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Clinical Visit Summary – A Great Idea that Needs Work

Clinical Visit Summary – A Great Idea that Needs Work

At our organization our physicians have been providing written patient instructions for several years.  This widespread custom grew out of existing capabilities within our EHR (a patient instructions form customized by specialty – such that statements of instructions could mostly be entered with a single click per instruction) AND compliance with our interpretation of a Joint Commission standard, which was to provide patients with a copy of their up-to-date medication list after most every visit.  After far too many meetings with doctors in multiple specialties and compliance directors across our health system – we developed a handout – which included customized instructions AND the current medication list.  As more doctors thought about what we were doing and how it could be done better for their practices, we developed dozens of customizations per specific practices and specialties.  More generic enhancements were also included, such as the name of the doctor who saw you that day (very important for residency and faculty practices), a list of new prescriptions, instructions on outdated medication disposal, and a list of new current and future orders.  This form was in fact very popular with patients and doctors until October of 2011, when I changed it to be compliant with Meaningful Use. 

What was formerly 1-2 pages now became 2-6 – as it now also included the problem list, the allergy list, vital signs, and where available, results.  Doctors were quite vocal, “What is all this crap!”  “It’s too long – patients will miss the important features and get lost!”  And my favorite comment, “Health IT + Meaningful Use = more wasted paper!”

Most of the concern interestingly was making the often “dirty” problem list directly visible to the patient.  In many instances, the cause was many doctors writing to the problem list (we have a single patient – one chart model), and few doctors ever deleting old problems.  Some problem lists had over 50 items listed (perhaps a dozen were relevant).  OK – as many people have said, even where health IT does not cause a problem, it shines a bright light at what is.  We have a problem list problem, and that was not visible until we started the journey towards Meaningful Use.  And the problem list problem revealed other problems – who owns problem list maintenance and something even more basic (though really very complicated) – what belongs on the problem list.  Some docs were using the problem list to house a concern or symptom cluster – as a reminder system for themselves to do further workup or think about a possible diagnosis at some future date. Others were using the problem list for past history and family history (even though there are dedicated fields for both elsewhere).  And it raised questions about what to do with patients who had previously had cancer.  Does that stay on the problem list forever?  If not, at what point does one move it to past medical history – or keep it on the problem list but with the appropriate V code for “personal history of…”?

We also received some very thoughtful comments about building in capabilities to mask information. For example, a patient is here with her spouse, and the doctor uncovers domestic abuse.  It then goes into the problem list and is printed and handed to the patient at check-out, and the patient’s abusive husband is now aware of what the doctor just promised the patient would be handled (for now) without her husband being informed.  Or… the director of our adolescent medicine eating disorders’ clinic saw that a basic tenant of eating disorder management – reducing hyper-self awareness of weight and BMI – was now in bolded print in the hands of the teenager who just promised the doc not to weigh herself 5 times a day.

Fortunately the Meaningful Use regs allow for doctors to withhold certain information if in the judgment of the provider, that information may be harmful to the patient.  But that meant we had to build a way to easily provide the summary AND easily provide a way to thoughtfully customize it – we think we are finally there.

But the biggest concern raised by many physicians – the clinical visit summary includes several mandatory fields, but does not mandate the most important field – specific patient instructions.  Or, for a patient struggling to get his diabetes under control, patient instructions, a dashboard, the care plan, and progress on goals – again, not a part of the Clinical Visit Summary.  And many docs felt that if they add these fields to an already bloated document – the patient may get lost in the “firehose” of information.

Bottom line.  The clinical visit summary is a good idea.  In general, patients love it.  They have in their hands (and/or electronically) key elements of their health information, and at a time when research tells us that much key health information and instructions are otherwise forgotten (often even before the patient leaves the office). If not for Meaningful Use, we would perhaps have moved in this direction, but not this far and this fast.  My wish for the Clinical Visit Summary in stages 2 and 3 of Meaningful Use… Learn from the experience of physicians and more importantly from patients.  Let’s include what works and what patients find useful? Let’s also consider removing or making optional what doesn’t work. Perhaps this could lead us to support a more flexible / customizable Clinical Visit Summary, that starts with key new elements (patient instructions and where appropriate, care plan and progress on goals), and when not necessary, have the ability to shorten or remove select fields that the patient may not want or find useful (except perhaps on an annual basis, and not every visit).

About Peter Basch, MD

Medical Director, Ambulatory EHR and Health Information Technology Policy
MedStar Health

Washington, DC

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