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Core Measures

Introduction.

The Core Quality Measures Collaborative (CQMC) is a  diverse coalition  of health care leaders representing over 75 consumer groups, medical associations, health insurance providers, purchasers and other quality stakeholders, all working together to develop and recommend core sets of measures by clinical area to assess and improve the quality of health care in America.  The coalition was established in 2015 by  America’s Health Insurance Providers  (AHIP) and the  Centers for Medicare & Medicaid Services  (CMS) and is convened by Battelle’s Partnership for Quality Measurement (PQM) in its role as the Consensus-Based Entity (CBE).  Please go to   https://p4qm.org/CQMC  for more information.

There is a great demand today for accurate, useful information on health care quality that can inform the decisions of consumers, employers, clinicians, and policymakers. This is increasingly important as the health care system moves towards value-based reimbursement models.

It is difficult to have actionable and useful information because clinicians must currently report multiple quality measures to different entities.  Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting health care providers.

To address this problem, CMS, commercial plans, Medicare and Medicaid managed care plans, purchasers, clinicians and other care provider organizations, and consumers worked together through the CQMC to identify core sets of quality measures that payers have committed to using for reporting as soon as feasible.  The guiding principles used by the CQMC in developing the core measure sets are that they be meaningful to patients, consumers, and clinicians, while reducing variability in measure selection, collection burden, and cost. The goal is to establish broadly agreed upon core measure sets that could be harmonized across both commercial and government payers.

Core Quality Measures

Using a multi-stakeholder, consensus-driven process, the CQMC, led by AHIP and its member plans, Chief Medical Officers, leaders from CMS, as well as national physician organizations, employers, and consumers, recommend core performance measure sets that promote alignment and harmonization of measure use and collection across payers in both the public and private sectors. 

Designed to be meaningful to patients, consumers, and clinicians, the alignment of these core measure sets will aid in:

• promotion of measurement that is evidence-based and generates valuable information for quality improvement,
• consumer decision-making,
• value-based payment and purchasing,
• reduction in the variability in measure selection, and
• decreased provider’s collection burden and cost.

CMS believes that by reducing burden on providers and focusing quality improvement on key areas across payers, quality of care can be improved for patients more effectively and efficiently.

To develop the core measure sets, the CQMC is split into workgroups and reviews measures currently in use by CMS and health plans as well as measures endorsed by the CBE for the individual measure sets. Based on this review and discussion, the workgroups identified a consensus core set for the selected clinical areas. This consensus core set was further discussed by all CQMC members before being finalized. Additionally, the CQMC developed a framework of aims and principles that informed the selection of core measure sets.

The core measures  can be found at:  https://p4qm.org/CQMC .

CMS is already using measures from each of the core sets. Using the notice and public comment rulemaking process, CMS also intends to implement new core measures across applicable Medicare and Medicaid quality programs as appropriate, while eliminating redundant measures that are not part of the core set.  Commercial health plans are rolling out the core measures as part of their contract cycle.

Ongoing monitoring by the CQMC of the use of these measures will enable modifications of measure sets, as needed, and based on lessons learned, including minimizing unintended consequences and selection of new measures as better measures become available.

Get Involved!

CMS looks forward to public input and comments on the measures included in these core measure sets when going through the public notice and rulemaking for implementation. 

Visit the PQM Website for more information about how to get involved in the CQMC.

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Meaningful Use: Clinical Summaries

One of the most mis-understood Meaningful Use core measures for EPs is the objective to: “Provide clinical summaries for patients for each office visit" The required measure threshold for this objective is that: “Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days."  EPs have the option to exclude this core measure if they “have no office visits during the EHR reporting period”.

So let’s define a few terms. What is a clinical summary and what data must it contain? CMS provides very specific clarification and for this measure defines a clinical summary as:

“An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) 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 administered during visit, summary of topics covered/considered during visit, time and location 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), and symptoms.”

We’ll what if you don’t have all that information to put into the clinical summary? What is the minimum that is required? CMS provides further detailed clarification of what minimum data set must be in the clinical summary:

“The EP must include all of the 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 the EP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)): Problem List, Diagnostic Test Results, Medication List, and Medication Allergy List."

One additional twist to this issue arises when a patient is seen by more than one EP at a practice and there are several visits and re-checks over several days, all related to a particular issue or episode. What is required then as far as the number of “office visits” and clinical summaries? Thankfully, CMS has also addressed this issue:   “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."

Jim Tate blogs regularly at HITECHAnswers .

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After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews

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Courtney R Lyles, Reena Gupta, Lina Tieu, Alicia Fernandez, After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews, Family Practice , Volume 36, Issue 2, April 2019, Pages 206–213, https://doi.org/10.1093/fampra/cmy045

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After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care.

First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care.

The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care.

There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.

Spurred by US health care reform and the subsequent Meaningful Use financial incentives, many US health care systems and clinicians have implemented electronic health records (EHRs) that adhere to specific requirements. This includes the requirement to provide a written clinical summary from the EHR to patients after each clinical encounter ( 1 )—referred to as an after-visit summary (AVS). AVS have had a rapid introduction into clinical practice ( 2 ), given that the vast majority of US hospitals (94%) and office-based health professionals (77%) met Stage 1 Meaningful Use metrics in 2014 ( 3 , 4 ), of which AVS was a core component. Even with impending changes to the Meaningful Use program in the coming years ( 5 ), the current practice of visit summaries in primary care is likely to continue as a part of patient-centred care, especially since consumers are now accustomed to written encounter summaries.

By providing patients with a written record of medical decisions and care plans, the use of AVS has the potential to improve patient knowledge, self-management and patient–provider communication. Numerous studies have documented barriers patients face in understanding and remembering information about their treatments and care plans after a visit ( 6–9 ). In particular, AVS use may hold great potential in addressing the well-documented barriers to patient–provider communication and shared decision making faced by vulnerable patients with limited health literacy and limited English proficiency ( 10–14 ). Despite this potential, there is limited research that explores AVS implementation in clinical practice and how its use has impacted patient and provider outcomes.

