Characteristics of outpatient clinical summaries in the United States

Christopher Salmon, Rachel O'Conor, Sereena Singh, Ravishankar Ramaswamy, Joseph Kannry, Michael S. Wolf, Alex D. Federman*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

7 Scopus citations

Abstract

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.

Original languageEnglish (US)
Pages (from-to)75-80
Number of pages6
JournalInternational Journal of Medical Informatics
Volume94
DOIs
StatePublished - Oct 1 2016

Keywords

  • After visit summary
  • Electronic health record
  • Health literacy
  • Patient centered

ASJC Scopus subject areas

  • Health Informatics

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