Awareness and Use of the After-Visit Summary Through a Patient Portal: Evaluation of Patient Characteristics and an Application of the Theory of Planned Behavior.

BACKGROUND: Patient portals are being used to provide a clinical summary of the office visit or the after-visit summary (AVS) to patients. There has been relatively little research on the characteristics of patients who access the AVS through a patient portal and their beliefs about the AVS. OBJECTIVE: The aim was to (1) assess the characteristics of patients who are aware of and access the AVS through a patient portal and (2) apply the Theory of Planned Behavior (TPB) to predict behavioral intention of patients toward accessing the AVS provided through a patient portal. METHODS: We developed a survey capturing the components of TPB (beliefs, attitude, perceived norm, and perceived behavioral control). Over a 6-month period, patients with a patient portal account with an office visit in the previous week were identified using our organization's scheduling system. These patients were sent an email about the study and a link to the survey via their portal account. We applied univariate statistical analysis (Pearson chi-square and 1-way ANOVA) to assess differences among groups (aware/unaware of AVS and accessed/did not access AVS). We reported means and standard deviations to depict belief strengths and presented correlations between beliefs and attitude, perceived norm, and perceived behavioral control. We used hierarchical regression analysis to predict behavioral intention toward accessing the AVS through the patient portal. RESULTS: Of the 23,336 patients who were sent the survey, 5370 responded for a response rate of 23.01%. Overall, 76.52% (4109/5370) were aware that the AVS was available through the patient portal and 54.71% of those (2248/4109) accessed the AVS within 5 days of the office visit. Patients who accessed the AVS had a greater number of sessions with the portal (mean 119, SD 221.5) than those who did not access the AVS (mean 79.1, SD 123.3, P<.001); the difference was not significant for awareness of the AVS. The strongest behavioral beliefs with accessing the AVS were being able to track visits and tests (mean 2.53, SD 1.00) followed by having medical information more readily accessible (mean 2.48, SD 1.07). In all, 56.7% of the variance in intention to access the AVS through the portal was accounted for by attitude, perceived norm, and perceived behavioral control. CONCLUSIONS: Most users of a patient portal were aware that the AVS was accessible through the portal. Patients had stronger beliefs about accessing the AVS with the goal of timely and efficient access of information than with engaging in their health care. Interventions to improve patient access of the AVS can focus on providers promoting patient beliefs about the value of the AVS for tracking tests and visits, and timely and efficient access of information.

Helpfulness of Clinical Visit Summary Content From Multi-Specialty Care: A Mixed-Methods Assessment.

OBJECTIVE: We surveyed patients who visited multiple outpatient specialty practices to understand what summary content was most helpful with the goal of optimizing meaningful outpatient clinical visit summary content. MATERIALS AND METHODS: We constructed a survey instrument to measure delivery, use, and contents of clinical visit summaries. We surveyed patients who visited with at least 2 different outpatient medical specialties to understand preferences. RESULTS: Most patients in our sample valued the summary information they received, and retained it as healthcare documentation (84%) and/or quick reference in supporting self-care (70%). Patients most commonly reported that information on results of completed tests (91%) and treatment plan instructions (89%) were very helpful. Additionally, patients expressed the importance of online access to clinical visit summary information. DISCUSSION: Most patients used the clinical visit summary as healthcare documentation, and valued online availability of their summary information. Patients most often reported that information on results of recently completed tests and specific instructions on treatment plan were very helpful. Patients who sought further information after their visit most often looked to a provider and/or online. CONCLUSIONS: Patients valued clinical visit summary accessibility and as a reference tool to summarize care and provide next steps. Optimal clinical visit summaries might collate and integrate assessments and recommendations from multiple specialties into coherent care plans for patients.

Preferences of older adults and their families for Meaningful Use clinical summaries.