Because of the paucity of information available, there were two complementary objectives of this study: (i) to explore the existing literature on the current use of AVS and (ii) to gain perspectives from clinical leaders about the current implementation and potential for integrating AVS into clinical practice. In particular, we sought to integrate findings from these objectives, with a specific focus on vulnerable patient populations.

Literature review

In January 2018, we conducted a comprehensive search on PubMed to identify articles from the queries ‘after visit summary’, ‘visit summary’, ‘visit discharge’ and ‘clinical summary’. Papers were included if they (i) were published in English language and (ii) represented research conducted in the USA (where the term AVS is most commonly used). We excluded papers if (i) they mentioned the term AVS (such as being listed as one of many related EHR tools) but did not provide any data on AVS use specifically or (ii) if they were referring to a broader process of visit communication that did not involve the standardized AVS tool. We also reviewed the references lists of included articles to identify additional studies with a focus on AVS use. Although we had a specific interest in the impact of AVS use among vulnerable patients, we conducted a broad literature review on AVS because there were few studies identified overall.

The included articles were categorized by study type, as there was wide variation in the research goals. For example, several studies focused on provider perceptions/use of the AVS, which varied greatly from studies assessing the readability of the document or longer term patient understanding of the information provided. We also categorized the research methods employed as higher (e.g. trials, strong comparison groups) versus lower quality (e.g. case studies, lack of comparison group). Finally, within each type of research study, the small sample size of the included articles allowed us to directly summarize the major findings and provide examples of the key outcomes examined.

Key informant interviews

To complement this literature review, we also conducted a small qualitative study among leaders in primary care about their perceptions of AVS use in routine practice. Rather than using a random sampling approach that might have captured practices without any current routine AVS use, we instead used purposive sampling to identify a sample of leaders in high-performing primary care practices more likely to be attesting for Meaningful Use certification in their practices. Specifically, we first used reputational sampling from published literature of large demonstration projects that systematically identified high-performing sites in both academic and safety primary care sites ( 15 , 16 )—identifying and interviewing experts who had recently completed multiple site visits and in-depth observations of primary care practices nationally (including variation by region and practice type). We then used snowball sampling to identify the remaining key informants, ensuring that a significant portion (at least 1/3) of key informants were leaders or had extensive experience working with safety net health care settings, as this was a major objective of our study. This selection process did not target positive versus negative opinions of AVS use specifically, as interviewees had experience with AVS in practice that could have differed substantially from one another. In total, we conducted interviews with key informants from nine primary care sites, concluding after we had reached thematic saturation of the current types of AVS use.

We used a semi-structured interview guide to gain perspectives about (i) current AVS practices within their system (e.g. who is responsible for AVS distribution, the process for distributing AVS and how AVS information is customized), (ii) the potential of AVS to improve patient knowledge and outcomes within their system and more broadly across primary care systems nationwide, (iii) strategies to improve the use of AVS and (iv) specific considerations for using AVS for the care of individuals with limited English proficiency and limited health literacy.

The interviews were audio-recorded and transcribed for analysis. We used descriptive qualitative methods ( 17 ) to organize, categorize and code the transcripts across all of the major interview discussion topics. More specifically, we coded discrete information provided in the interviews into categories (such as the staff member responsible for AVS distribution at each site, the AVS features used the most, the AVS features viewed as least useful), as well as used thematic coding to capture broader ideas about team-based care, workflows and other topics that could influence the impact of AVS use in clinical care. All four co-authors conducted the key informant interviews and reached consensus on the final coding categories and emergent themes, and two of the co-authors (CRL and LT) completed the coding process on all transcripts once the codebook was established.

The University of California San Francisco Institutional Review Board deemed this study as not classifying as human subjects research.

Our literature review resulted in 263 articles (243 from PubMed, 20 manually identified from reference lists). We excluded 246 articles, resulting in 17 final articles ( Table 1 ). We developed four major categories of studies (not mutually exclusive):

Summary of articles included in after visit summary (AVS) literature review

EHRs, electronic health records; RCT, randomized controlled trial.

1. Case studies of implementation ( 15 , 18–22 );

2. Qualitative/quantitative assessments of patient perceptions ( 23–30 );

3. Qualitative/quantitative assessments of clinician perceptions ( 18 , 25 , 26 , 28 , 31 );

4. Observational studies or interventional research ( 25 , 32 , 33 ).

A substantial number of these studies used less rigorous methodological designs (such as convenience samples with pre-post self-reported measures); but 8 of the 14 studies ( 23–29 , 31 ) employed in-depth survey, qualitative or experimental methods.

Examples or case studies of AVS implementation in real-world practice

The articles examining implementation of AVS emphasized team-based approaches that utilized standard workflows. One study encouraged team-based responsibility, with nurses and medical assistants (MAs) delivering the AVS and care plan at the conclusion of the visit ( 15 ). Another study discussed the potential to integrate AVS into a health coaching model, using the AVS document as a tool to assess patient understanding ( 19 ). In the three content analyses, one study found only half of AVS contained information about follow-up appointments and only a quarter contained tailored AVS sections ( 18 ), while the others found that AVS were written with complex language and at a readability level requiring a higher level of education to understand ( 22 , 34 ).

Patient perceptions of AVS

Patient perspectives on AVS were favourable. In total, four qualitative studies ( 23 , 26 , 28 , 29 ) reported that patients used the document to relay information to their families or other physicians ( 23 , 28 , 29 ). However, patients expressed concerns about the accuracy of their information ( 26 , 28 , 29 ) and the potential for privacy breaches ( 28 , 29 ). While the overall readability of the AVS was problematic in some cases ( 26 , 29 ), many patients desired more information (such as more detailed information or context about their diagnoses and treatment/disease management) ( 30 ). Quantitative studies ( 24 , 25 , 27 ) echoed these themes: a vast majority of patients found the AVS useful, but only half or fewer reported using them after the visit.

