meaningful use after visit summary

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After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews

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Courtney R Lyles, Reena Gupta, Lina Tieu, Alicia Fernandez, After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews, Family Practice , Volume 36, Issue 2, April 2019, Pages 206–213, https://doi.org/10.1093/fampra/cmy045

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After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care.

First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care.

The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care.

There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.

Spurred by US health care reform and the subsequent Meaningful Use financial incentives, many US health care systems and clinicians have implemented electronic health records (EHRs) that adhere to specific requirements. This includes the requirement to provide a written clinical summary from the EHR to patients after each clinical encounter ( 1 )—referred to as an after-visit summary (AVS). AVS have had a rapid introduction into clinical practice ( 2 ), given that the vast majority of US hospitals (94%) and office-based health professionals (77%) met Stage 1 Meaningful Use metrics in 2014 ( 3 , 4 ), of which AVS was a core component. Even with impending changes to the Meaningful Use program in the coming years ( 5 ), the current practice of visit summaries in primary care is likely to continue as a part of patient-centred care, especially since consumers are now accustomed to written encounter summaries.

By providing patients with a written record of medical decisions and care plans, the use of AVS has the potential to improve patient knowledge, self-management and patient–provider communication. Numerous studies have documented barriers patients face in understanding and remembering information about their treatments and care plans after a visit ( 6–9 ). In particular, AVS use may hold great potential in addressing the well-documented barriers to patient–provider communication and shared decision making faced by vulnerable patients with limited health literacy and limited English proficiency ( 10–14 ). Despite this potential, there is limited research that explores AVS implementation in clinical practice and how its use has impacted patient and provider outcomes.

Because of the paucity of information available, there were two complementary objectives of this study: (i) to explore the existing literature on the current use of AVS and (ii) to gain perspectives from clinical leaders about the current implementation and potential for integrating AVS into clinical practice. In particular, we sought to integrate findings from these objectives, with a specific focus on vulnerable patient populations.

Literature review

In January 2018, we conducted a comprehensive search on PubMed to identify articles from the queries ‘after visit summary’, ‘visit summary’, ‘visit discharge’ and ‘clinical summary’. Papers were included if they (i) were published in English language and (ii) represented research conducted in the USA (where the term AVS is most commonly used). We excluded papers if (i) they mentioned the term AVS (such as being listed as one of many related EHR tools) but did not provide any data on AVS use specifically or (ii) if they were referring to a broader process of visit communication that did not involve the standardized AVS tool. We also reviewed the references lists of included articles to identify additional studies with a focus on AVS use. Although we had a specific interest in the impact of AVS use among vulnerable patients, we conducted a broad literature review on AVS because there were few studies identified overall.

The included articles were categorized by study type, as there was wide variation in the research goals. For example, several studies focused on provider perceptions/use of the AVS, which varied greatly from studies assessing the readability of the document or longer term patient understanding of the information provided. We also categorized the research methods employed as higher (e.g. trials, strong comparison groups) versus lower quality (e.g. case studies, lack of comparison group). Finally, within each type of research study, the small sample size of the included articles allowed us to directly summarize the major findings and provide examples of the key outcomes examined.

Key informant interviews

To complement this literature review, we also conducted a small qualitative study among leaders in primary care about their perceptions of AVS use in routine practice. Rather than using a random sampling approach that might have captured practices without any current routine AVS use, we instead used purposive sampling to identify a sample of leaders in high-performing primary care practices more likely to be attesting for Meaningful Use certification in their practices. Specifically, we first used reputational sampling from published literature of large demonstration projects that systematically identified high-performing sites in both academic and safety primary care sites ( 15 , 16 )—identifying and interviewing experts who had recently completed multiple site visits and in-depth observations of primary care practices nationally (including variation by region and practice type). We then used snowball sampling to identify the remaining key informants, ensuring that a significant portion (at least 1/3) of key informants were leaders or had extensive experience working with safety net health care settings, as this was a major objective of our study. This selection process did not target positive versus negative opinions of AVS use specifically, as interviewees had experience with AVS in practice that could have differed substantially from one another. In total, we conducted interviews with key informants from nine primary care sites, concluding after we had reached thematic saturation of the current types of AVS use.

