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. What is a clinical summary and what data must it contain? Submit an Article. Meaningful use core measure #13 requires the Eligible Professional to provide clinical summaries for patients on each office visit. 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But the measure that they’re using is that clinical summaries are provided to patients for more than fifty percent of office visits within three days… 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”. 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. Meaningful use core measure #13, the patient-generated clinical visit summary. saved. Authors Srinivas Emani 1 , Michael Healey, David Y Ting, Stuart R Lipsitz, Harley Ramelson, Vladimir Suric, David W Bates. EPs have the option to exclude this core measure if they “have no office visits during the EHR reporting period”. 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.”. If the, “When a patient visit lasts several days and the patient is seen by multiple, Universal Community Health moves from text-enabled telehealth to robust ‘tele-assisted care’, Konica Minolta pays $500K to settle EHR whistleblower case, AI-assisted EHR documentation will need human help, Symptom checker at Royal Marsden Hospital reduces COVID infection risk for cancer patients, Online scheduling portals promote care continuity – but may widen gaps in access, Healthcare execs say telehealth is their No. Electronic Health Records; Meaningful Use; Primary Health Care; Quality Improvement; The Centers for Medicaid Services (CMS) recommend physicians provide patients with an After-Visit Summary (AVS) following a clinic visit. Digital's ability to personalize is improving care delivery. Get news, updates, event invitations, and more delivered to your Inbox. 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. What is the minimum that is required? Request a Media Kit Get news, updates, event invitations, and more delivered to your Inbox – Sign Up. Please try again. Machine Learning & AI for Healthcare: Driving outcomes and innovation, Healthcare Security Forum: Strategic. 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. Meaningful Use was defined by the use of certified electronic health records (EHR) technology in a meaningful manner ensuring that the certified EHR technology connects in a manner that provides for the electronic exchange of health information to improve the quality of care. More specifically, this particular measure, the objective for after-visit-summaries is to provide one for each out-patient visit.

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