Clinician perceptions of AVS

The studies examining clinician perceptions were focused on physicians. Overall, physicians had moderately favourable views of the ease and potential of using AVS for patient care and education ( 25 , 28 , 31 ). However, they expressed concerns about the high complexity of information and the lack of tailoring to the needs of specific patients ( 25 , 26 , 28 ), particularly with regard to literacy level and language. In addition, physicians expressed concerns about not always having sufficient time during practice to update the problem list or medication list and therefore mentioned errors and extraneous information (e.g. outdated diagnostic codes) ( 31 ).

Observational or interventional research using AVS

Three articles evaluated interventions centred on clinical applications of AVS, most of which did not result in significant findings. There was high variability in whether patients reported using AVS after their initial visits, from a small minority ( 25 ) to a majority of patients who received highly personalized versions ( 32 ). A randomized controlled trial of AVS content did not find significant differences in patient adherence, satisfaction or recall of medical information when directly comparing AVS documents with varying amounts of content ( 25 ). Patients’ recall of the information on the AVS was low (only ~33% of content categories); this recall of information was unexpectedly not related to patients’ health literacy status or the amount of information displayed.

In our key informant interviews, the final sample of nine interviewees represented academic, safety net and private practices ( Table 2 ). The vast majority of participants were using the Epic EHR system in their practice (similar to many other health care settings nationwide ( 35 )), even though we did not use this as a specific inclusion criterion. Despite this, several of the participants were also able to discuss more than one EHR given their experiences with multiple site visits or their previous clinical experience prior to Epic implementation.

Summary of key informant interviewees by site and role

Current state of AVS implementation

A high-level summary of the current AVS use is found in Table 3 . Major findings included the following.

Summary of current after-visit summary (AVS) implementation by interview site

EHRs, electronic health records.

Regular distribution of AVS

Likely driven by Meaningful Use, most clinics issued a printed AVS at the majority (if not all) of visits. In addition, many clinics used the ‘patient instructions’ section of the AVS to include personalized information like counselling recommendations and guidance for self-management.

I would say it’s probably the sections that are most used by the clinician are the blank free text space where you do write out some instructions.

Patients satisfied with AVS, but might not be using it

Several interviewees talked about positive patient perceptions (mirroring the literature review results above): ‘Patients actually really, really like having the information’. However, few to no interviewees suggested that the patients referred to the AVS post-visit: ‘I think the patient treats it like they would treat any other confusing piece of paper, which is either to throw it away before they leave the clinic or after they get home’.

Clinics not using AVS for patient teaching

The majority of practices did not use the AVS in a standard way to reinforce specific information with patients, instead printing and handing it out without explanation.

I’ve yet to find anyone, anyplace where someone goes over the After Visit Summary with the patient. And I’ve asked many places [even in high-performing sites] because it seems so obvious that you want to do that in terms of closing the loop…. It’s such a terrific way to close the loop, and it’s just surprising. People just don’t do it.

Slightly less than half of interviewees did mention highlighting some information on the AVS. Yet this was not done in a standardized way across clinicians or visits.

Importance of specific features of the current AVS

When considering specific features of the AVS ( Table 4 ), almost all participants expressed that the patient instructions section was most useful because of the ability to customize information easily. The medication list (if accurate) was also mentioned as useful. Finally, upcoming visits and care plans were also highlighted as potentially important (but perhaps not always standard).

Summary of best and worst features of after-visit summary (AVS) document by interview site

Next steps: overcoming barriers

The key informants unanimously felt that AVS could improve clinical outcomes if utilized properly. When asked about future changes in the Meaningful Use program related to the AVS, interviewees did not foresee abandoning this document in practice.

I think [the AVS] could be really important. I don’t think it’s important the way it’s used now, but I think it could be extremely important and extremely helpful.

Moving forward, improvements in AVS use were related to the following themes:

Team-based workflows

Interviewees expressed that non-clinicians are well positioned to use the AVS with patients for operational next steps (like follow-up appointments). Within the one clinic with a standard MA workflow already in place, the interviewee commented, ‘MAs really like it. They like being part of the process of closing the loop and just helping the patient with those final details’. In addition, MAs or other staff could likely counsel related to lifestyle (such as diet or exercise) or other content with additional training and/or support. For example, one interviewee stated that the MA could use the AVS more effectively, but only with guidance from a provider:

The problem is the MA would have to know which part of the After Visit Summary to go over because you don’t want to go over more than like a couple of things, because people are not going to walk on practice remembering eight or 10 things.

Focus within the AVS

In addition, there were many comments related to the idea that the AVS ‘seems to want to serve too many purposes’. In addition to multiple content areas like medications and diagnoses, clinicians also wrote in personalized instructions in varying ways. Therefore, the current AVS format was long and complex, especially to find specific necessary information from a single visit. Increased ability to customize the AVS in straightforward ways was viewed as critical.

Tailoring by language and literacy

Because the AVS was not available in non-English languages or with low-literacy text, interviewees requested adjusting content to improving patient communication. For example:

For our folks that speak other languages, we are really limited in terms of written instructions we can provide for them. I don’t have any good workaround for that. If there’s a way to do like the med chart with pictures, not just all words… [The AVS is] basically four pages of words.

Among a small amount of published literature on the topic, we found that patients perceive AVS positively, but few appear to routinely refer to the document after the visit. Clinicians surveyed in the published literature were less satisfied than patients with AVS. Moreover, beyond this literature review of existing research, we also conducted our own qualitative investigation among primary care leaders about their perceptions of AVS in high-performing clinical practices. Among these key informant interviewees, we found similar implementation experiences across a varied group of primary care practices. While a hardcopy AVS were distributed in virtually all encounters, there was uncertainty about whether patients used AVS and a lack of routine practice to educate patients about AVS content. The customized patient instructions section was viewed as most useful within the AVS, but this could be buried in the midst of other content. Despite such challenges, interviewees expressed overall positivity about the potential of the AVS to improve patient understanding in the future.