We used a semi-structured interview guide to gain perspectives about (i) current AVS practices within their system (e.g. who is responsible for AVS distribution, the process for distributing AVS and how AVS information is customized), (ii) the potential of AVS to improve patient knowledge and outcomes within their system and more broadly across primary care systems nationwide, (iii) strategies to improve the use of AVS and (iv) specific considerations for using AVS for the care of individuals with limited English proficiency and limited health literacy.

The interviews were audio-recorded and transcribed for analysis. We used descriptive qualitative methods ( 17 ) to organize, categorize and code the transcripts across all of the major interview discussion topics. More specifically, we coded discrete information provided in the interviews into categories (such as the staff member responsible for AVS distribution at each site, the AVS features used the most, the AVS features viewed as least useful), as well as used thematic coding to capture broader ideas about team-based care, workflows and other topics that could influence the impact of AVS use in clinical care. All four co-authors conducted the key informant interviews and reached consensus on the final coding categories and emergent themes, and two of the co-authors (CRL and LT) completed the coding process on all transcripts once the codebook was established.

The University of California San Francisco Institutional Review Board deemed this study as not classifying as human subjects research.

Our literature review resulted in 263 articles (243 from PubMed, 20 manually identified from reference lists). We excluded 246 articles, resulting in 17 final articles ( Table 1 ). We developed four major categories of studies (not mutually exclusive):

Summary of articles included in after visit summary (AVS) literature review

EHRs, electronic health records; RCT, randomized controlled trial.

1. Case studies of implementation ( 15 , 18–22 );

2. Qualitative/quantitative assessments of patient perceptions ( 23–30 );

3. Qualitative/quantitative assessments of clinician perceptions ( 18 , 25 , 26 , 28 , 31 );

4. Observational studies or interventional research ( 25 , 32 , 33 ).

A substantial number of these studies used less rigorous methodological designs (such as convenience samples with pre-post self-reported measures); but 8 of the 14 studies ( 23–29 , 31 ) employed in-depth survey, qualitative or experimental methods.

Examples or case studies of AVS implementation in real-world practice

The articles examining implementation of AVS emphasized team-based approaches that utilized standard workflows. One study encouraged team-based responsibility, with nurses and medical assistants (MAs) delivering the AVS and care plan at the conclusion of the visit ( 15 ). Another study discussed the potential to integrate AVS into a health coaching model, using the AVS document as a tool to assess patient understanding ( 19 ). In the three content analyses, one study found only half of AVS contained information about follow-up appointments and only a quarter contained tailored AVS sections ( 18 ), while the others found that AVS were written with complex language and at a readability level requiring a higher level of education to understand ( 22 , 34 ).

Patient perceptions of AVS

Patient perspectives on AVS were favourable. In total, four qualitative studies ( 23 , 26 , 28 , 29 ) reported that patients used the document to relay information to their families or other physicians ( 23 , 28 , 29 ). However, patients expressed concerns about the accuracy of their information ( 26 , 28 , 29 ) and the potential for privacy breaches ( 28 , 29 ). While the overall readability of the AVS was problematic in some cases ( 26 , 29 ), many patients desired more information (such as more detailed information or context about their diagnoses and treatment/disease management) ( 30 ). Quantitative studies ( 24 , 25 , 27 ) echoed these themes: a vast majority of patients found the AVS useful, but only half or fewer reported using them after the visit.

