Objective:
Measure:
Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days.
Clinical Importance
The Clinical Summary—which includes basic clinical information regarding the care provided, such as medications, upcoming appointments, or other instructions—affords better communication around pertinent health information. The clinical summary is shared with both patients and family members to increase awareness of what occurred during office visits and can be used to assist in care coordination.
Lessons from the Field
Implementers in the field have identified the importance of workflow when compiling an after visit summary for their patients. The goal is for everyone who works with the patient to enter as much data as their particular license permits. The physician can simply review the information that front desk or nursing staff enters into the EHR, allowing the physician more time to focus on the patient. This takes a clinical team coming together with representation from each of the job roles. Once a workflow is defined, vigilant implementation is encouraged so that the clinic can work out any bugs and develop confidence in the process before going live across all patients and providers.
One clinical summary workflow that has worked in the field is when providers do all they can to finish their assessment and plan prior to the patient leaving the exam room. The summary doesn’t require a cognitive discussion for a particular problem; but it should include the diagnosis, labs and referrals that are made. The remaining details about the visit do not need to be included for the clinical summary to be printed and given to the patient.
Clinical summaries are not always ready and available at the end of the patient appointment, although sending a clinical summary through a patient portal when available provides some relief. Some patients request hard copies and the nature and sensitivity of patient situations may present challenges. It is important to be creative in adjusting processes and workflows to accommodate all situations. In order to alleviate the pressures of providing “just in time” clinical summaries, some practices post notices in their office alerting patients to the availability of the patient portal and option to provide self-addressed stamped envelopes for a hard copy.