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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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