One of the core "meaningful use" [PDF] measures intended to engage patients and families requires you to give patients specific information. This timely information can enhance patient satisfaction, increase patient knowledge, reduce anxiety, and improve follow-up compliance.
Clinical summaries should be given to 50 percent or more of your patients within three business days of each office visit.
What does a "clinical summary" include?
An after-visit clinical summary gives a patient relevant and actionable information and instructions, including, but not limited to:
- Patient name;
- Office and physician contact information;
- Date and location of visit;
- Updated and current medication list;
- Updated vitals;
- Patient symptoms;
- Visit summary;
- Procedures and other instructions;
- Updated problem list;
- Immunizations or medications administered;
- Summary of topics covered;
- Time/location of next appointment/testing, if scheduled;
- Laboratory and other diagnostic test orders; and
- Test and/or laboratory results (if received before 24 hours after visit).
You can deliver patient summaries via several different methods and still meet the meaningful use measure:
- An online patient portal,
- Personal health records,
- Secure email,
- Electronic format, or
- A printed copy.
If you choose to make the information available to patients in an electronic format, you must also have the capability to generate a paper format upon request. You have discretion to withhold certain patient information if you believe substantial harm may arise from disclosure. Patients with access to their information through a patient health portal have the benefit of accessing their most current health information. Information patients receive in copy form are only as current as the time the copy itself was made.
When should a patient receive a "clinical summary"?
All visits during which a physician renders clinical judgment should be communicated to the patient. The meaningful use measure will count any billable visit, including:
- Concurrent care or transfer of care visits,
- Consultant visits (when referred by another physician or provider), and
- Prolonged physician service without direct (face-to-face) patient contact (i.e., telehealth).
What else should I consider?
- Make the clinical summary part of your regular workflow. Does your electronic health record (EHR) have a template for clinical summaries? Can you create your own template or manipulate an existing template to hold all of the necessary elements for a clinical summary?
- Make sure you've developed procedures within your office to give patients clinical summaries in the required three business days.
Physicians who meaningfully use a certified EHR may qualify for EHR incentives up to $44,000 under Medicare or up to $63,750 under Medicaid. Many of the meaningful use measures offer exclusions. (See Do You Qualify for "Meaningful Use" Exclusions?) Physicians who have no office visits during the meaningful use reporting period are excluded from providing clinical summaries. A physician who receives no patient requests for electronic copies of patient health information during the meaningful use reporting period can qualify for an exclusion, as well.
Texas regional extension centers (RECs) can help your practice with the meaningful use measures through onsite technical consulting. Their services are designed to take your practice from its current state – whether you are starting with a paper-based system or looking to optimize your current EHR system – to "meaningful use" to qualify for the federal EHR incentives. The Texas RECs understand the unique challenges physicians face and will work with you to fully realize the benefits of EHRs in improving efficiencies and patient care.
Visit TMA's REC Resource Center to learn more about the Texas RECs, available incentives, REC and incentive eligibility, and meaningful use. Still have a question? Contact the TMA Health Information Technology helpline at (800) 880-5720 or email HIT.
Action, Sept. 1, 2011