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How do I provide clinical summaries to patients for each office visit?

Providing clinical summaries (also called after-visit summaries) to your patients can help them better understand their health conditions and adhere to your treatment plans.  Most patients have difficulty remembering and understanding the medical instructions and information given to them either verbally or in writing from their providers.  Research shows that 40 percent to 80 percent of medical information provided by practitioners is forgotten by patients immediately after clinical visit, and of the information that is remembered, almost one-half is remembered incorrectly.  Patients’ lack of understanding can result in adverse health outcomes, decreased adherence to treatment, and ultimately, dissatisfaction with the clinical encounter and care.

Clinical summaries are an after-visit summary that provides a patient with relevant and actionable information and instructions containing, but not limited to, the patient name, provider’s office contact information, date and location of visit, an updated medication list and summary of current medications, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other  appointments and testing patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.  Patients can use this information to manage their health.  This information can also be accessed as needed, for example, if a patient forgets the provider’s instructions or the date of a follow-up appointment, the information is available without having to call or contact their provider’s office.

Core Objective for Eligible Professionals:  

• Provide clinical summaries for patients for each office visit.  

Measure:

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

Exclusion:

• Any eligible professional who has no office visits during the EHR reporting period.

This objective requires that you provide all patients a clinical summary after each office visit.  An “office visit” is defined as any billable visit that includes: 1) concurrent care or transfer of care visits, 2) consultant visits, and 3) prolonged physician service without direct (face-to-face) patient contact (telehealth).  A consultant visit occurs when a provider is asked to render an expert opinion or service for a specific condition or problem by a referring provider.

You may provide the clinical summary as a paper or electronic copy.  Both copies can be and should be produced by certified EHR technology.  Electronic copies can be provided electronically using PHR, patient portal, secure email, or electronic media such as CD or USB.  If an electronic media is chosen, a paper copy must also be provided to patients if they request it.  Clinical summaries must use the capabilities the certified EHR technology includes and must be in human readable format that is easy read and understand.  As allowed by the HIPAA Privacy Rule, eligible professionals may choose to withhold certain information from the clinical summary if its disclosure could cause substantial harm to patients.

The ability to calculate the measure is included in the certified EHR technology.  The denominator for the measure is the number of unique patients seen by the eligible professional for an office visit during the EHR reporting period.  Note that only patients whose records are maintained using the EHR technology are included in the calculation.  The numerator is the number of patients in the denominator who are provided a clinical summary of their visit within 3 business days.  

Related Resources:

The After-Visit Summary (AVS) – This Group Health Cooperative paper that provides useful background information and factors for successful implementation of after-visit (clinical) summaries.
Recurrent Hypoglycemia: A Care Transition Failure – This case and commentary posted on the AHRQ Morbidity & Mortality webpage provides an example of patient failure when a clinical summary is not provided at discharge.  Also discussed are the value of patient and family engagement in their care processes and the role of EHR technology.
After the Visit -  A Summary for the Patient: Making it Meaningful – PowerPoint presentation by Sarah Nosal of The Institute for Family Health on the benefits and key components of implementing clinical and after-visit summaries.