Providing Clinical Summaries To Patients After Each Office .
Providing Clinical Summaries toPatients after Each Office Visit:A Technical GuideJuly 2012Prepared by:Jeff Hummel, MD, MPHQualis HealthSeattle, WashingtonPeggy Evans, PhD, CPHITQualis HealthSeattle, WashingtonWith contributions from:Trudy Bearden, PA-C, MPAS, CPHIT, Qualis Health, Pocatello, IdahoSusan McBride, PhD, Texas Tech University Health Sciences, Dallas, TexasRoger Chaufournier, MHSA, CSI Solutions LLC, Bethesda, MarylandPhilip Deering, REACH, Minneapolis MinnesotaBarbara Stout, RN, BSC, Kentucky Regional Extension Center, Lexington, KentuckywirecWashington & IdahoRegional Extension Centerwww.wirecQH.orgA Qualis Health Program
Table of ContentsExecutive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4The Purpose of the After-Visit Summary (AVS). . . . . . . 4Table 1: Contents of an AVS. . . . . . . . . . . . . . . . . . . . . 5Key Components of a System for Assuring PatientReceives an AVS at the End of the Office Visit. . . . . . . 6The Five Steps to Developing a SuccessfulAVS Workflow Process . . . . . . . . . . . . . . . . . . . . . . . . . 8FiguresFigure 1:Key components of a system forassembling the AVS . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Figure 2:The Planned Care Model. . . . . . . . . . . . . . . . . . . . . . . . 7Figure 3:The huddle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Step 1—The Huddle. . . . . . . . . . . . . . . . . . . . . . . . . 8Step 2—Pre-visit Summary . . . . . . . . . . . . . . . . . . . 10Step 3—Rooming the Patient. . . . . . . . . . . . . . . . . . 12Step 4—The Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Step 5—Printing the AVS. . . . . . . . . . . . . . . . . . . . . 21Figure 4:The pre-visit summary. . . . . . . . . . . . . . . . . . . . . . . . . . 11Figure 5:Rooming the patient. . . . . . . . . . . . . . . . . . . . . . . . . . . 14Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Figure 6:Completing the chart during the visit . . . . . . . . . . . . . . 17Figure 7:Provider assures data entry for AVS. . . . . . . . . . . . . . . 18Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 2 of 24
Executive SummaryThe Centers for Medicare and Medicaid Services (CMS)include the practice of giving a clinical summary topatients after each office visit as an element of MeaningfulUse of an electronic health record (EHR) Stage One.Giving every patient a clinical summary after each officevisit is one of the most challenging of all meaningfuluse elements because of the complexity of both theinformation flow and the workflows involved.Clinical Summary—DefinedCMS has defined the clinical summary as “an after-visitsummary (AVS) that provides a patient with relevantand actionable information and instructions containingthe patient name, provider’s office contact information,date and location of visit, an updated medication list,updated vitals, reason(s) for visit, procedures and otherThis document is a guide to help eligible professionalsand their organizations gain a better grasp of how tosuccessfully meet the criteria of giving clinical summariesto patients after each office visit. It discusses the tworequirements to accomplishing these goals and assistsorganizations in meeting them.instructions based on clinical discussions that took place1) Assuring that the information for the AVS has beenentered, updated, and validated in the EHR beforethe end of the visit.of other appointments and tests that the patient needs to2) Developing process steps for assuring that eachpatient receives an AVS before the end of the visit.during the office visit, any updates to a problem list,immunizations or medications administered during visit,summary of topics covered/considered during visit, timeand location of next appointment/testing if scheduled, ora recommended appointment time if not scheduled, listschedule with contact information, recommended patientdecision aids, laboratory and other diagnostic test orders,test/laboratory results (if received before 24 hours aftervisit), and symptoms.”For each of these workflows, we describe in detail thesteps required to successfully meet the demands ofthe task.Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 3 of 24
