Home > EHR, meaningful use, Medicare > 2011 ACR Informatics Summit Questions: Part 2

2011 ACR Informatics Summit Questions: Part 2

At the recent ACR Informatics Summit, I received several questions regarding the Medicare/Medicaid EHR Incentive Program, or “meaningful use” (MU). I thought it might be useful to reexamine some of the questions in a series of entries.  If interested, please also see the first part of the series.

Question: What do I need to provide to patients in terms of the “clinical summary,” and are radiology results part of it?

Answer: CMS answered this question directly in guidance through a specification for the associated functional measure here, and a FAQ here.  CMS’ basic message is that EPs should share with their patients any data that can be populated into the clinical summary by their certified EHR technology which, at a minimum, must be the problem list, diagnostic test results, medications, and medication allergies.  The other information that EPs should include in the clinical summary if their certified EHR technology is able to do so is listed in the previously mentioned specification and FAQ.

The key is that the content of the electronic clinical summary is also limited by the functionality of the EP’s certified EHR technology, so it is helpful to look at ONC’s product certification criteria, standards, and implementation specifications associated with clinical summaries to find out what vendors’ HIT products must, at a minimum, enable EPs to do.  To be certified for the associated certification criterion at 45 CFR 170.304(h), HIT products are required to enable EPs to make available as human-readable and electronic: 1) problem list (ICD-9 or SNOMED); 2) lab-test results (LOINC); 3) medications (any source vocabulary included in RxNorm); and 4) medication allergies.  The electronic version of the clinical summary must be in the HL7 CDA CCD format (with the associated implementation specification) or the ASTM CCR format.

The electronic clinical summary can be shared with the patient via a PHR, patient portal on the web site, secure e-mail, or electronic media (CD, DVD, USB flash drive, etc).  The EP is allowed to provide a printed copy of the clinical summary instead of an electronic version.  If the patient specifically requests it, the EP must provide a paper copy regardless.

Categories: EHR, meaningful use, Medicare
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