Providing a Clinical Summary to Patients – Part 2

Meaningful Use Core Measure 13 for EPs Part 2

In Part 1 of this post we discussed the basics of core measure #13, what is included in a clinical summary and what forms are acceptable. Like many of the meaningful use objectives and measures you will find situations that need a little more guidance and explanation than the basics. So here is more information for providing clinical summaries.

First let’s look at the purpose of a clinical summary in context to meaningful use. It is threefold:

  1. Record of the visit – this helps patient and family members remember what happened, what they are to do, and what’s next.
  2. Patient engagement – helping to support engagement in making personal choices and management about their health especially with chronic conditions. This in turn will help improve clinical quality outcomes.
  3. Correct Information – patients seeing their summaries can potentially find incorrect information which can be corrected in their records.

So what if my patient has a preferred language that is not English and my EHR only prints in English? Although we can all see that a clinical summary given to a patient that cannot read it would not be particularly helpful, a provider is not required to communicate with a patient in their preferred language. This includes the clinical summary.

If an EP sees patients in both inpatient and outpatient settings, only those as inpatients should be calculated as patient visits. CMS FAQ #10068 states; In this case, EPs should base both the numerators and denominators for meaningful use objectives on the number of unique patients in the clinic setting, since this setting is where they are eligible to receive payments from the Medicare and Medicaid EHR Incentive Programs.

What if I am a OB/GYN and I bill my obstetrical visits as a bundled global OB charge? Do I need to make clinical summaries available for each of those visits? The answer here is yes. Each time a patient is seen you need to make a clinical summary available no matter how you are billing the visit.

To include or not to include. An EP has up to 3 business days after a visit to provide the patient with a clinical summary. If diagnostic test results have returned before a clinical summary is released, they should be included in that summary. If clinical summaries are provided at the end of patient visit, diagnostic test results do not have to be included. The EP is also not required to send additional or revised clinical summaries for diagnostic results which are received within 24 hours of the patient’s visit.

Incorporating clinical summaries for the patient will not come without some challenges. After all it has not been a standard of practice. The easiest way to make sure all you patients receive a clinical summary is to make it standard practice and hand it to them before they leave. Some of the challenges to this might be insufficient time to complete the summary which might extend a patient visit. Is the summary information easily read and understood by the patient? Might the information in the summary create more patient concerns?

Take some time to evaluate how this process will be done at your facility to have a smooth transition in the work flow.