IntroductionThe Purpose of the After-Visit SummaryPresident Obama signed the Health InformationTechnology for Economic and Clinical Health (HITECH)Act, enacted under the American Recovery andReinvestment Act signed into law as of February 17, 2009.Under HITECH, the Centers for Medicare and MedicaidServices (CMS) are able to provide financial incentives toeligible healthcare professionals (EPs) and hospitals fordemonstrating “meaningful use” of their electronic healthrecord (EHR) systems.The AVS has three purposes.One of the criteria for meeting meaningful use for EPsis the ability to provide clinical summaries to patientswithin three business days of an office visit. This measurehas been one of the most difficult for providers to meetbecause it requires significant workflow adjustments bothfrom the perspective of entering information into the EHRbefore the end of the visit, as well as developing standardprocess steps for staff so that each patient receives asummary prior to leaving the clinic.The Regional Extension Centers for Health InformationTechnology (REC) program was created through theHITECH Act to support primary care providers withselecting, implementing, and optimizing their use of EHRs,with the ultimate goal of helping EPs reach meaningfuluse. There are currently 62 RECs in the United States andUS territories, one of which is the Washington & IdahoRegional Extension Center (WIREC). WIREC is operatedby Qualis Health, a nonprofit healthcare consulting firmbased in Seattle, Washington, and works with over3,000 primary care providers in 600 practices to reachmeaningful use. The workflow guidance in this documentis based on the experiences of the WIREC, with feedbackfrom other REC partners.1) Enhances the ability of patients to remember,and, if necessary, convey to family members,the content of interactions with their care team.(Lukoshek, 2003, Kessels, 2003, Throop, 2009).2) Supports greater patient engagement inmaking good choices about healthy behaviors andthe self-management of chronic conditions, whichis essential to improving clinical- and patient-orientedquality outcomes. (Coulter, 2012).3) Improves the quality of information in the EHR throughtransparency, by giving patients and family membersan opportunity to see information in their records sothey can help the care team identify and correct dataerrors. (Markle Foundation, 2012).The components of a best practice to accomplish thesepurposes are shown in Table 1 on page 5. The informationfor the AVS must be gathered and validated prior to theend of the visit at which time the AVS is printed, given toand reviewed with the patient, and either printed or madeaccessible via a web portal for the patient to access at alater time.Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 4 of 24
Table 1: Contents of an After-Visit SummarySectionContent1. IDPatient name, visit date, encounter provider, PCP2. Provider comments1. Here’s what you have2. Here’s what it means3. Here’s what you do3. Vital signs for visit1. BP & Pulse2. Weight and BMI4. Encounter diagnoses1. Reason for visit: chief complaint2. Diagnoses corresponding to the issues addressed3. Diagnoses associated with incidental orders5. Encounter orders1. Tests ordered2. Treatments Medications: ordered, reordered or discontinued Other treatments3. Referrals6. Results of tests availableby the end of the visit1. Laboratory tests2. Imaging tests3. ECGs and other ancillary tests7. Updated medication list1. Medications2. Date last updated8. Current allergy list1. Allergies2. Dates last reviewed9. Problem list1. Acute and chronic problems by ICD/SNOMED2. Dates last reviewed with updated status10. Chronic condition monitoring1. List of recommended monitoring with results and dates of last2. List of recommended monitoring activities due3. For tobacco users, resources available for cessation11. Health maintenance (HM)1. Reconcile patient information on most recent HM results/dates with EHR data2. Order and pend interventions that are dueProviding Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 5 of 24
Key Components of a System for Assuring Patient Receives anAfter-Visit Summary at the End of the Office VisitThe order in which the information from Table 1 appears on the AVS is not the same as the order in which it is collectedduring a visit. Patients must be able to look at an AVS and quickly see the most important content of the visit, specificallywhat was decided during the visit, in a format that helps the patient easily understand what they need to do. On theother hand, the process of registration, rooming, and seeing the provider will determine the order in which informationthat goes into the AVS is collected.The information for the AVS that non-provider members of the care team collect before the provider enters the examroom is of major value to the provider and the patient in making sound clinical decisions. The key steps in assemblingthe information for the AVS are shown in flow diagram format in Figure 1.Figure 1. Key components of a system for assembling the AVS1The Huddle: Preparing the Care Team2The Pre-Visit Summary: Activating the Patient3Rooming the Patient: Synchronizing Patient and Care Team4The Visit: Productive Interactions5Publishing the After-Visit Summary (AVS)These 5 key workflow components represent the steps necessary for a patient to receive an AVS at the end of an officevisit. They are based on the Planned Care Model developed by Wagner and associates initially to describe the elementsof chronic illness care shown in Figure 2 on page 7 (Glasgow, 2001). Using this model, the purpose of integratingdelivery system design, decision support, and clinical information systems with community resources includingself-management support, is to facilitate productive interactions between a prepared proactive practice team andan informed activated patient as a strategy for improving outcomes.Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 6 of 24
