.”

    At the same time I moonlighted at a GPs offices whose records read:

    Jason Smit,
    3/1/63 6#3 oz,
    4/1/70 URI PenVK,
    6/4/73 Fx R arm, casted,
    6/4/83 Appendix, Dr. Baker,
    etc.

    Now I get sent a three page document for a routine eye exam, a two page suture removal, 40 pages from the VA covering 3 examinations. The sad thing is the ONLY time I read every word of the record is when I have been hired to do so by the plaintiff or the defense. Legally they may define the case, medically they are just fluff.

    And why? Because we get paid by the word (indirectly). If you want to bill for a Level 4 or 5 exam or a comprehensive eye exam you need to produce a lot of words even if far fewer words would communicate better. It sucks, but that is our system and EHR is great at it!

    I saw a patient Sunday afternoon with acute loss of vision. Of his 65 page hospital record the only information I need in my chart is “Righted side occipital CVA secondary to uncontrolled HTN, D/C on Diovan and ASA.”

    But I can’t get that.

    Rumor has it that one of our carriers is dealing with a patient who was pronounced dead at the ER. Record says, “Alert and oriented x3, neck supple, lungs clear, RR s murmur……good peripheral pulses….Assessment: Dead on Arrival.” LOL. Sure, it’s just a careless error, now where is the next one?

    @Jim GIlhooly – How much does the consultant’s report have to reflect the exam and work-up. If I spent an hour interviewing the patient and spend $5,000 on lab tests, can I say, “After extensive evaluation we are left with a diagnosis of idiopathic uveitis” or do I have to repeat all the negatives?

    The second best thing about EHR is that we will all be connected even if we don’t communicate
    The best thing about EHR is that I can read my partner’s handwriting.

  11. A column like this really indicates how far off base the EMR vendors are when they design and build their products. As a retina doc who was been EMR since 2006, I have struggled with delivering consult letters to my referring physicians. In fact, the selection of my last two EMR packages has been driven by their ability to generate customizable letters. I have tried to avoid the boilerplate by making many different letters to make them as specific as possible for each diagnosis variant. I still have to modify these letters to convey all the information I want but it prevents me from having to dictate 60 letters a day. I know my referrings want it short and sweet. No one wants seven pages of review of systems and I think it is insulting to both send and receive letters like that.

    One thing I can tell you for sure is that the meaningless use mandated summary is an absolute joke and would never suffice for any kind of physician communication. To even suggest that proves that you have no clue on what physicians need.

  12. It will be easier to send “the facts”. Hopefully the system will allow the physician to communicate less factual information such as background information and his or her thoughts or concerns about the patient that may not be visible in the data information.

  13. I am a medical biller. I am also a patient at more times that I feel to elaborate on. But your EMR is only as good as the person entering the information.

    To be specific, I was admitted to Abington Hospital with acute pain in the lower left side. Diverticulosis and this was my 3rd attack. Needless to say I would have to get surgery (arthoscoptic). The person in the middle of the night took my history and physical information and by the time the real surgeon came in I was told that I had cancer in the breast and my ovaries removed. I will from this day forward request a written copy of my hospital and doctor stays and double check on the bills sent to my insurance carrier or carriers.

    OMG…are you kidding me. Totally wrong!! Good thing I am alert !! I said my name, date of birth and then continued to rant at the surgeon who spoke english to me and said the (person) taking my history clicked on all the wrong keys (he spoke broken english) thus giving me that elaborate history. So you can take your EMR’s and throw them in the trash can. We better have written notes to substantiate a patient’s medical procedure/history and outcomes. Just sayin!!

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