Many family physicians and their patients have, over time, learned to appreciate the value that some elements of an electronic health record (EHR) can bring to the patient visit. One such component recently investigated by researchers is the EHR-generated outpatient after-visit summary (AVS).
Findings from their study are detailed in the Aug. 7 issue of the Journal of the American Medical Informatics Association(jamia.oxfordjournals.org).
In the article, titled "Patient and clinician perspectives on the outpatient after-visit summary: a qualitative study to inform improvements in visit summary design," authors define the AVS as "a paper or electronic document intended to inform patients about their health and health care issues."
They noted that the AVS, until recently, was included in meaningful use standards that required physicians who participated in that EHR program to offer the document -- delineated with 20 very specific elements -- to patients.
However, despite widespread use of these summaries, researchers wanted to "maximize the document's utility" and went straight to clinicians and patients to get their perspectives via focus groups and individual interviews. Qualitative assessments were conducted in community-based adult primary care practices in Chicago, New York City and Long Island, N.Y.
- Researchers consulted with clinicians and patients to learn how the outpatient after-visit summary (AVS) generated by electronic health record systems could be improved.
- Physicians and patients viewed the AVS as a valuable tool for communicating health care information, guiding self-management and relaying information about specific health care-related tasks to complete.
- Both groups also emphasized the need for improvement and offered suggestions for how to make the document more useful and meaningful.
Generally, researchers found that physicians and patients "viewed the AVS as a valuable tool for communicating health care information, guiding self-management and relaying information about specific health care-related tasks to complete."
However, both groups also "emphasized the need for improvement" and offered suggestions for how to make the document more useful and meaningful.
Researchers discovered that not all patients viewed the AVS through the same lens. They noted that the majority saw it as a summary of their specific medical encounter that included issues discussed, care received and a list of medications.
However, a smaller group of patients "saw great value of the AVS in its summary of general health and health care issues rather than visit-specific issues."
These patients said they preferred using EHR web portals to access visit-specific information and preferred having a hard copy of the AVS on hand to present when needed -- for instance during check-in for a hospital visit.
"Patients with such views said they often carried the AVS with them in a wallet or purse and showed it to clinicians when seeking medical care while traveling, at emergency department visits or when speaking with pharmacists about their medications," said authors.
Patients liked the AVS for other reasons as well; for instance, as a prompt to clarify health issues with their physician, as a reminder for future appointments, and as a convenient way to share health information with family and other health care providers.
Interestingly, when patients spotted incorrect or unfamiliar information about diagnoses or medications in their AVS, it sparked conversations with their physicians.
So what pieces of information do patients want to see in the summary handed to them after a medical visit?
Researchers discovered that patients valued having outlined for them
- the name and contact number of their primary care physician and of the practice, as well as the name of the physician or nurse practitioner they saw if it wasn't their usual primary care physician;
- the reason for the visit;
- vital signs;
- self-care instructions;
- referral and follow-up details; and
- a list of medications.
Most patients said it was not important to include in the summary their own contact information and other non-health information such as age and race.
Patients were split on the inclusions of other details such as tests ordered and test results, immunization history, medication allergies, medical history and problem list.
Medication lists, in particular, drew patient suggestions for improvement. Many patients suggested that medications no longer being taken should be removed from the list. They also called for the inclusion of details about why a particular medication was prescribed. "Many patients preferred a single 'current' list of medication over multiple lists of medications to stop, start or modify," said the authors.
Patients also wanted clarification as to why a referral was made.
They were outspoken when it came to the accuracy of information in their AVS. One patient noted that her AVS listed 20 medications but that she was currently taking only six.
"God forbid something happened and they pump all the medicine in me and I ain't taking none of them," she told interviewers.
Patients also had questions about medical information that remained on the patient summary several years after a condition such as depression had been resolved. And several patients were concerned about privacy issues related to sensitive medical information such as a mental health disorder or sexually transmitted disease.
Researchers conducted a total of eight clinician focus groups -- some in Manhattan, some in Chicago -- that included 38 physicians and 18 nurse practitioners.
"In general, clinicians viewed the AVS as a potentially important document for patients," noted the authors. However, many focus group participants suggested that the AVS, in its current form, was too long and too complicated for many patients to digest, especially those with limited health literacy.
"Clinicians shared similar views of the AVS with patients," noted the authors. And physicians' suggestions for improvement often mirrored those of patients, they added. For instance, most physicians agreed that including reasons for medications and referrals was a good idea.
"I think categorizing medications would actually be very useful because I find many patients don't know why they take (certain) medications and for what reason," said one physician.
In addition, many physicians said they would prefer to see a single list of current medications -- and would exclude those medications that had been changed or discontinued.
Clinicians also had formatting suggestions. For instance, they asked for simple changes such as
- larger fonts,
- more white space and
- explicit section headings that would stand out and make the document easier to read.
Some physicians wanted to be able to "alter the text of areas they felt were important to highlight for patients," said the authors. The lack of availability in languages other than English also was a common concern.
Many clinicians said the form was simply too long.
"Some people have 25 diagnoses on their list. You shouldn't have that on (there) every time they get a visit summary… If the doctor touched on the follow-up of a chronic condition then that should be on the AVS," said one physician.
Workflow issues were a top concern for clinicians and included the time involved in filling out the form -- particularly inputting information useful to patients such as specific instructions or goals of care that required additional typing.
Clinicians also reported time concerns when it came to reviewing the AVS with patients -- which often involved retrieving the document from a printer in another part of the office and then finding a private area for those patient conversations that would not violate the Health Insurance Portability and Accountability Act.
Physicians also noted that the time it took to correct inaccurate information on the AVS took away from the time they had to discuss more pressing health concerns with patients.
"Incremental improvements" in AVS content and formatting would require "outside-the-box thinking by EHR vendors and fundamental programming and design changes," concluded the authors.
They noted that the National Institute of Standards and Technology also promoted shortening the AVS and recommended a one-page summary that was similar to the amount of information suggested by patients and physicians in the study.
"Such efforts would have the potential to improve patients' understanding of their health care and self-management responsibilities as well as their satisfaction with care," said the authors.