APMA News - February 2011 - (Page 46)

I IT Consultant I Mastering the Clinical Summary Measure By MiChaEl Brody, dPM This month’s IT Consultant column will deal with one of the more difficult aspects of meeting meaningful-use criteria: the clinical summary measure. To meet this measure, we are required to provide clinical summaries for patients for each office visit. As defined by CMS, a clinical summary is an after-visit summary that provides a patient with relevant and actionable information and instructions. The summary must include: If you believe substantial harm may arise from the disclosure of particular information, you may choose to withhold that information from the clinical summary. You may not charge patients for the clinical summary. You can provide it on paper; via personal health record (PHR), such as Microsoft Healthvault or Google Health; through your patient portal (discussed in more detail later in this article); on a CD; or by USB drive. EHR software. The options you have depend upon the features available in your EHR software. Whether you provide a printed or electronic clinical summary, your EHR program will track whether or not you generated the summary, the method used to generate the summary, and the date the summary was created. It will track your actions to determine whether or not the summary was created within three business days. To meet this measure, you must provide clinical summaries 50 percent of the time. This means that a patient who visits your practice six times during the year could receive up to six clinical summaries and must receive a minimum of three clinical summaries in order for you to meet meaningful use requirements. We all will run into patients who do not have PHRs, who do not want a printout of the clinical summary, or who refuse to take one. If more than half of your patients fall into this category, it may create problems for you in meeting this measure. If your software has a built-in patient portal, you will be able to provide patients with an account on the portal, and then post the information to the portal for the patient’s review, thus satisfying the requirement to provide the clinical summary. Whether or not the patient accesses the summary is his or her decision. If a patient requests printouts of the clinical summary, you must provide him or her with the paper copy and cannot force the patient to use the portal. The clinical summary measure is one of the more work-intensive measures of meaningful use, but it is a core measure, and you will need to meet it to receive your incentive payment. n • • • • • • • • • • • • • • Patient name Practice name/information Date of the visit Reason for the visit (chief complaint) Vitals that were measured during this visit Current medication list Current problem list Services provided (a written summary, not a CPT code) Medications administered and procedures completed Time/date of next appointment (can be a date or can be a timeframe, such as three months) List of tests ordered and referrals provided and time/date for each, if available Location for any tests/referrals and whom the patient is to see Lab results for tests performed during this visit if received within 24 hours after this office visit Patient educational materials provided (either verbally or on paper) The clinical summary measure is one of the more work-intensive measures of meaningful use, but it is a core measure, and you will need to meet it to receive your incentive payment. Once the information is in the computer, the software can generate the clinical summary, but how do you manage the workflow of delivering it to the patient? If you complete the patient’s chart at the time of the encounter, your front desk staff can print the summary and hand it to the patient as he or she is checking out of the office. Otherwise, you have three business days to deliver the summary to the patient. If the patient does not walk out the door with the clinical summary, you have two options for getting the clinical summary to the patient: mail or electronic delivery. If you choose to mail summaries, consider including information on services you provide to promote your practice to your existing patients. Electronic delivery can be accomplished by publishing the clinical summary to the patient’s PHR or to a patient portal that is bundled with your Ensure all required information is documented in the electronic health record (EHR) in such a manner that it can be put into the clinical summary. Work with your software vendor to complete this task, if needed. 46 Dr. Brody is a noted expert on health information technology. He is a member of the Health Information Technology Standards Panel, the New York E-Health Coalition, and the Healthcare Information Management and Systems Society. APMA News l February 2011

Table of Contents for the Digital Edition of APMA News - February 2011

APMA News - February 2011
Contents
In Short
President’s Message
A New Era in APMA Communications
Model Fee-Parity Law Now Available
Looking Forward to 2011 with ASPS
Nadia Sadeghi: A Long Road to Podiatric Medicine
Destination Boston: 2011 Annual Scientific Meeting
Annual Scientific Meeting Registration Form
Insurance Advisor
2011 Call for Awards Nominations
Members Who Know Media
CPME Update
Federal Advocacy Forum
Young Members Update
Coding Update
Talking Practice Enhancement
IT Consultant
New Members
Death Notices
In Memoriam: John Carson
Worthy of Note
Resolutions Submissions
Development Update
APMAPAC Update
Classified Advertising
Dates to Remember
Advertising Index

APMA News - February 2011