Home Forums Discussions Meaningful Use How are Practices handling clinical summaries

How has your practice handled MU core measure 13. Clinical Summaries for 50%+ of office visits within 3 business days are dispensed to the patient?

We are going to use Updox's patient portal, the Doctor will likely 'template' a good chunk of full notes into AC, and Dictate/have Transcribed the rest. The chart will not be signed until well after the patient leaves, however, so no printing.

My thought. Transcribed notes comes back (or plan is sitting in AC with chart signed). Staff member copy-pastes relevant section from Transcription's word Doc, into Plan section in AC (or skips this part if templated in AC already). File>Print into Updox . Then, Send to Patient portal. Times 20+ patients a day, it could take 45min to an hour. Any suggestions on a faster method?

Implore your doc to finish the note while in the room...either typing and templating or Dragon dictating. One thing I changed a bit in my style of "the Plan" is to have a section called "Info for patient". I then type (using the program Shortkeys mostly) like I am talking to the patient, e.g. "1.I want you to check your bp daily and record the results. Bring this record with you to your next visit. 2. Please consider stopping smoking. If you are interested I can make some suggestions which might help you quit. 3.CT chest with and without contrast. 4. Consult Dr. Schreiber to schedule a screening colon exam. 5. Return in 6 weeks....etc..."

Then, when you choose to print out the stuff, choose "Print Preview". There you can highlight and delete things you do not want the patient to have such as comments like "The patient was strongly urged to better control his bp but to this point, he has been fairly non-compliant."

Then print and the doc is finished, the patient has their scripts, orders, referrals, tests and summary of their visit. Granted, it means more of the responsibility for the secretarial junk is put on the doc but I know of no other way to get around this. Thank you, MU.

Leslie,

This is my goal, but with the Doc seeing 30+ patients per day, and not not being the friendliest on computers, having him use templates for more than the routine care patients' notes isn't an option right away. Regarding Dragon, he speaks so low and fast that the program will get 2 words right out of every 10. Using macro's through dragon is an option, along with the templates, but I doubt that Dragon would be used in-room when the patient is in there.

Well, my reply would be that, if he intends to comply with Obamacare and plans to do MU then he will in all likelihood HAVE to change some things. The one thing that is for sure is that NO EMR will ever fit any doc's style completely. Unfortunately, the doc is the one that will have to do the changing. Otherwise, he might as well stick with paper and forgo MU.

Leslie: I have been doing much the same. However, I have been thinking that the patient may see both 'ways of saying it' if they ever request their chart. i.e. "The patient has been non-compliant and thus far refused to take medication necessary to control BP." "Please consider trying to take your medicine for better control"

One solution I have seen is a doctor who wrote all his notes as if 'to' the patient. For instance: "I recommend you control your BP with sticking closely to the plan we discussed." I would be interested in seeing if any AC forum readers write all their notes 'to' the patient as well.

Another doctor friend of mine dictates, but he does it in the room. This might sound strange, but it can be very enlightening and appreciated by the patients. It serves as a good review of the visit, and they are surprised it is actually so well-organized in the doctors mind.

Chris,
I never put anything really incriminating in the chart. What I write is always true but may not be "liked" by the patient. If they request their chart then, in my experience, they are planning to go elsewhere. I feel the new doctor deserves to know the real problems which have been encountered while I tried to treat this patient.

I agree with Leslie and do very similar.

We're about 75% compliant with MU already, so going backwards isn't an option. I have to be the messenger who gets shot in this scenario! (The IT guy generally is).

You know, even though the patient might become enraged, this is probably a really good thing for him/her to see if they have been refusing medication. We see this all the time (as do all pcps). We have one who refuses to see a breast surgeon for the lump. I think I'm going to talk to Alice about dismissing her unless she goes.

Another option is to make them sign something for the chart that clearly states they are electing to go against medical advice. But I agree with letting them go perhaps, as they don't seem to trust your medical rec and probably will be happy to sue later saying it wasn't fully explained.