BACKGROUND: This study assessed the perceptions of older adults regarding the plan of care (POC) contained in the clinical summary mandated by the Electronic Health Records (EHR) Incentive Program. METHODS: A qualitative descriptive design was selected for this study. Older adults (≥65) with chronic cardiac diagnoses were invited to participate. The investigator shadowed the physician during the patient encounter, interviewed the patients following their encounter, and asked patients to complete standard health literacy and cognitive screening tools and the Patient Activation Measure. Directed content analysis was used to analyze transcripts. RESULTS: Patients (n=40) found the clinical summary useful for sharing information with family members and other physicians, reminding and informing, and for engaging in behavior change. Seventy-six percent reported that they would not go online to access the clinical summary for multiple reasons, including not being "computer savvy" and privacy concerns. Participant recommendations for a re-designed, improved clinical summary are included. The clinical summary helps patients and families communicate among health care professionals in a complex, disjointed health care system that often burdens patients with that responsibility. The majority of participants were happy with the paper version and offered multiple reasons for not wanting online access that may help us to focus on more compelling reasons for patient portal use. CONCLUSIONS: Qualitatively, it appears that the clinical summary is a useful tool for engaging people with chronic disease in self-management. The participants in this study told us what many of us already know to be true; that the documentation we provide patients and families is less than ideal.

Delivery of Standardized Patient Instructions in the After-Visit Summary Reduces Telephone Calls Between Clinic Visits.

Telephone calls from patients can be a large source of between-visit work in outpatient clinics. A baseline audit at the study clinic identified medication refills and test results as the most common preventable calls. The authors created a dot phrase with standardized text detailing methods for refilling medications and reviewing test results and instructed providers to use it in the after-visit summary (AVS). After implementation of the AVS dot phrase, telephone calls for medications and results had an adjusted absolute decrease of 23.9 (95% CI = 15.4-32.4) calls per day to 16.2 (SD 7.7) calls per day, a relative reduction of 61%. Providers reported significantly fewer inbox requests for both refills ( P = .04) and test results ( P = .01). Using a standardized AVS dot phrase to inform patients on how to navigate care needs can significantly reduce between-visit workload for clinic staff and providers.

Challenges optimizing the after visit summary.

BACKGROUND: The after visit summary (AVS) is a paper or electronic document given to patients after a medical appointment, which is intended to summarize patients' health and guide future care, including self-management tasks. OBJECTIVE: To describe experiences of health systems implementing a redesigned outpatient AVS in commercially available electronic health record (EHR) systems to inform future optimization. MATERIALS AND METHODS: We conducted semi-structured interviews with information technology and clinical leaders at 12 hospital and community-based healthcare institutions across the continental United States focusing on the process of AVS redesign and implementation. We also report our experience implementing a redesigned AVS in the Epic EHR at the Mount Sinai Hospital in New York City, NY. RESULTS: Health systems experienced many challenges implementing the redesigned AVS. While many IT leaders noted that the redesigned AVS is easier to understand and the document is better organized, they claim the effort is time-consuming, Epic system upgrades render AVS modifications non-functional, and primary care and specialty practices have different needs in regards to content and formatting. Our team was able to modify the document by changing the order of print groups, modifying the font size, bolding section headers, and inserting page breaks. Similar to other health systems, our team found that it is difficult to achieve some desired features due to limitations in the EHR platform. CONCLUSION: Health IT leaders view the AVS as a valuable source of information for patients. However, limitations to AVS modifications in EHR systems present challenges to optimizing the tool. EHR vendors should incorporate learning from healthcare systems innovation efforts and consider building more flexibility into their product development.

Evaluation of a patient-centered after visit summary in primary care.