Clinician perceptions of AVS

The studies examining clinician perceptions were focused on physicians. Overall, physicians had moderately favourable views of the ease and potential of using AVS for patient care and education ( 25 , 28 , 31 ). However, they expressed concerns about the high complexity of information and the lack of tailoring to the needs of specific patients ( 25 , 26 , 28 ), particularly with regard to literacy level and language. In addition, physicians expressed concerns about not always having sufficient time during practice to update the problem list or medication list and therefore mentioned errors and extraneous information (e.g. outdated diagnostic codes) ( 31 ).

Observational or interventional research using AVS

Three articles evaluated interventions centred on clinical applications of AVS, most of which did not result in significant findings. There was high variability in whether patients reported using AVS after their initial visits, from a small minority ( 25 ) to a majority of patients who received highly personalized versions ( 32 ). A randomized controlled trial of AVS content did not find significant differences in patient adherence, satisfaction or recall of medical information when directly comparing AVS documents with varying amounts of content ( 25 ). Patients’ recall of the information on the AVS was low (only ~33% of content categories); this recall of information was unexpectedly not related to patients’ health literacy status or the amount of information displayed.

In our key informant interviews, the final sample of nine interviewees represented academic, safety net and private practices ( Table 2 ). The vast majority of participants were using the Epic EHR system in their practice (similar to many other health care settings nationwide ( 35 )), even though we did not use this as a specific inclusion criterion. Despite this, several of the participants were also able to discuss more than one EHR given their experiences with multiple site visits or their previous clinical experience prior to Epic implementation.

Summary of key informant interviewees by site and role

Current state of AVS implementation

A high-level summary of the current AVS use is found in Table 3 . Major findings included the following.

Summary of current after-visit summary (AVS) implementation by interview site

EHRs, electronic health records.

Regular distribution of AVS

Likely driven by Meaningful Use, most clinics issued a printed AVS at the majority (if not all) of visits. In addition, many clinics used the ‘patient instructions’ section of the AVS to include personalized information like counselling recommendations and guidance for self-management.

I would say it’s probably the sections that are most used by the clinician are the blank free text space where you do write out some instructions.

Patients satisfied with AVS, but might not be using it

Several interviewees talked about positive patient perceptions (mirroring the literature review results above): ‘Patients actually really, really like having the information’. However, few to no interviewees suggested that the patients referred to the AVS post-visit: ‘I think the patient treats it like they would treat any other confusing piece of paper, which is either to throw it away before they leave the clinic or after they get home’.

Clinics not using AVS for patient teaching

The majority of practices did not use the AVS in a standard way to reinforce specific information with patients, instead printing and handing it out without explanation.

I’ve yet to find anyone, anyplace where someone goes over the After Visit Summary with the patient. And I’ve asked many places [even in high-performing sites] because it seems so obvious that you want to do that in terms of closing the loop…. It’s such a terrific way to close the loop, and it’s just surprising. People just don’t do it.

Slightly less than half of interviewees did mention highlighting some information on the AVS. Yet this was not done in a standardized way across clinicians or visits.

Importance of specific features of the current AVS

When considering specific features of the AVS ( Table 4 ), almost all participants expressed that the patient instructions section was most useful because of the ability to customize information easily. The medication list (if accurate) was also mentioned as useful. Finally, upcoming visits and care plans were also highlighted as potentially important (but perhaps not always standard).

Summary of best and worst features of after-visit summary (AVS) document by interview site

Next steps: overcoming barriers

The key informants unanimously felt that AVS could improve clinical outcomes if utilized properly. When asked about future changes in the Meaningful Use program related to the AVS, interviewees did not foresee abandoning this document in practice.

I think [the AVS] could be really important. I don’t think it’s important the way it’s used now, but I think it could be extremely important and extremely helpful.