Figure 2. The Planned Care ModelDeveloped by The Sandy MacColl Institute ACP-ASIM Journals and BooksThe steps presented here to produce an AVS serve to organize the visit by preparing the practice, activating the patients,and bringing both parties together for productive interactions. In most cases these steps will require planning, practice,and some degree of modification to individual clinical settings to be successful. The five steps are:1) The huddle is a short meeting in which the care team,including the provider, prepare for each patient andplan their work at the start of each day.2) The pre-visit summary is a short paper documentthe front desk clerk gives each patient upon arrivalat the clinic containing key information from themedical record to review before seeing the care team.3) While rooming the patient, the clinical assistant (CA)1gathers standard information such as vital signs,reviews the pre-visit summary with the patient toupdate information in the EHR, and addresses caregaps raised in the huddle, which may include enteringpended orders and synchronizing goals of thepatient with those of the care team.4) During the patient visit the provider and the patientmake clinical decisions, which the provider enters intothe EHR as orders for tests, treatments and referrals.The provider enters these decisions into the EHRas orders.5) At the end of the visit the provider reviews theAVS with the patient and prints a copy.When these steps are performed reliably, giving anaccurate clinical summary to the patient at the end ofthe visit is relatively straightforward. Omitting theseinformation management steps makes it more difficult toassure that patients and their clinical team receive the fullvalue from the visit and the clinical summary.1 For purposes of brevity, the term clinical assistant or CA has been applied to the back-office clinical personnel that most commonly work in a dyad with primary careproviders. Depending on state scope of practice laws this role may also be filled by medical assistants, (MAs) licensed practical nurses (LPNs) or licensed vocational nurses(LVNs), with scopes of practice that vary from state to state. Best practice workflows can be modified to reflect scope of practice and composition of the primary care team.Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 7 of 24
The Five Steps to Developing a Successful After-Visit Summary Workflow ProcessStep 1. The HuddlePurpose:Workflow Considerations:The purpose of the huddle is to mentally prepare theclinical team, synchronize staff expectations, andassemble the information and equipment needed forthe visit (Bodenheimer, 2007). The huddle is also anThe exact workflow of the huddle will depend on the teamcomposition, how long they have been having huddles,and how innovative they have been in using the huddleto drive change. Whether the team consists of a providerand a single CA or a more complex configuration, the goalof the huddle is to rapidly review the charts of the patientson the day’s schedule and make a list for each patientof missing information to retrieve prior to the visit andone or two care gaps to close while rooming the patient.Once the routine of the huddle has been established itmakes sense for a designated team member in advanceof the huddle to carefully “scrub” the chart of everypatient making a complete list of missing information andall the care gaps that could be closed for each patientduring their visit. Once this list for the day is complete,the provider joins the other team members for the huddlein which the action list for each patient is prioritized. Thehuddle itself should occur at the start of each day, andtake no more than a total of 10 or 15 minutes.opportunity for team members to plan ways to effectivelyengage patients in gathering information that will beincluded in the AVS. This step of mental preparation foreach patient on the day’s schedule is designed to improvethe team’s efficiency in making clinical decisions duringthe limited time the patient is in the clinic.In order to be of value, the huddle must result in actionsthat improve the efficiency of the clinical team for the restof the day. Useful action items resulting from a huddle areof three types: 1) decisions to assemble information andresources prior to a patient’s arrival, 2) decisions to closequality gaps in a patient’s overall care, and 3) contingencyplanning for same-day access and other situations thatmay impact the care team’s day (Murray, 2003).Ideally, the EHR will have a dashboard or “snapshot”view displaying key information for each patient includingdemographics, PCP, reason for visit, problem list,medication and allergy lists, health maintenance actionshighlighting those that are due, and the chart note fromthe most recent visit. It is easier to quickly assess eachpatient’s care gaps during the huddle than after thepatient arrives in the office with an agenda of their ownthat may take precedence. The provider and the CAshould spend no more than an average of 30 secondson each patient looking for action items that the CA willperform before the provider sees the patient. The CAshould have a paper copy of the patient list for the day onwhich to quickly write down action item(s) resulting fromthe huddle.Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 8 of 24