Measure 13 (clinical summaries) is a good starting point for a discussion of the next phase in MU. By "next phase" I do NOT mean "phase 2": I mean "using MU to improve patient care". For many of us, ever since we heard about the MU program, our focus has been on meeting the MU criteria to get the incentive. In the process of doing so, I could see some potential real value to the patient; this is not all an exercise to get us some money. Having gotten the payment, I would like to move towards using AC and MU to improve patient care. If you consider the idea of providing "an after-visit summary that provides a patient with relevant and actionable information and instructions", which is what the MU measure says; well that is a pretty laudable goal. While I have not always done it, I have often felt that it would be a good idea. So if AC can make it easily doable, then it is a win-win; better patient care and we get the MU incentive.

Given that I want to provide a summary, the next issue is "exactly what do I want to provide"? The required list provided in the measure: (click here and go to the definition of terms for "clinical summary"). It is actually not a bad list.

It would nice if you could edit the list (removing certain sections) and format it to our liking. But here is the issue: on one hand, you want to be able to tailor the document to include the items and look the way you choose, but on the other, you want it to happen quickly and effortlessly. Some compromise is in order.

What are our choices now?
1. Apparently you can meet the MU measure by offering the summary; if the patient refuses, there is no need to print one. This is most easily achieved by hitting "preview" in the "Print instructions (summary)" screen and then closing, without printing. This meets the MU requirement without any patient benefit. Brock, you might consider that. It is what I did initially.

2. You can do print the CCD and give that to the patient after each visit. Upside is meeting MU, providing some significant useful information to the patient, and doing so very quickly and easily. Downside: lots of extra paper and verbiage, often to the point of overwhelming the patient and wasting their time.

3. Use the "Plan" section of AC which is then printed and given to the patient (without the CCD). This also gives significant useful information (date of visit, who they saw, medication list and new and dc'd meds, ordered tests and referrals) and is very fast and easy. Downside: it doesn't meet MU, though you can hit "preview" (including the CCD) and then print the letter but not the CCD, and you are all set with MU as well.

One proposal for AC: in the letter writer there is an option to select sections of the encounter which are included in the letter. How about a similar option to select which portions of the CCD are printed to be provided to the patient? That would make it quick, easy, and worthwhile to use the CCD to meet the criteria.

Boondoc, Alice has done that in the past, but not in her private practice. She has told me of when she had stopped prescribing Vioxx a few years before the hoopla started, but it had been mentioned in some medical journals. When patients insisted upon it, she just pulled out that letter for them to sign. All of her patients on it except one, when they read the letter for them to sign, elected to go ahead and change the medication. That one told her that the pain was so bad, they just had to take the risk.

That letter is a good idea.

JBS,

Good points. The doctor here provides the best patient care he can, while seeing enough patients per day to keep the lights on. Slowing down the 'front-end' flow even by 2-3 minutes extra per patient is not something the doc wants to. However, here we all see the potential for some great things to happen with patient care and information. The clinical summary has the capability to cut down on post-visit phone calls, wrong med dosages being taken, etc.

Our Problem: For the majority of our encounters, there will be little/no info in the 'plan' section when the patient leaves the office. We are still dictating many office visits, and have to wait 24-48hours for that dictation to come back to fill in the 'right side' of the chart note. (Objective and Plan).

I'm getting creative by using this approach:

1. Mr. Smith is seen - Demographics, Vitals, CC-HPI-PMH/SH-FH Meds and Allergies are all filled in.
2. Mr. Smith Leaves office
3. Chart is open in exam room - Nurse forwards chart to other Staff
4. Dictation comes back 24-48hrs later
5. Staff member opens up Mr. Smiths chart from inbox. Copy/Pastes Dictated portion of the note into Amazing Charts.
6. 'Prints' into Updox the Clinical Summary + CCD. Uploads to Portal
7. Sends Mr. Smiths chart to the Doctor to be signed.

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If we just used Templates for everything, and the doc signed the note in the room, this would be avoided. However, The doctor feels that he can dictate faster than he can type and is careful regarding using templates heavily, as he believes that CMS would have a hissy-fit if they thought we were rubber-stamping our notes.
Thoughts?

Tampabrock: may not be an option, but learning to *fast* touch type might simplify things greatly along with templates and QUickKeys for abbreviations

And Brock, how about using Dragon?

Boondoc: Every day the staff is getting faster, now its up to me to put in some good templates and get their feedback on it!

JBS: The Doc speaks VERY fast and low. We have a version of dragon that is only 2-3 years old, but it cant keep up with him. The doc actually suggested using Dragon Macros, plus slowing down to fill in the blanks. Im going to give that a shot and set up a test