This is the first study to our knowledge that comprehensively studied the current use of AVS in real-world practices in combination with stakeholder perceptions across multiple health care settings about the best ways to improve AVS use for maximum impact. While interviewees in this study provided recommendations for improving the content of AVS to improve implementation, any content changes would be insufficient without additional workflows to support patient use and understanding. Future research is needed to understand whether and how AVS contribute to improved patient outcomes (e.g. understanding/retention, clinical outcomes) and to directly compare the impact of different workflows of AVS distribution. There is no published literature about electronic delivery of AVS through online patient portals, or comparisons of digital versus printed distribution. In addition, there is a need for research to compare workflows of teach-back ( 36 ) using AVS to determine the best modes for patient understanding and retention.

Our study supports previous research on patient–provider communication. For example, patients in our literature review expressed high interest in access to information from their medical encounters via AVS, which is similar to many other studies on patient interest in and satisfaction with access to their online medical record information ( 37 , 38 ). Moreover, our findings support previous work that that training and/or tools can improve in-person communication ( 39 ), especially for vulnerable patient populations ( 40 , 41 ), but this is the first study to our knowledge of whether the AVS is being used for patient education and teach-back. Moreover, implementation of these improved communication strategies into real-world settings requires overcoming obstacles such as under-staffing and insufficient time during visits.

There are several limitations of this study. First, the literature review may have missed studies using a structured process for delivering patient education materials at the conclusion of visits or hospitalizations. In addition, our qualitative sample was small and is not broadly generalizable, and most participants gave feedback on a single EHR product. In addition, the interviewees were all providers without any patient representation. However, we reached thematic saturation with this small but diverse set of interviewees across multiple health care settings.

Moving forward, patient summaries of information like AVS will likely continue to play a role in primary care. AVS utility for both patients and clinicians will likely increase as content and design are improved. The growth of the patient-centred medical home and the emphasis on team-based care will likely result in new roles and responsibilities for communication with patients, and AVS may take centre stage in workflow redesign. Over time, as federal policies and incentives for EHR use change, AVS will survive only if clinicians and patients find them relevant and useful.

Funding: The Roundtable on Health Literacy of the National Academies of Sciences, Engineering, and Medicine provided support for our investigations into AVS. CRL is supported by AHRQ R00HS022408.

Conflict of interest: The authors report no conflicts of interest.

We would like to thank all the people we interviewed who contributed their time to this project.

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Tieu L , Sarkar U , Schillinger D et al.  Barriers and facilitators to online portal use among patients and caregivers in a safety net health care system: a qualitative study . J Med Internet Res 2015 ; 17 : e275 .

Ha Dinh TT , Bonner A , Clark R , Ramsbotham J , Hines S . The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review . JBI Database System Rev Implement Rep 2016 ; 14 : 210 – 47 .

Wolff K , Cavanaugh K , Malone R et al.  The diabetes literacy and numeracy education toolkit (DLNET): materials to facilitate diabetes education and management in patients with low literacy and numeracy skills . Diabetes Educ 2009 ; 35 : 233 – 45 .

White RO , Eden S , Wallston KA et al.  Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting . Patient Educ Couns 2015 ; 98 : 144 – 9 .

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Assessing the Quality of the After-Visit Summary (AVS) in a Primary-Care Clinic

Affiliations.

• 1 From the Department of Family and Community Medicine, University of Texas Southwestern Medical School, Dallas, TX (THM); Family Medicine Residency Program, Gwinnett Medical Center, Lawrenceville, GA (AO); Department of Family and Community Medicine, University of Texas Health Sciences Center-San Antonio, San Antonio, TX (KK); Department of Family and Community Medicine, University of Texas-Southwestern Medical School, Dallas (KB, PD). [email protected].
• 2 From the Department of Family and Community Medicine, University of Texas Southwestern Medical School, Dallas, TX (THM); Family Medicine Residency Program, Gwinnett Medical Center, Lawrenceville, GA (AO); Department of Family and Community Medicine, University of Texas Health Sciences Center-San Antonio, San Antonio, TX (KK); Department of Family and Community Medicine, University of Texas-Southwestern Medical School, Dallas (KB, PD).
• PMID: 30610143
• DOI: 10.3122/jabfm.2019.01.180055

Background and objective: As part of Affordable Care Act, the Centers for Medicaid Services (CMS) recommend physicians provide patients with an After-Visit Summary (AVS) following a clinic visit. Information should be relevant and actionable with specific instructions regarding their visit and health. Until recently, this recommendation was included as part of meeting the standard for Stage 1 Meaningful Use for all physicians using electronic-health-record (EHR) technology. In 2016, CMS issued a Notice of Proposed Rulemaking to institute parts of the Medicare Access and CHIP Reauthorization Act of 2015 Merit-based Incentive Payment System, which continues to focus on quality, resource use, and use of certified EHR technology. The purpose of this study was to assess the usefulness of the AVS for patients seen at the Parkland Family Medicine Residency Clinic.

Methods: Electronic medical records of 250 randomly selected patients seen at the Parkland Family Medicine Residency Clinic between July 2013 and July 2014 were reviewed using the 3 W's question format, a modified version of the National Patient Safety Foundation's "Ask Me 3 Program," designed to improve communication between patients and their health care providers.

Results: The goal of the quality improvement study was to ensure that all patients receive a meaningful (relevant, accurate, and actionable) AVS after each clinic visit. Chart review indicated that 100% of patients received an AVS after each clinic visit. Of these patients, 51.2% were Spanish speaking, 47.2% English speaking, and 1.6% spoke neither English nor Spanish. Of the non-English-speaking patients, 84.8% received the AVS in their first language; the other 15.2% received the AVS in English. Sixteen percent (16%) of patients overall were considered to have received a nonmeaningful AVS. Reasons for the AVS not being meaningful included not containing any information on the patient's presenting problem (39.2%), physician intervention (35%), or plan of care (18.4%).

Conclusions: This study confirmed that although we demonstrate meaningful use of our EHR system, the content of the AVS needs to be improved on.

Keywords: Electronic Health Records; Meaningful Use; Primary Health Care; Quality Improvement.

© Copyright 2019 by the American Board of Family Medicine.

