MU Stage1 Final Rule - Clinical Summaries

SECTION #  Section 170.304(h)—Clinical Summaries

MU OBJECTIVE Provide clinical summaries for patients for each office visit.

MU STAGE 1 MEASURE Clinical summaries provided to patients for more than 50% of all office visits within 3 business days.

CERTIFICATION CRITERION Final Rule Text: §170.304(h). Clinical summaries. Enable a user to provide clinical summaries to patients for each office visit that include, at a minimum, diagnostic test results, problem list, medication list, and medication Allergy list. If the clinical summary is provided electronically it must be: (1) Provided in human readable format; and (2) Provided on electronic media or through some other electronic means in accordance with: (i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and (ii) For the following data elements the applicable standard must be used: (A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2); (B)Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and (C) Medications. The standard specified in §170.207(d).

STANDARDS §170.205(a)(1) §170.205(a)(2) §170.207(a)(1) §170.207(a)(2) §170.207(c) §170.207(d)

TEST CRITERIA # §170.304(h) http://healthcare.nist.gov/docs/170.304.h_ClinicalSummaries_v1.1.pdf

SOLUTION DESIGN / TECHNOLOGY (Add details here)

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DEVELOPMENT STATUS The CCR can be extracted using the code in development and available on the Trac server for download. This will provide what the provider needs that is machine and human readable, however, a patient portal that is secure and easy to deploy for delivery of the documents would be a plus. Hopefully KRM will be providing a solution that can be used. Other open source solutions would be welcome. Most of the personal health records will consume a CCR.

An effort to convert a CCR to a CCD and to a QRDA document is underway as part of the CCR-CCD project. Volunteers are always welcome on that project. Right now the project includes others that do not even use VistA such as the folks supporting OpenEMR, another open source medical records system and what is being developed as broad applications.

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