Moving forward, improvements in AVS use were related to the following themes:

Team-based workflows

Interviewees expressed that non-clinicians are well positioned to use the AVS with patients for operational next steps (like follow-up appointments). Within the one clinic with a standard MA workflow already in place, the interviewee commented, ‘MAs really like it. They like being part of the process of closing the loop and just helping the patient with those final details’. In addition, MAs or other staff could likely counsel related to lifestyle (such as diet or exercise) or other content with additional training and/or support. For example, one interviewee stated that the MA could use the AVS more effectively, but only with guidance from a provider:

The problem is the MA would have to know which part of the After Visit Summary to go over because you don’t want to go over more than like a couple of things, because people are not going to walk on practice remembering eight or 10 things.

Focus within the AVS

In addition, there were many comments related to the idea that the AVS ‘seems to want to serve too many purposes’. In addition to multiple content areas like medications and diagnoses, clinicians also wrote in personalized instructions in varying ways. Therefore, the current AVS format was long and complex, especially to find specific necessary information from a single visit. Increased ability to customize the AVS in straightforward ways was viewed as critical.

Tailoring by language and literacy

Because the AVS was not available in non-English languages or with low-literacy text, interviewees requested adjusting content to improving patient communication. For example:

For our folks that speak other languages, we are really limited in terms of written instructions we can provide for them. I don’t have any good workaround for that. If there’s a way to do like the med chart with pictures, not just all words… [The AVS is] basically four pages of words.

Among a small amount of published literature on the topic, we found that patients perceive AVS positively, but few appear to routinely refer to the document after the visit. Clinicians surveyed in the published literature were less satisfied than patients with AVS. Moreover, beyond this literature review of existing research, we also conducted our own qualitative investigation among primary care leaders about their perceptions of AVS in high-performing clinical practices. Among these key informant interviewees, we found similar implementation experiences across a varied group of primary care practices. While a hardcopy AVS were distributed in virtually all encounters, there was uncertainty about whether patients used AVS and a lack of routine practice to educate patients about AVS content. The customized patient instructions section was viewed as most useful within the AVS, but this could be buried in the midst of other content. Despite such challenges, interviewees expressed overall positivity about the potential of the AVS to improve patient understanding in the future.

This is the first study to our knowledge that comprehensively studied the current use of AVS in real-world practices in combination with stakeholder perceptions across multiple health care settings about the best ways to improve AVS use for maximum impact. While interviewees in this study provided recommendations for improving the content of AVS to improve implementation, any content changes would be insufficient without additional workflows to support patient use and understanding. Future research is needed to understand whether and how AVS contribute to improved patient outcomes (e.g. understanding/retention, clinical outcomes) and to directly compare the impact of different workflows of AVS distribution. There is no published literature about electronic delivery of AVS through online patient portals, or comparisons of digital versus printed distribution. In addition, there is a need for research to compare workflows of teach-back ( 36 ) using AVS to determine the best modes for patient understanding and retention.

Our study supports previous research on patient–provider communication. For example, patients in our literature review expressed high interest in access to information from their medical encounters via AVS, which is similar to many other studies on patient interest in and satisfaction with access to their online medical record information ( 37 , 38 ). Moreover, our findings support previous work that that training and/or tools can improve in-person communication ( 39 ), especially for vulnerable patient populations ( 40 , 41 ), but this is the first study to our knowledge of whether the AVS is being used for patient education and teach-back. Moreover, implementation of these improved communication strategies into real-world settings requires overcoming obstacles such as under-staffing and insufficient time during visits.

There are several limitations of this study. First, the literature review may have missed studies using a structured process for delivering patient education materials at the conclusion of visits or hospitalizations. In addition, our qualitative sample was small and is not broadly generalizable, and most participants gave feedback on a single EHR product. In addition, the interviewees were all providers without any patient representation. However, we reached thematic saturation with this small but diverse set of interviewees across multiple health care settings.

Moving forward, patient summaries of information like AVS will likely continue to play a role in primary care. AVS utility for both patients and clinicians will likely increase as content and design are improved. The growth of the patient-centred medical home and the emphasis on team-based care will likely result in new roles and responsibilities for communication with patients, and AVS may take centre stage in workflow redesign. Over time, as federal policies and incentives for EHR use change, AVS will survive only if clinicians and patients find them relevant and useful.