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After Visit Summaries: A Tool Whose Time Has Come for Use in Dentistry

In dentistry, an after visit summary (AVS) can be thought of in both the context of a standalone dental practice and as a combined summary integrating oral health-related information with medical information. In this commentary, the authors explore the AVS from both perspectives and make a case for considering the AVS as an important piece of the larger puzzle needed to improve oral health and general health literacy for all patients.

The concept of providing patients with an AVS is gaining attention as a result of the electronic health record (EHR) incentive program commonly known as “meaningful use” (MU). MU is a part of the Health Information Technology for Economic and Clinical Health (HITECH) Act that went into effect in February 2009 (DesRoches et al, 2013). However, the authors believe that AVS remains a foreign concept among the vast majority of dental practices in the United States that are either not eligible for MU or not aware of it (Schroeder et al, 2013).

In medical practice, an AVS is a clinical summary document that provides a patient with relevant and actionable information and instructions. It contains basic information, such as the patient’s name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures performed and followup instructions based on clinical discussions that took place during the office visit. It may also include any updates to a problem list and immunizations or medications administered. An important part of the AVS is the information provided on next steps for the patient, such as the time and location of the next scheduled appointment or a recommended appointment time, a list of additional appointments to schedule for needed laboratory or other diagnostic tests with contact information, recommended patient decision aids, and test or laboratory results (if received before 24 hours after visit) (CMS, 2013).

For patients with chronic disease or conditions that require self-management support, the content and methods of communication with patients and families are of critical importance (Horowitz et al, 2012). The AVS is a potential cornerstone of the self-management effort, whether the oral health care services are delivered alone or as part of an integrated health care system. In the hospital setting, many hospital outpatient ambulatory clinics have begun using an AVS in some cases, spurred on by MU incentives. The dental clinics within many of these hospitals also have begun using an AVS.

The potential exists to expand use of medical and dental AVS information to help patients understand their health conditions and guide them to self-manage their chronic diseases. Because people receive and process information differently and act on changing life and health practices when they are ready, it is important to ask patients directly how they learn best. The authors believe that educational materials, both print and electronic, need to be

• developed and tested with the ultimate target population,
• science-based in content,
• written in plain language,
• culturally appropriate,
• consistent with principles of health literacy, and
• aligned with the information given verbally.

The overall dental practice approach and how the care team delivers the prevention messages to patients are important (Horowitz et al, 2013); Maybury et al, 2013). Further, we believe it is important that the communication skills of providers with their patients should be enhanced (Rozier et al, 2011).

A previous Institute of Medicine report called for closer integration between dentistry and medicine on all levels of the health care system: research, education, and patient care (IOM, 1995). One of the first institutions to respond to the report was the Marshfield Clinic Health System (MCHS). Through its network of 50+ regional medical centers operated by Marshfield Clinic and nine federally qualified dental centers operated by Family Health Center of Marshfield, Inc., care is provided to approximately 400,000 patients residing in mostly rural counties of central, northern, and western Wisconsin by integrating medicine and dentistry in patient care, research, and educational endeavors.

Recognizing the impact of oral disease on both quality of life and systemic health, MCHS undertook the challenge of coordinating seamless care to its largely rural population across regional medical and dental centers by developing the first integrated medical-dental EHR (iEHR) in the country (Acharya et al, 2012). This integrated environment allows medical and dental providers to share real-time information about their patients’ medication, problems, adverse and allergic reactions, vitals, appointments, and demographics and administrative records from any of its regional centers and collaborating hospitals using its system. With the focus on patient-centric care, MCHS has also developed an AVS for both medical and dental practices, a printed copy of which is given to patients following each visit and is also available to the patients through the patient portal. The Health IT solution allows for the provider to select appropriate sections to be included in the patient’s AVS. For example, dental providers can remove the sections “immunization administered during visit” and “test/laboratory results” since dental providers usually are not involved in administering immunizations or conducting lab tests during office visits.

We believe strongly that oral health providers are key members of the multidisciplinary health team. Apart from the systemic diseases such as diabetes that are interconnected with oral diseases, there are several oral manifestations of systemic conditions. MCHS’s involvement in the Patient Centered Medical Home and Accountable Care Organization models is an important effort that will aid in increased understanding of the role of oral health within these models. As a pilot initiative, MCHS is coordinating its efforts in the management of about 16,000 diabetic patients it serves and the importance of their oral health. The AVS could serve as an important care coordination tool for the patients and the multi-disciplinary teams inside and outside of the health system, as it currently encapsulates core clinical summaries like referrals, medications, diagnostics information, problem lists and others as defined by the Centers for Medicare & Medicaid Services (CMS) (CMS, 2013). Early diagnosis and treatment can result from oral cavity examination findings that indicate an underlying systemic condition. Such findings can be shared by the dental providers with their patients and the patients’ medical providers. An AVS would clearly facilitate a better multi-disciplinary care team approach for managing not only diabetes but similar chronic conditions that require management of the oral health component. MCHS is also currently working on generating a combined AVS for the patients who may have had both medical and dental visits on the same day, which could be ideal for integrated health systems. However, there are still several challenges to achieving this.

The authors have found that there is a lack of formal definition of MU for dentistry within the context of the regulatory definition (ADA, 2010). Also lacking are interoperable electronic medical and dental health records in the EHR vendor community. However, since health IT has been rapidly changing the landscape of American health care in recent years, future capabilities exist not only to digitize the paper-based workflow but also to improve quality, efficiency, and patient-centered care (Buntin et al, 2010). Doing so will, we believe, result in integrating dentistry into the mainstream health care delivery model.

In our opinion, the adoption of the AVS could be extremely beneficial in transforming healthcare to a patient-centric care model in which patients can be engaged in their own health, assisted in remembering the activities that occurred during specific office visits (Lukoschek et al, 2003; Throop and Seidman, 2009), and facilitated in better self-management of their chronic conditions (Coulter, 2012). At the same time, by virtue of patients/guardians access to their own health information, health care providers may be incentivized to optimize the quality of the patient notes entered into the EHR (Markle Foundation, 2012). Yet, enabling the adoption of the AVS in dental practice will not be a trivial task because it will require substantial workflow changes, carry significant costs, and require smart Health IT solutions and support from dental vendors. However we believe that the benefits outweigh the challenges. Aside from hospital-based dental practices and community health centers, dental schools are excellent venues to test the use of the AVS, especially those that are located on the same campus as medicine, nursing, and pharmacy, where students can learn together to use EHR and AVS.

