Providing a Clinical Summary in Stage 1 Meaningful Use

Meaningful Use Core Measure 13 for EPs Part 1

 Meaningful use core measure #13 requires the Eligible Professional to provide clinical summaries for patients on each office visit. To satisfy this objective, the EP must attest to providing patients of at least 50% of all office visits a clinical summary within 3 business days of that visit. The EP is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology.

Here is how the calculation for meaningful use attestation with the numerator/denominator looks:

Number of office visits for which Clinical summaries were provided within 3 days + Number of Patient refusals  / Number of office visits by the EP during the EHR reporting period.  ≥ 50%

So what is on a clinical summary and what type of media is acceptable? The final rule for stage 1 meaningful use defines a clinical summary as: 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, 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.

The EP is required to include all of this information which their certified EHR can produce. If the EHR cannot produce a summary with all of this information the minimum required is a problem list, diagnostic test results, medication list, and a medication allergy list.

According to CMS acceptable forms of the clinical summary include:

  • Printed document on paper
  • Acquired to a personal health record
  • Available in a patient portal for patient to view
  • Send by secure email
  • Electronic media such as a CD or flash drive

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