Funding: The Roundtable on Health Literacy of the National Academies of Sciences, Engineering, and Medicine provided support for our investigations into AVS. CRL is supported by AHRQ R00HS022408.

Conflict of interest: The authors report no conflicts of interest.

We would like to thank all the people we interviewed who contributed their time to this project.

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After Visit Summary? We Don't Need Any Lousy AVS ... Or Do We?

— avs turned out to be a not so meaningful use.

by Fred Pelzman , MD October 29, 2015

Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

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.

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

Affiliation.

• 1 Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States. [email protected].
• PMID: 27076485
• PMCID: PMC4848387
• DOI: 10.2196/jmir.5207

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.

Keywords: after-visit summary (AVS); beliefs; electronic health records (EHRs); meaningful use; patient portal.

Publication types

• Research Support, Non-U.S. Gov't
• Analysis of Variance
• Attitude to Computers
• Electronic Health Records* / statistics & numerical data
• Electronic Mail
• Middle Aged
• Office Visits
• Regression Analysis
• Surveys and Questionnaires

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• J Patient Exp
• v.7(5); 2020 Oct

Patient-Reported Use of the After Visit Summary in a Primary Care Internal Medicine Practice

Sarita pathak.

1 Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA

2 Multiethnic Health Equity Research Center, University of California San Francisco, CA, USA. Summerville is now with the Department of Orthopedics and Sports Medicine, The Permanente Medical Group, South San Francisco, CA, USA

Gregory Summerville

Celia p kaplan, sarah s nouri, leah s karliner.

Participants completed a cross-sectional survey about their use of the after visit summary (AVS) at a previous primary care visit. Of 355 participants, 294 (82.8%) recalled receiving it, 67.4% consulted it, 45.9% consulted it more than once, and 31.6% shared the AVS. In multivariable analysis, higher education and older age were associated with AVS consultation. Among the subset of 133 patients recalling personalized free-text instructions, 96% found them easy to understand and 94.4% found them useful. Our findings suggest that the AVS is a useful communication tool and improvement efforts should emphasize clarity for those most vulnerable to communication errors.

Introduction

The United States implemented health-care reforms in 2009 to offer financial incentives to health-care organizations for providing clinical summaries to patients after an office visit ( 1 , 2 ). These clinical summaries are also known as the after visit summary (AVS). The AVS is a patient-specific document curated by the clinician and given to patients electronically or on paper after a medical encounter. It typically contains information specific to the patient such as diagnoses, medications, and upcoming appointments. Clinicians may also include personalized free-text instructions for an individual patient to help them understand the treatment received and physician-recommended plan. The 3 main purposes of the AVS include enhancing the ability of patients to remember the content of their clinical interactions, supporting patients in making better health decisions to improve their health outcomes, and improving the quality of information available in the patients’ electronic health records (EHR) ( 2 ).

While the AVS is not a requirement, its quick uptake and wide adoption have resulted in the AVS being a standard of care for outpatient visits ( 3 – 5 ). In fact, health systems continue to invest in ways to optimize the AVS ( 4 ). Given the pressure to address numerous comorbidities during a single primary care encounter, the information patients must process and retain during a brief visit is abundant and increasingly complex ( 6 ). In theory, the AVS presents an opportunity that should be seized to educate patients about their disease, summarize the discussion that took place during the encounter, and highlight the most important next steps in a patient’s treatment plan ( 2 , 3 ).

Prior to the advent of the AVS, research has shown that 29% to 72% of medical information delivered to patients by health-care practitioners is forgotten immediately and almost half of the information recalled by patients is incorrect ( 7 , 8 ). Numerous methods, including oral, written, and pictographic communication, have been studied to assess if their use increases patients’ knowledge of their medical problems. There is minimal research, however, documenting patient use of the AVS despite it becoming an integral element of the encounter ( 6 , 9 ). We set out to assess patient recall and reported use of the AVS from a previous primary care visit and investigate the usefulness of patient-specific information.

