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Step 5: Achieve Meaningful Use Stage 1

Clinical Summaries

Objective:

Provide clinical summaries for patients for each office visit.

Measure:

Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days.

Clinical Importance

The Clinical Summary—which includes basic clinical information regarding the care provided, such as medications, upcoming appointments, or other instructions—affords better communication around pertinent health information. The clinical summary is shared with both patients and family members to increase awareness of what occurred during office visits and can be used to assist in care coordination. 

CMS Resources

The following resources are available to help you meet the Clinical Summaries meaningful use core measure:

Related CMS EHR Incentive Program Frequently Asked Questions

Lessons from the Field

"Developing an after visit summary takes a multidisciplinary team. Bringing multiple team members together to input information at different times during a patient appointment ensures all information is recorded and the patient can pick up a copy at the end of the visit."

— Phil Deering, Regional Coordinator, Regional Extension Assistance Center for Health Information Technology (REACH) 

Implementers in the field have identified the importance of workflow when compiling an after visit summary for their patients. The goal is for everyone who works with the patient to enter as much data as their particular license permits. The physician can simply review the information that front desk or nursing staff enters into the EHR, allowing the physician more time to focus on the patient. This takes a clinical team coming together with representation from each of the job roles. Once a workflow is defined, vigilant implementation is encouraged so that the clinic can work out any bugs and develop confidence in the process before going live across all patients and providers.

"Developing a workflow that allows providers to finish their initial assessment during the visit and enter only the information needed to print a clinical summary ensures that the summary is completed in a timely manner and is given to patients after each visit."

— Tony Petrillo, PA-C, Springfield Medical Care Systems, Vermont Information Technology Leaders 

One clinical summary workflow that has worked in the field is when providers do all they can to finish their assessment and plan prior to the patient leaving the exam room. The summary doesn't require a cognitive discussion for a particular problem; but it should include the diagnosis, labs and referrals that are made. The remaining details about the visit do not need to be included for the clinical summary to be printed and given to the patient.

"The Clinical Summaries are one of the most difficult core measures to accomplish for some providers because often times, they are not completed prior to the patient leaving the clinic."

— Sandra Ignacio, Implementation and Optimization Specialist, Polaris Danforth in partnership with Massachusetts eHealth Institute 

Clinical summaries are not always ready and available at the end of the patient appointment, although sending a clinical summary through a patient portal when available provides some relief. Some patients request hard copies and the nature and sensitivity of patient situations may present challenges. It is important to be creative in adjusting processes and workflows to accommodate all situations. In order to alleviate the pressures of providing "just in time" clinical summaries, some practices post notices in their office alerting patients to the availability of the patient portal and option to provide self-addressed stamped envelopes for a hard copy.

National Learning Consortium Resources

The NLC resources are examples of tools that are used in the field today, and that are recommended by “boots-on-the-ground” professionals. The NLC, in partnership with HealthIT.gov, shares this collective EHR implementation knowledge and resources throughout this site.

National Learning Consortium Resources
Resource NameDescriptionSource

Providing Patients in Ambulatory Care Settings a Clinical Summary of the Office Visit

Download

[DOCX - 3.9 MB]

Fact sheet outlining details and implementation considerations for a clinical summary.

Health Information Technology Resource Center (HITRC)

Clinical Summary FAQs

Download

[DOCX - 1.1 MB]

Frequently Asked Questions (FAQs) and tips related to Core Measure 10: Clinical Summaries

Health Information Technology Resource Center (HITRC)

Tips for Engaging Safety Net Patients Using Health IT

View

Webinar that provides tips on how safety net providers and staff can use Health IT to increase patient engagement.

Health Resources and Services Administration (HRSA)

Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide

Download

[PDF - 2 MB]

Guide to help eligible professionals (EPs) and their organizations gain a better grasp of how to successfully meet the criteria of giving clinical summaries to patients after each office visit.

Qualis Health

FAQs about the Patient Portal (for Patients)

Download

[DOCX - 739 KB]

A patient-facing FAQ document on patient portals provides information on several frequently asked questions from patients including what is a patient portal, why is it important, what can it be used for, and how to get access.

Health Information Technology Resource Center (HITRC)

Using Patient Portals in Ambulatory Care Settings Fact Sheet

Download

[DOCX - 754 KB]

A fact sheet on patient portals provides background information, Meaningful Use requirements, common concerns, and tips for launching the portal.

Health Information Technology Resource Center (HITRC)

The material in these guides and tools represents the collective EHR implementation experiences and knowledge gained directly from the field of ONC’s outreach programs (REC, Beacon, State HIE) and through the Health Information Technology Research Center (HITRC) Communities of Practice (CoPs) in their performance of technical support and EHR implementation assistance to primary care providers. The information contained in these resources is not intended to serve as legal advice nor should it substitute for legal counsel. The resource list is not exhaustive, and readers are encouraged to seek additional detailed technical guidance to supplement the information contained herein.

Reference in this web site to any specific resources, tools, products, process, service, manufacturer, or company does not constitute its endorsement or recommendation by the U.S. Government or the U.S. Department of Health and Human Services.

Related CMS EHR Incentive Program Frequently Asked Questions

For additional questions around meaningful use, visit the CMS EHR Incentive Program Frequently Asked Questions (FAQs).

 

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