Not All Who Have Fluid Have Heart Failure
It is not that a majority of my colleagues are being intentionally misleading or committing fraud. I have the advantage that I know my patients and have digested their health, and their health records, meticulously.
Take, for example, the Medicare patient of mine who recently took a trip for the holidays to the Northeast. He has substantial chronic renal insufficiency, with a baseline creatinine concentration in the low 2s. He is regularly followed by a nephrologist and by me. He has normal heart function, as demonstrated by prior detailed investigations. He also has a recalcitrantly consistent average health literacy. When everything is status quo, he does fine.
When he was with his family, he began eating as they did, and they were eating saltier holiday foods than was their norm as well. As would be expected, his kidneys could not handle the added burden of sodium. He gained 19 lb, quickly, developed swelling, and became progressively dyspneic.
On presenting to the hospital, my patient was told in the emergency department that he had had a heart event, his heart wasn't pumping well, and he had "congestive heart failure." He had already begun to receive CHF education before the cardiologist ever saw him. The cardiologist frightened him, telling him all of the things that they would need to do to address his "weak heart," with no mention of his creatinine or renal status. Once the ECG had been interpreted—with a normal ejection fraction, normal heart muscle, and normal chamber measurements and function—my patient never saw the cardiologist again, not even to deliver the results.
I saw the patient as soon as he returned home. The hospital he was seen in did a very commendable and above-average job. I had some of his records, including labs and the ECG, by the time I saw him. The internist who saw him also did a very above-average job; she phoned me to discuss the case. She clearly cared, and her overall competence showed in our discussion. The patient and I both liked her.
Unfortunately, she still referred to his hospitalization for volume overload due to dietary indiscretion in the face of chronic renal insufficiency as "congestive heart failure" during our conversation. When I pointed out her ECG's findings, which were entirely compatible with his baseline ECGs, she corrected herself ultimately in saying that the patient did not have CHF.
This is the parlance of our day: Volume overload, regardless of cause, is CHF. Unfortunately, my patient's chart, as is the case for many others, now includes "CHF" as the diagnosis. It is now in the CMS database. His admission for "CHF" will adversely affect my statistics and those of our ACO for a full cycle. There is no mechanism for me, as a primary care physician (PCP) or ACO medical director, to correct the database at CMS—no editing, no appeal.
If my patient is ever admitted to that hospital again during a future family visit, then there is every reason to expect that this diagnosis will be regurgitated and coded again, regardless of whether it has anything to do with his presentation.
It is the nature of this beast of the US healthcare that we have created, or allowed to be created. We are reaping what we have sown. As long as colloquial looseness of diagnostic phraseology persists, we will continue to reap this harvest. A unified, all-access, nationwide EHR will not correct this. It will probably compound it. Garbage in, always in.
The Optimal Consult Note
Ideally, a consultant's note should be concise as it addresses the issues of patient care. It should be brief and not duplicative, logically structured, and of educational value. Such a note is an effective note. It is not one that is "optimally reimbursed" by today's payers.
There are those who feel obligated to point out that consult notes at teaching hospitals have a greater onus upon them to have educational content. I disagree. Because medicine, surgery, diagnostics, and therapeutics continue to evolve, and because we are all committed to lifelong learning, I believe all notes should be both effective and potentially educational. Given the infusion of patient care staff who have had only a small fraction of the hours of training those physicians receive in the course of their training, this need is perhaps as great as it has been in the post-Flexner era. Critical reasoning skills and the power of the mind should be recognized and rewarded, rather than the ability to copy and paste or regurgitate.
It is inherently incumbent upon the requestor of the consult to ask good questions, if good answers are to be expected. The same medicolegal liability carrier that insists that its covered surgeons not operate without "preoperative clearance" from the PCP will also insist that its covered PCPs never write, "This patient is cleared for surgery."
The surgeon who asks specific questions about specific concerns will be the genesis of a much better, more accurate assessment. After all, it is the surgeon who knows what he or she will be doing to the patient in the operative suite, and the risks of the procedure, the anesthetic he or she prefers to use, and so forth.
As one of my CT surgeon friends said to me years ago, "The surgeon who cannot figure out on whom he should not operate, should not be operating." By virtue of the thought processes evoked, the surgeon who asks specific questions and receives specific advice on how to mitigate risks—or, alternatively, that " no further steps can be taken at this time to reduce the patient's risks for foreseeable medical complications"—will be in much better standing than the one who received a check mark in the box on the preoperative clearance form that "this patient is cleared for surgery."
A Challenging Conclusion
Done correctly, a consultant's note can challenge both the requesting and the providing physicians (or nonphysicians) to think more fully and broadly, improve patient care and outcomes, and reduce unnecessary testing or treatment while also being educational. Unless and until payers recognize that it isn't the length of the consult that matters as much as how the consult is created and used, the system as a whole and both patients and providers will continue to suffer.
The reality is that insurers also suffer under the current system. After all, they are paying for volumes of lower-quality information, much of which may be only cursorily reviewed, if not left unread.
Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143:1753-1755. https://www.ncbi.nlm.nih.gov/pubmed/6615097 Accessed January 12, 2015.
Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. https://emr-simplicity.com/pdf/Article_Off the Record - Avoiding the Pitfalls of Going Electronic - New England Journal of Medicine 4.17.08.pdf Accessed January 12, 2015.
Fitzgerald FT. The emperor's new clothes. Ann Intern Med. 2012;156:396-397. https://annals.org/article.aspx?articleid=1090707 Accessed January 11, 2015.
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Cite this: Gregory A. Hood. Consult Notes: Too Many Words, Too Little Information? - Medscape - Mar 11, 2015.