Measure 13 Clinical Summaries
13 of 15 Core
Stage 1
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Clinical Summaries
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Objective
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Provide clinical summaries for patients for each office visit.
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Measure
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Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days.
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Exclusion
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Any EP who has no office visits during the EHR reporting period.
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Definition of Terms
Clinical Summary - An after visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, providers office contact information, date and location of visit, an updated medication list, updated vitals, reasons 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 adminsted during visit, summary of topics covered/considered during visit, time an dlocation 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), symptoms.
Office Visits - Office visits include separate, billable encounters that result from evaluation and management services provided to the patient and include (1) Concurrent care or transfer of care visits, (2) Consultant visits, or (3) Prolonged Physician Service without Direct (Face to Face) Patient Contact (Tele-Health). A consultant visit occurs when a provider is asked to render an expert opinion/service for a specific condition or problem by a referring provider.
Attestation Requirements
NUMERATOR / DENOMINATOR
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DENOMINATOR: Number of unique patients seen by the EP during the EHR reporting period.
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NUMERATOR: Number of office visits in the denominator for which the patient is provided a clinical summary within three business days.
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EXCLUSION: EP's who have not office visits during the EHR reporting period would be excluded from this requirment. Ep's must enter "0" in the Exclusion box to attest to exclusion from this requirement.
The resulting percentage must be more than 50 percent in order for an EP to meet this measure.
Additional Information
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The provider is permitted, but not required, to limit the measure of this objective to those patients whose records are maintained using certified EHR technology.
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The provision of the clinical summary is limited to the information contained within the certified EHR technology.
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The clinical summary can be provided through a PHR, patient portal on the web site, secure e-mail, electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request.
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If an EP believes that substantial harm may arise from the disclosure of particular information, an EP may choose to withhold tht particular information from the clinical summary.
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Providers should not charge patients a fee to provide this information.
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When a patient visit lasts several days and the patient is seen by multiple EPs, a single clinical summary at the end of the visit can be used to meet the meaningful use objective for provide clinical summaries for patients after each office visit.
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The EP must include all of teh items listed under "Clinical Summary" in the above "Definition of Terms" section that can be populated into the clinical summary by certified EHR technology. If the EP's certified EHR technology cannot populate all of these fields, then at a minimum th eEP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of thei program (according to 170.304(j))):
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Problem List
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Diagnostic Test Results
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Medication List
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Medication Allergy List
