MU2 – #7 Clinical Summaries in Just One Business Day
This is Part 7 in a series provided by Jeanne Chamberlin, Director of EMR Consulting, at MSOC Health. Visit our blog site to see articles 1 -6.
Most practices found it difficult to provide patients with a Clinical Summary within 3 business days. Stage 2 gets tougher. Although the criteria stays at 50%, the Clinical Summary will need to include additional information and must be provided to the patient within 1 business day for 50% of office visits.
What’s the Point? Providers generally focus on how difficult this measure is to meet, rather than the true value that it can have for your patients. The Clinical Summary is a key tool in helping your patients remember and follow your treatment recommendations. To get the most out of the Clinical Summary, a provider or nurse would hand the Summary to the patient and review it with them at the conclusion of their visit. Unfortunately, many busy practices have not yet been able to accomplish this goal.
Tips to Ease the Burden:
- Technically, you are required to include only the information that is available in the Certified EHR system at the time the Clinical Summary is provided to the patient. If some of the information has not yet been entered, you can still print and hand the “Preliminary” document to the patient, allowing you to count it for the purposes of Meaningful Use.
- Instead of printing and handing the Clinical Summary to the patient, post it to the patient portal within 1 business day and encourage patients to view it online. This strategy will help you meet other Stage 2 measures as well (50% of patients have access to the portal and 5% actually view/download their information). If a preliminary copy is posted, you must repost the final version within 4 business days.
- The Clinical Summary does not have to be the physician’s documented visit note. Use the required information list below and identify where each is documented in your EHR. Decide who will enter each data item and create a workflow where these are entered during the office visit, even if other portions of the visit note are completed later. Most EHRs have a “letter” or “document” function that will allow you to create a document pulling in information that has been entered into specific data fields. Create and print this alternate document as your Clinical Summary or post it to the Patient Portal.
- The federal rules prohibit the use of passive systems to tell patients they may ask for a Clinical Summary (like a sign in the lobby), however, you may ask patients if they would like a summary of today’s visit and count those that say no as having received it.
- For all the tips above, you’ll need to be sure you understand how your EHR’s Meaningful Use reports capture the fact that it was provided, posted, or offered and rejected so that you can “mark it done” and get credit.
Clinical Summary – Required Information for Stage 2:
- Patient Name, Provider Name, Date and Location of Visit
- Vital Signs recorded at the visit, including BMI
- Patient Demographics – Race, Ethnicity, Language, Age, Gender (added for Stage 2)
- Smoking Status (added for Stage 2)
- Problem List and/or Current Conditions
- Medication List
- Medication Allergies
- Diagnostic Tests Ordered with results when available
- Patient Instructions
- Recommended Patient Decision Aids (added for Stage 2)
- Care Plan Field (added for Stage 2)
Need help unraveling the complexities of Meaningful Use? MSOC Health can help! Contact Jeanne Chamberlin, Director of EMR Consulting at 919-442-2422 or firstname.lastname@example.org.