Dawn of a New and Improved Consult Letter

Dawn of a New and Improved Consult LetterMy last blog clearly touched a nerve, as evidenced by the number of comments (14 in 5 days) and their spirited tone. Clearly—and we agree on this—the consult letter is a key part of patient care. The issue is how to get useful information efficiently transferred from the specialist to the primary-care physician without compromising the nuanced content and without reducing the patient encounter to a series of data points—the fear voiced by many of those who commented.

The question at the heart of this matter is what constitutes a consult letter in today’s medical practice and what it should be in the future. Currently, it may be a well-worded letter that ideally is concise and to the point; however, at the other end of the spectrum, an EHR-generated exam note is increasingly serving as the consult letter. My previous blog was really an indictment of the templated notes that more and more physicians are sending in lieu of consult letters. These are often bloated, undecipherable multipage notes that physicians find useless in communicating or identifying the impression and care plan. (This is the fundamental objection expressed in the comments from Drs. Dugger, Franc, Werner, Raulston, Kuhl, and others.)

The new Summary of Care document—a creation of the meaningful use program—replaces the EHR-generated exam note. While its emphasis is on transmitting discrete data, there is nothing that precludes physicians from incorporating narratives that convey the desired nuance. The Summary of Care can accommodate a long list of data, but it does not have to be a “data dump”—data that the sending physician feels is not relevant can be omitted. What physicians typically find most valuable in the summary is a limited set of data—diagnosis, medications, procedures, lab test results, and immunizations, along with a care plan. Descriptive text can be inserted/appended if the physician feels it would add value.

The value of the Summary of Care format is its simplicity, consistency, and data-rich content, which together enable the receiving physician to easily identify the information that is important to him or her (typically, the impression and care plan), and to incorporate that information into the patient’s chart. The data is subsequently available to the physician and can be retrieved and/or reported as needed. This stands in stark contrast to the templated exam note that currently functions as a consult letter.

Designed correctly, the Summary of Care will serve as a new and improved consult letter, delivering system-wide efficiencies while preserving the personal “art of diagnosis” (to quote Christian Wertenbaker’s comment). Nothing prevents a physician who crafts well-constructed consult letters from continuing to send them along with the Summary of Care. But it is my prediction that as EHR software continues to evolve and to develop more content-rich Summaries of Care, fewer and fewer physicians will find it necessary to supplement them in this manner. And given how overburdened and harried so many doctors already are, that will be a good thing.

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.