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.

CMS Resources

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

• EHR Meaningful Use Specification Sheet for Eligible Professionals – Core Measure 13 of 15 [PDF - 129k]

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 following resources are examples of tools that are used in the field today for clinical summaries. These tools have been recommended by "boots-on-the-ground" professionals for use by others who have made the commitment to implement or upgrade to certified EHR systems.

Learn more about The National Learning Consortium.

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.