The After Visit Summary (AVS) 

John M. Byrne, D.O., Rob Durkin, M.D., Richard Cho, RN BSN, Deanna Callahan, MPA, Shane Elliott, MBA

VA Loma Linda Healthcare System

1 
Outline 

• Introduction

• Background

• AVS Development

• Software Features

• Initial Evaluation Plan

• Questions

2 
Poll Question

In which area of expertise do you work? 

• Clinical

• Information Technology

• Administrative 

• Research

• Other 

3 
Background - 

Patient Retention of Clinical Information

• Patients forget 40-80% of information from 

healthcare providers1 

• What they do remember, they remember half 

incorrectly1

• More information given, the less patients remember2 

• Poor retention leads to poor adherence, medication 

errors, missed appointments and perceptions of poor 

communication 

4 
Background – Patient Engagement

• Patients desire information about their care3 

• Patients desire more information than they typically 

receive about their illness and their treatment plan3

• Combing oral and written information is better than 

oral or written only4 

• Sharing electronic health record information on 

personal health records increases patient 

engagement5 

5 
Background – After Visit Summaries (AVS) and Personal 

Health Records (PHR)

• Why printed AVS and not just a PHR?

– Printed after-visit summaries enhance patient 

trust and confidence in their physician 3 

– Veterans have access to MyHealtheVet, however 

65% not registered6

– Only 25% In-Person Authentication6 

– Experience at other sites with PHR and AVS

• AVS third most frequently accessed 

information on PHR Group Health, Seattle7 

6 
Background – After Visit Summaries 

and Patient Satisfaction

• Kaiser Permanente found through regression 

analysis that AVS contributes to overall outpatient 

satisfaction8 

7 
Poll Question

• When you or your family have seen a 

physician, did you receive an after-visitsummary? 

• Always

• Most of the time

• Sometimes 

• Rarely

• Never 

8 
Background - Meaningful Use Criteria 

• Centers for Medicare and Medicaid Services (CMS) criteria for 

physician/hospital reimbursement for implementing an electronic 

health record (EHR) 9, 10

– Use computerized order entry

– Drug-drug and drug-allergy checks

– Maintain up-to-date problem list

– Generate and transmit prescriptions electronically 

– Maintain active medication list

– Maintain active medication allergy list

– Record key demographics

– Record and chart changes in vital signs

– Record smoking status for patients 13-years and older

– