Meaningful Use and Clinical Summaries

One of the most difficult meaningful use measures that practices must meet is the one requiring them to give patients a clinical summary for each office visit more than 50 percent of the time.

TMA frequently gets questions regarding this measure, such as: 

  • What if my patients don't want it?
  • Is this only for patients that request it?
  • What should be included in the summary?  

You must offer a summary to more than 50 percent of the patients, not just those who request one. You don't have to give summaries to patients who don't request them, although you may be surprised that many will appreciate having the information. You may give patients a summary in many ways. It can be printed, uploaded to a patient's electronic personal health record (PHR), or uploaded to a patient portal. Be sure the patient has signed up for the portal for this to count. You may also give it to the patient on a portal device such as a USB drive. 

If the patient refuses a summary, be sure to document that you made the offer and the patient refused so that you can count that office visit in your numerator towards the 50-percent requirement. Some electronic health record (EHR) vendors track this by asking physicians to "print to file" so it is documented. 

Take a moment to review what data elements are pulled into the clinical summary. They are listed under Definition of Terms on the clinical summary link in the first paragraph. Some physicians may make notations not intended for patient viewing, and it is vital that you understand exactly what is extracted into the summary. For example, one clinical summary indicated the patient was an alcoholic because the calibration within the EHR based that information on the number of drinks per week. 

To help physicians, the Office of the National Coordinator for Health Information Technology established regional extension centers (RECs) to provide onsite health information technology (HIT) consulting in physician practices. For questions about eligibility and REC services, visit the REC Resource Center on the TMA website.  

For questions about meaningful use or other HIT issues, contact TMA's HIT Department by telephone at (800) 880-5720 or by email, or visit the TMA EHR Incentive Program Resource Center


Action, Jan. 4, 2013


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