Although there is currently little evidence to support improved outcomes from using an AVS, the authors believe that providing information to patients about their disease, including their individual risk for disease, along with health support tools, has the potential to benefit individual patients and patient populations overall. We recommend research be conducted to build the evidence base on how best to construct an AVS that will be effective in fostering better self-management skills and behavior change that would lead to improve oral health and overall health outcomes.

• Acharya, A., N. Yoder, and G. Nycz. 2012. An integrated medical-dental electronic health record environment: A Marshfield experience. In Integration of medical and dental care and patient data, by V. Powell, J. H. Din, M. Franklin, A. Acharya, and M. H. TorresUrquidy. London: Springer London. Health Informatics Series, Vol 3: Pp. 331-351.
• American Dental Association. 2010. Electronic health record: Will federal government require it by 2014? American Dental Association News June 21, 2010. Available at: http://www.ada.org/news/4306.aspx (accessed May 26, 2014).
• Buntin, M. B., S. H. Jain, and D. Blumenthal. 2010. Health information technology: laying the infrastructure for national health reform. Health Affairs (Millwood) 29(6):1214-9. https://doi.org/10.1377/hlthaff.2010.0503
• CMS (Center for Medicare and Medicaid Services). 2013. Eligible professional meaningful use core measures, measure 13 of 14. Available at: http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/downloads/13_Clinical_Summaries.pdf (accessed April 26, 2014).
• Coulter, A. 2012. Patient engagement –What works? Journal of Ambulatory Care Management 35(2):80-89. https://doi.org/10.1097/JAC.0b013e318249e0fd
• DesRoches, C. M., D. Charles, M. F. Furukawa, M. S. Joshi, P. Kralovec, F. Mostashari, C. Worzala, and A. K. Jha. 2013. Adoption of electronic health records grows rapidly, but fewer than half of U.S. hospitals had at least a basic system in 2012. Health Affairs. https://doi.org/10.1377/hlthaff.2013.0308.
• Horowitz, A. M., M. Q. Wang, and D. V. Kleinman. 2012. Opinions of Maryland adults regarding communication practices of dentists and staff. Journal of Health Communication 17: 1204-1214. https://doi.org/10.1080/10810730.2012.665427
• Horowitz, A. M., J. C. Clovis, D. V. Kleinman, and M. Q. Wang. 2013. Use of recommended communication techniques by Maryland dental hygienists. Journal of Dental Hygiene 4:181-1192. https://doi.org/10.1371/journal.pone.0119855
• Institute of Medicine. 1995.  Dental Education at the Crossroads: Challenges and Change . Washington, DC: The National Academies Press. https://doi.org/10.17226/4925
• Lukoschek, P., M. Fazzari, and P. Marantz. 2003. Patient and physician factors predict patients’ comprehension health information. Patient Education and Counseling 50, 201-10. https://doi.org/10.1016/s0738-3991(02)00128-3
• Markle Foundation. 2012. P6: Patients’ access to their own health information. Available at: http://www.markle.org/health/markle-common-framework/connectingprofessionals/p6 (accessed May 26, 2014).
• Maybury, C., A. M. Horowitz, M. Q. Wang, and D. V. Kleinman. 2013. Use of communication techniques by Maryland dentists. Journal of the American Dental Association 144:1386-1396. https://doi.org/10.14219/jada.archive.2013.0075
• Rozier, G. R., A. M. Horowitz, and G. Podschun. 2011. Dentist-patient Communication Techniques Used in the United States: Results of a national survey. Journal of the American Dental Association 142:518-530. https://doi.org/10.14219/jada.archive.2011.0222
• Schroeder, D., K. Schwei, C. Rottscheit, C. Schneider, P. H. Chyou, and A. Acharya. 2013. Adoption of health information technology among dental practices in the United States. AMIA 2013 Annual Symposium Proceedings, Pp. 1248;2.
• Throop, C., and J. Seidman. 2009. The Ix after-visit summary. Center for Information Therapy. Available at: www.ixcenter.org (accessed June 24, 2014).

https://doi.org/10.31478/201407b

Suggested Citation

Horowitz, A. M., L. A. Robinson, M. W. Ng, and A. Acharya. 2014. After Visit Summaries: A Tool Whose Time Has Come for Use in Dentistry. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201407b

The views expressed in this discussion paper are those of the authors and not necessarily of the authors’ organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.

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After Visit Summary? We Don't Need Any Lousy AVS ... Or Do We?

— avs turned out to be a not so meaningful use.

by Fred Pelzman , MD October 29, 2015

Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

One of the many folders we are greeted with each morning in our electronic health record in-basket is entitled "System Notice." This folder contains messages sent from the support team to everyone using the electronic health record, informing them of planned service maintenance, global changes or new functionality, and other housekeeping items.

This week we received one entitled "Removal of All After Visit Summary Validations."

Here is what they told us in the message: "The AVS requirement is no longer required as a Meaningful Use measure by CMS."

Essentially, this is informing us that the Meaningful Use After Visit Summary is going to be "turned off." At the end of every office visit, we are greeted by a prompt, a soft stop in the system, recommending that an After Visit Summary be printed for the encounter and handed to the patient, to satisfy one of the Meaningful Use requirements.

The wording of the encounter prompt is that the Meaningful Use requirement of an After Visit Summary (AVS) being printed for this encounter was not completed, and that this patient is not active on the patient portal. We are told to "click here" to return to the encounter and print the AVS.

The only point of this After Visit Summary being printed and handed to the patient seemed to be that it satisfied a Meaningful Use requirement. It suggests that it wasn't being done for the purpose of actually taking really good care of our patients, just satisfying one of those boxes we all know and love.