In 2013-2014, patients were recruited as part of a larger study assessing tobacco use in an academic primary care internal medicine practice located in San Francisco, California ( 10 ). Those patients who did not endorse tobacco use were instead automatically directed to the AVS survey, the results of which are presented here. The AVS survey served as the control survey for the tobacco study. The survey was self-administered on a wireless, touch-screen, mobile computer tablet immediately prior to a follow-up visit in the waiting room of the primary care practice. Signed consent was obtained on the tablet prior to the start of the survey.

At the time of the survey, the AVS was only available in English. Survey development was based on the limited literature available about the AVS and the authors’ experiences with the AVS both as physicians and patients. The survey assessed patient recall about:

• whether they received an AVS after their previous primary care visit,
• manner of delivery (in-person, via the electronic patient portal, or both),
• whether and how many times they consulted it post-encounter,
• whether they shared it with friends or family members, and
• if they recalled receiving personalized free-text instructions.

If they did recall receiving free-text instructions, they were then asked how easy or difficult they were to understand, how useful they found them, and which topics were addressed. With the consensus of 2 physician authors, the topics addressed in the instructions were categorized into medication information, tasks to complete before the next visit, lifestyle advice, and educational materials about specific medical conditions, general practice information, return precautions, and other. Chart review was performed to verify patient recall of whether they received free-text instructions. To investigate predictors of AVS consultation, the outcome was modeled using logistic regression, including the following variables: age, gender, education, race/ethnicity, clinician type, and insurance. Analyses were conducted using Stata version 13 (StataCorp LP, College Station, Texas). The study was approved by the Committee on Human Research at the University of California, San Francisco.

Of the 355 patients who completed the survey, 47% (n = 168) were women, 13% (n = 46) had low educational attainment (high school/12 years or less), 27% (n = 95) were ≥65 years, and 42% (n = 146) were racial/ethnic minorities ( Table 1 ). Most of the patients (82.8%, n = 294) recalled receiving an AVS after their last primary care appointment ( Figure 1 ). Two-thirds of the patients (67.4%, n = 194) reported consulting the AVS since their last appointment, with almost half (45.9%, n = 89) consulting it more than once. Nearly one-third of the patients (31.6%, n = 90) reported sharing the AVS with friends or family members.

Demographic Characteristics of Patients by Self-Report of After Visit Summary Consultation (n = 355).

Abbreviation: SD, standard deviation.

a  Missing data for 11 participants.

b  Missing data for 4 participants.

c  Medicare and Medicaid are both forms of medical coverage available in the United States. Medicare is a federal health insurance plan available to individuals aged 65 years and older or to those with specific disabling health conditions. Medicaid is a federal program administered by individual states and provides health coverage to individuals with low income.

Patient recall of receiving an AVS. AVS indicates after visit summary.

In logistic regression, 3 variables were positively associated with AVS consultation including education, race-ethnicity, and age ( Table 2 ). Specifically, higher educational attainment, Asian race-ethnicity, and older age were all associated with higher odds of AVS consultation.

Association of Individual Characteristics With the Likelihood of AVS Consultation.

Abbreviations: AVS, after visit summary; CI, confidence interval; OR, odds ratio.

Among the subset of 133 (45.2% of 294) patients who recalled seeing personalized free-text instructions in the AVS, 96% (n = 120) found them very easy or easy to understand, and 94.4% (n = 118) found them very or somewhat useful. The 4 most common patient-reported topics addressed in the instructions were medication information (59.4%, n = 79), what to do before their next visit (57.9%, n = 77), lifestyle advice (27.8%, n = 37), and symptoms or problems that should prompt the patient to seek care (27.1%, n = 36). Chart review to verify whether patients correctly recalled receiving free-text instructions demonstrated that 82% actually had them documented in their AVS.

