Meaningful Use: Clinical Summaries

Jim Tate, Meaningful Use Expert

Let’s Summarize Clinical Summaries for Meaningful Use

One of the most mis-understood Meaningful Use core measures for Eligible Professionals is the objective to: “Provide clinical summaries for patients for each office visit”. The required measure threshold for this objective is that: “Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days”.  EPs have the option to exclude this core measure if they “have no office visits during the EHR reporting period”.

So let’s define a few terms. What is a clinical summary and what data must it contain? CMS provides very specific clarification and for this measure defines a clinical summary as:

“An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, 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 tests that the 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.”

We’ll what if you don’t have all that information to put into the clinical summary? What is the minimum that is required? CMS provides further detailed clarification of what minimum data set must be in the clinical summary:

“The EP must include all of the items listed under ‘Clinical Summary’ in the above ‘Definition of Terms’ section that can be populated into the clinical summary by certified EHR technology. If the EP’s certified EHR technology cannot populate all of these fields, then at a minimum the EP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)): Problem List, Diagnostic Test Results, Medication List, and Medication Allergy List”.

One additional twist to this issue arises when a patient is seen by more than one EP at a practice and there are several visits and re-checks over several days, all related to a particular issue or episode. What is required then as far as the number of “office visits” and clinical summaries? Thankfully, CMS has also addressed this issue:  “When a patient visit lasts several days and the patient is seen by multiple EPs, a single clinical summary at the end of the visit can be used to meet the meaningful use objective for “provide clinical summaries for patients after each office visit. “

Jim Tate is author of The Incentive Roadmap® The Meaningful Use of Certified Technology: Stage 1. Version 3.0 now available for purchase.