Backwards Logic

The fact that the moment it is not required it is gone raises the hackles on the back of our necks.

This is all backwards. This is why we don't like checking boxes that satisfy requirements.

This is why the best way to take the best care of our patients and to produce true quality needs to come from us, the providers, the patients, and the entire team working on the patient's health.

We should rely on people who are designing a system to generate data to make us think we've provided quality.

The After Visit Summary collects data from within the EHR and the encounter, and prints it out in tabular format, for the patient to have with them as they leave the office. More paper, more trees being killed. Unclear benefit to the patient.

The AVS lists the patient's vital signs as documented in the encounter, their smoking status, problem list, current medications, allergies, immunization history, some demographics, referrals placed during that office visit, medications prescribed, labs ordered, and any patient instructions or education materials that were added through the electronic health record.

I've asked many of my patients what they do with this After Visit Summary, and mostly they end up in the same place that the endless paper discharge summaries our patients receive when they leave the emergency room or the inpatient service do: shoved to the bottom of their bags. Maybe, just maybe, if the need arises, the patients take a peek at what Dr. Pelzman was thinking, but for the most part I don't think it really makes much of a difference in their lives.

While the practice became the satisfying of a Meaningful Use requirement, the theory of an After Visit Summary was, like a hospital discharge summary, to create a useful documentation of what happened, and what needs to happen next, and what might happen.

What if we could figure out a way to make the spirit of an After Visit Summary become a viable one, a truly useful one for the patients -- then maybe we should turn that functionality back on.

A Meaningfully Useful AVS

What would an actually useful After Visit Summary contain?

It's a great question, and not an easy one to answer.

Just listing a bunch of things that have been downloaded from the electronic health record is probably not that useful, either to other providers who might see the patient, or to the patient themselves when they leave the office.

If it actually contained living, actionable information, links to what they should do about aspects of their health, ways to refill their medicines or tell us they've stopped them, links to the orders in the system so that they can see the results when they come back, reminders that pop up on their smartphone to tell them to put into play the activities that were recommended during the office visit. A mutually agreed on summary of what we had talked about in the visit, what I and they thought, and what I and they planned to do next.

Then we might really have something.

Some of this exists in crude form within the patient portal, and I hope we can move forward with creating really useful smart functionality out of a system that is at the moment just a bunch of paper and a meaningless bureaucratic check box.

So, in summary, the After Visit Summary for this column is:

1. Useless functionality is being turned off.

2. Not much thought went into creating the needed functionality to make it a really useful thing in the first place.

3. Potential exists to create a truly useful After Visit Summary that helps our patients move their health along the trajectory we planned during our office visit together.

4. Stay tuned.

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Final Medicaid Managed Care Rule Explained

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CMS recently finalized two key regulations: “ Ensuring Access to Medicaid Services ” (Access Rule) and “ Medicaid, CHIP Managed Care Access, Finance, and Quality ” (Managed Care Rule), aimed at improving access to care in Medicaid across delivery systems (fee-for-service and managed care) and authorities (state plan and waiver services). The Managed Care Rule addresses five primary areas: (1) access in managed care, including network adequacy, (2) state directed payments, (3) medical loss ratio standards, (4) in lieu of services and settings, and (5) quality and performance assessment. This blog summarizes the Managed Care Rule at a high level; more detailed blogs will follow. My colleague Kelly Whitener recently summarized the Access Rule .

(1) Access to Services in Managed Care 

The Managed Care Rule divides access to services in managed care into four topics: (1) information requirements, (2) monitoring requirements, (3) network adequacy standards, and (4) network adequacy enforcement, each of which is addressed to a lesser degree in current regulations.

  First, current regulations require that the state Medicaid agency operate a website that provides certain specified information, either directly or by linking to individual managed care organization (MCO), prepaid inpatient health plan (PIHP), prepaid ambulatory health plan (PAHP), or primary care case management (PCCM) entity websites. Second, current regulations require that states submit to CMS within 180 days after each contract year a report (with ten required items) on each managed care program administered by the state (this report is known as MCPAR and it is not widely publicly available).

Third, current regulations require that state Medicaid agencies develop a quantitative network adequacy standard for each of seven provider types (if their services are covered by the managed care plan’s risk contract) taking into consideration nine different elements, and states have some flexibility to grant exceptions to the standards. Fourth, current regulations require that each MCO, PIHP, and PAHP provide to the state Medicaid agency documentation that demonstrates that it maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. The state agency, in turn, is required to submit to CMS an analysis that supports the assurance of the adequacy of the network of each managed care plan, along with supporting documentation.

New Final Rule

The final rule requires that state agencies include managed care plan information, either directly or by linking to individual MCO, PIHP, PAHP, or PCCM entity websites, on one web page; include clear and easy-to-understand labels on documents and links; verify at least every three months the accurate function of the website and the timeliness of the information presented; and explain that assistance in accessing the information on the website, including oral interpretation and written translation, is available at no cost. 

The final rule adds two items to the ten currently required in the MCPAR annual report: the availability and accessibility of any in lieu of services (ILOS) within the managed care contracts and the results of an enrollee experience survey. The rule also requires that the state agency post the MCPAR(s) on its website within 30 days of submitting it to CMS. 

The rule requires states to establish and enforce appointment wait time standards for routine visits to primary care providers, both pediatric and adult (15 business days from request), obstetrics and gynecological providers (OB/GYN, 15 business days from request), and outpatient mental health and substance use providers, both pediatric and adult (10 business days from request). To monitor compliance, states will be required to use secret shopper surveys. Importantly, the results of secret shopper surveys must be submitted to CMS and posted on the state agency’s website.

The rule requires that each managed care plan submit a “payment analysis” to the state Medicaid agency that compares the total amount paid by the plan for primary care, OB/GYN, mental health, and substance use disorder services during the prior rating period with the total that would have been paid by the plan if the plan had used published Medicare payment rates for those services. The state agency, in turn, is required to include these payment analyses in the analysis it must submit to CMS and to post its analysis on the state agency’s website within 30 calendar days of submission. The rule also requires states to conduct annual enrollee experience surveys.