OBJECTIVE: To test the impact of a redesigned, patient-centered after visit summary (AVS) on patients' and clinicians' ratings of and experience with the document. METHODS: We conducted a difference-in-differences (DiD) evaluation of the impact of the redesigned AVS before and after its introduction in an academic primary care practice compared to a concurrent control practice. Outcomes included ratings of the features of the AVS. RESULTS: The intervention site had 118 and 98 patients in the pre- and post-intervention periods and the control site had 99 and 105, respectively. In adjusted DiD analysis, introduction of the patient-centered AVS in the intervention site increased patient reports that the AVS was an effective reminder for taking medications (p = .004) and of receipt of the AVS from clinicians (p = .002). However, they were more likely to perceive it as too long (p = .04). There were no significant changes in overall rating of the AVS by clinicians or their likelihood of providing it to patients. CONCLUSIONS: A patient-centered AVS increased the number of patients receiving it and reporting that it would help them remember to take their medications. PRACTICE IMPLICATIONS: Improvements in the patient-centeredness of the AVS may improve its usefulness as a document to support self-management in primary care.

Characteristics of outpatient clinical summaries in the United States.

In the United States, federal regulations require that outpatient practices provide a clinical summary to ensure that patients understand what transpired during their appointment and what to do before the next visit. To determine whether clinical summaries are appropriately designed to achieve these objectives, we examined their content and formatting and their usability. We obtained a convenience sample of clinical summaries from 13 diverse practices across the U.S. and assessed their characteristics using validated measures. We also interviewed key informants at these practices to assess their views of the documents. The summaries were generated by seven different electronic health record platforms. They had small font sizes (median, 10 point) and high reading grade levels (median, 10). Suitability, measured with the Suitability Assessment of Materials was low (median score, 61%) and understandability and actionability, measured with the Patient Education Materials Assessment Test, were fair to moderate (65% and 78%, respectively). Content and order of content were inconsistent across the summaries. Among physicians, 46% found the summaries helpful for clarifying medications while 38% found them helpful for conveying follow-up information. Results suggest that clinical summaries in the U.S. may often be suboptimally designed for communicating important information with patients. A patient-centered approach to designing them is warranted.

Physician Perceptions and Beliefs about Generating and Providing a Clinical Summary of the Office Visit.

BACKGROUND: A core measure of the meaningful use of EHR incentive program is the generation and provision of the clinical summary of the office visit, or the after visit summary (AVS), to patients. However, little research has been conducted on physician perceptions and beliefs about the AVS. OBJECTIVES: Evaluate physician perceptions and beliefs about the AVS and the effect of the AVS on workload, patient outcomes, and the care the physician delivers. METHODS: A cross-sectional online survey of physicians at two academic medical centers (AMCs) in the northeast who are participating in the meaningful use EHR incentive program. RESULTS: Of the 1 795 physicians at both AMCs participating in the incentive program, 853 completed the survey for a response rate of 47.5%. Eighty percent of the respondents reported that the AVS was easy (very easy or quite easy or somewhat easy) to generate and provide to patients. Nonetheless, more than three-fourths of the respondents reported a negative effect of generating and providing the AVS on workload of office staff (78%) and workload of physicians (76%). Primary care physicians had more positive beliefs about the effect of the AVS on patient outcomes than specialists (p<0.001) and also had more positive beliefs about the effect of the AVS on the care they delivered than specialists (p<0.001). CONCLUSIONS: Achieving the core meaningful use measure of generating and providing the AVS was easy for physicians but it did not necessarily translate into positive beliefs about the effect of the AVS on patient outcomes or the care the physician delivered. Physicians also had negative beliefs about the effect of the AVS on workload. To promote positive beliefs among physicians around the AVS, organizations should obtain physician input into the design and implementation of the AVS and develop strategies to mitigate its negative impacts on workload.

Examination of office visit patient preferences for the after-visit summary (AVS).

The federal government advocates the practice of routinely providing an after-visit summary (AVS) to patients after each office-based visit as an element of stage 1 meaningful use. A significant potential benefit of the AVS is improved patient engagement achieved by enabling patients and family members to better understand and retain key health information. The methodology for this study was a mixed-methods pilot study to examine, through the perspectives of adult primary care patients, how relevant and actionable data can be better formatted in the AVS. Results of this study suggest that the goal of the AVS to serve as a communication tool to engage and support patients is frequently not being met. Further study is needed to understand, from the viewpoints of patients and providers, what barriers are keeping them from optimally providing and using the information on the AVS.