We found that the majority of patients reported receiving and consulting the AVS, highlighting the importance of using this post-visit summary as a communication tool for patient-specific care. Furthermore, patients reported personalized free-text instructions to be both useful and easy to understand.

Older adult’s higher consultation of the AVS may be related to the multiple and more complex medical problems they experience compared to younger patients. This complexity requires a carefully laid out clinical plan that may be challenging for patients to remember from a brief conversation, leading clinicians and patients to rely on additional written communication to maximize understanding and adherence ( 6 , 9 ).

While our sample was overall highly educated, our results indicate that those with lower educational attainment are less likely to consult the AVS. The text-heavy format of the AVS utilized at this specific medical practice, rather than easier to digest formats, may account for this finding. Alternative formats that include pictograms and graphics, as well as the use of AVS teach-back methods prior to the patient’s departure from the practice may allow for more accessible communications specifically for patients with low health literacy ( 9 ). Previous studies have also shown that a combination of both written and oral information results in improved retention of information when compared to each modality in isolation ( 11 , 12 ). It is unclear why Asians were the race-ethnic group most likely to consult the AVS, and this deserves further exploration.

While the AVS is no longer a requirement for health-care professionals, health-care organizations in the United States have prioritized patients’ electronic access to their health information ( 5 ). Some EHRs, such as Epic (EpicCare, Epic Systems; Verona, Wisconsin), continue to make the AVS automatically available electronically for patients enrolled in the EHR’s online portal; thus, continuing to optimize the AVS is critical for clearer, more accessible health communication.

Limitations

Limitations of this study include a cross-sectional design, data collection limited to a single academic primary care practice preventing generalizability of the results, lack of verification of receiving the AVS, and potential recall bias on the part of participants. While we did include educational attainment, we did not have a direct measure of health literacy. Chart review verified that while most patients correctly recalled receiving personalized instructions, others did not, suggesting that some who answered that the instructions were easy to understand and useful may have been referring to the AVS in its entirety. The remainder of our data were self-report. In addition, we were not able to investigate the association of personalized instructions or tailoring of the AVS with outcomes such as adherence or disease management.

Our finding of patient engagement with the AVS is encouraging and suggests that the use of the AVS as a communication tool is, in fact, useful to patients. While limited, the literature on AVS show that patients find the tool very useful but have identified numerous ways it can be improved ( 6 , 9 ). Our study verifies past findings but also uncovers an important disparity that not all patients benefit equally. In fact, those at highest risk for poor communication and understanding after a visit—those with lower educational attainment and likely limited health literacy—appear least likely to engage with the AVS. In addition, the AVS in this practice, and likely many others, is currently only available in English, necessarily excluding those with limited English proficiency from benefit. The potential practical implication of the study is that both the format and implementation of the AVS in practice should be made accessible to all, with particular emphasis on those most vulnerable to communication errors.

Acknowledgments

Authors thank the patients and staff of the Division of General Internal Medicine, University of California San Francisco.

Author Biographies

Sarita Pathak is a PhD candidate at Emory University School of Public Health. She is interested in health disparities and cancer prevention and tobacco control.

Gregory Summerville is a sports medicine specialist with a passion for helping his patients achieve their goals of maintaining an active healthy lifestyle.

Celia P Kaplan has over 25 years of research experience conducting studies in health disparities among underserved US minority populations, with a particular emphasis on Latino health.

Sarah S Nouri is a primary care internist and a research fellow focusing on communication and palliative medicine.

Leah S Karliner is a primary care internist and a communication health services researcher dedicated to improving the qualitiy and equity of care delivery for older patients.

Author's Note: Sarita Pathak is now affiliated with Emory University Rollins School of Public Health, Atlanta, GA, USA.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The parent study was supported by National Institutes of Health National Institute on Drug Abuse (R01DA034253) and National Institutes of Health National Research Service Award T32HP19025.