(2)   State Directed Payments (SDP) 

In 2016 regulations, CMS formally established the option for states to use State Directed Payments (SDPs). SDPs are an option for states to implement requirements on (ie., “direct”) how their managed care organizations (MCOs) pay providers. Under the 2016 regulations, states can require MCOs to participate in multiplayer models, use a value based purchasing method, or use a minimum or maximum fee schedule or set a uniform payment increase for selected providers. The 2016 regulations did not heavily emphasize transparency, reporting, and evaluation of SDP spending.

Since 2016, use of SDPs has increased dramatically, and CMS’s Managed Care Rule is intended to increase transparency and oversight of SDPs. To improve reporting on SDP spending, the rule will require states to: (1) use existing medical loss ratio reporting as a vehicle to collect annual SDP spending data and, (2) after reporting instructions are developed by CMS, report annual provider-specific data through the transformed Medicaid statistical information system (T-MSIS). The T-MSIS submission must specify the total dollars expended by each MCO for SDPs, including amounts paid to individual providers. The rule also sets out detailed requirements for evaluation reports states are required to submit for most types of SDPs that amount to more than 1.5% of managed care program costs, and requires states to publicly post the reports.

CMS’s new regulation clarifies that SDPs must be reasonable and that states make documentation of payment rates available to CMS upon request. CMS also adds a new option for states to require MCO payments to be set at 100% of the Medicare payment rate.   

The rule increases oversight of provider taxes, an important mechanism that states use to fund SDPs. Medicaid law broadly prohibits states from using “hold harmless” arrangements when financing SDPs with provider taxes. A hold harmless arrangement is one where the state charges a provider tax to finance the state’s Medicaid share, but there is a direct or indirect arrangement to later reimburse providers for their tax payments. CMS’s rule reaffirms that states must comply with hold harmless rules and further requires states to collect and make available to C MS attestations from providers receiving SDP payments certifying that the providers are not participating in any hold harmless arrangements (or, per a modification that was not in the proposed rule, the state may be granted an exception if it can provide a satisfactory explanation about why the attestation is unavailable). 

(3)   Medical Loss Ratio Standards (MLR) 

Current regulations require state Medicaid agencies to submit to CMS annually a “summary description” of the annual MLR reports received from each MCO with which they contract. The regulations specify that the summary description must include the amount of the numerator, the amount of the denominator, the MLR percentage achieved, the number of member months, and any remittances owed.

  New Final Rule

The final Managed Care rule clarifies that the summary description must be provided for each MCO under contract with the state and that it also includes line items for the amount of SDPs made by the MCO to its providers and the amount of SDPs made by the state Medicaid agency to each MCO. Unfortunately, the regulations do not require all of this MLR reporting to be made public, significantly reducing the public accountability of state managed care contractors.

(4)   In Lieu of Services and Settings (ILOS)

For many years, Medicaid managed care plans have covered “in lieu of services” (ILOS), which are services that are provided in substitution of traditional state plan services. In 2016 regulations, CMS formally established authority for covering these services. While the 2016 regulations require the services be medically appropriate, cost-effective, and specified in MCO contracts, there is little additional detail about ILOS services and oversight.

The Managed Care Rule includes provisions to standardize and improve use of ILOS to meet the needs of enrollees. First, the rule establishes a new and broader definition of ILOS which is inclusive of services that are “an immediate or longer-term substitute for a covered service or setting” or that “can be expected to reduce or prevent the future need to utilize the covered service or setting.” This definition opens the door to ILOS being used to cover a broader range of health interventions that improve prevention or address health-related social needs.

The rule also improves oversight and accountability of ILOS. States will be required to provide CMS with an annual ILOS report and data on their ILOS spending as a percentage of projected and actual spending. The rule sets a new limit requiring ILOS spending to be no more than 5% of the capitation for managed care plans. Additionally, the regulation increases reporting and evaluation requirements for states using ILOS.

The rule also codifies numerous enrollee protections with respect to ILOS, such as requirements that enrollees retain all rights and protections available under managed care regulations (including appeals rights) and that ILOS may not be used to discourage access to state plan services. 

(5)   Quality Assessment and Improvement

Current managed care regulations include numerous provisions designed to assess and improve quality, but they fall short. States are required to implement a written quality strategy for assessing and improving the quality of health care services furnished by an MCO, PIHP, or PAHP, but these processes have not been sufficiently transparent and inclusive. States are required to conduct External Quality Review (EQR) activities, but there is a long lag time for reporting, meaning the data is often very old. In addition, current EQR regulations limit the data that must be included in reports, meaning valuable data is missing, such as network adequacy data. Finally, while the 2016 managed care regulations required states to establish managed care quality rating systems, the ratings systems have not been sufficiently impactful. For example, states are only required to publish a single quality rating for each MCO, PIHP, or PAHP on websites that are often not very helpful to enrollees.

The final Managed Care rule requires states to seek public comment on the state’s quality strategy at least every three years regardless of whether significant changes are made. States must post the full evaluation of the effectiveness and results of the triennial review of the quality strategy, not just the state’s proposed plan. States are also required to submit the plan for CMS review and input. 

For EQR reporting, the rule will help ensure consistency and align data in the annual reports with the most recently available information used to conduct mandatory EQR activities. It would also require EQR technical reports to include any outcomes data and results from quantitative assessments, as well as data from the mandatory network adequacy validation activity, and mandate states post reports on state websites for five years.

The final rule would also improve the managed care Quality Rating System (QRS). It advances the QRS as a one-stop-shop where enrollees could access information about Medicaid and CHIP eligibility and managed care; compare plans based on quality and other factors key to plan selection, such as the plan’s drug formulary and provider network (if multiple plans are available); and to aid enrollees in selecting a plan that meets their needs. The rule implements new requirements for the QRS website to make it a robust tool to support choice counseling and enrollment. The rule also sets stronger mandatory metrics for QRS systems, including processes to review and update metrics, and requires states to issue a quality rating for each mandatory measure, not just a single overarching rating for each plan. 

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