Some tests can be predicted based on the patient’sreason for visit and can be ordered during the huddle.Placing orders in the huddle can also serve as analternative workflow if the EHR does not allow a CA toplace a pended order while rooming the patient for theprovider to sign during the visit. The advantage of havingthe test results available at the start of the visit must beweighed against the disadvantages of:Getting Started — Tips for Success: The key to getting started is to keep the focus fairlyspecific and not do too much. It is important to seta limit on the length of a huddle. A huddle lastinglonger than 10-15 minutes may not be sustainablefor a team. Limit the scope of the huddle to what can bereasonably accomplished. It is better to do less andstay on schedule than to try to do more and disruptthe care team’s day. With time, a team will becomeadept at handling more clinical tasks, and the burdenof overdue health maintenance issues willgradually decline. A good way to get started is to generate only oneaction item for each patient and prioritize the actionitems. If a critical report is missing and must beobtained prior to the visit, then that becomes theaction. If no such information exists then the teamshould identify one health maintenance action item.If there are no overdue health maintenance issuesthen the team should proceed to the next patient.Chronic conditions can wait until the team hasbecome adept at the mechanics of a huddle andcarrying out a handful of simple action items. Atsome point these starting activities will becomesecond nature, and the team can start to addchronic conditions.1) Assuming the information in the EHR on which thedecision to place the order is based is correct (whichmay not the case),2) The risk of having to send the patient back to thelaboratory for a second blood draw for tests that couldnot be predicted at the time of the huddle, and3) The fact that the patient has no opportunity toparticipate in clinical decisions made in the huddle.Figure 3 illustrates the huddle workflow of ahigh-performance care team.Figure 3. The huddleCA opensthe day’sscheduleCA scrubs chart of each patient1) Information needed for visit2) HM care gaps3) Chronic disease care gapsProvider joins huddleand team prioritizeseach patient’saction itemTeam reviewsthe day’scontingencyplanHuddle endsProviding Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 9 of 24
Common Issues:Step 2. Pre-visit Summary1. Not my patient: If a patient on a provider’s schedulehas a different PCP, and the PCP is in the clinicthat day, it makes sense for the two providers to talkin advance of the visit to decide how the patientshould be handled. If the patient’s PCP is not in theclinic then the team should treat the patient as theywould their own patients in terms of action items fromthe huddle.Purpose:2. Not my CA: If the provider is working with a clinicalassistant other than the usual team member it isprudent for the provider to assure the assistant knowshow to carry out specific action items decided in thehuddle. Different teams in the same clinic may be atdifferent stages of huddle proficiencyLike the huddle, a pre-visit summary is not a requirementfor meaningful use of an EHR. However, the accuracy ofinformation obtained from patients is time limited andmust be updated by the clinical team if it is to be accurateenough to use in clinical decision-making and includedin the clinical visit summary. The pre-visit summary is anefficient way to 1) engage and activate patients in thinkingabout specific details of their health information, 2) ensureaccurate current information by showing the patient theEHR record of recommended health maintenance issuesand have the patient identify gaps, and 3) reduce the timerequired to update patient charts prior to their seeing theprovider (Beard 2012, Keshavjee 2008, Krist 2011).3. Patients added to the schedule after the huddle:
Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide Page 3 of 24 Executive Summary The Centers for Medicare and Medicaid Services (CMS) include the practice of giving a clinical summary to patients after each office visit as an element of Meaningful Use of an electronic health record (EHR) Stage One.
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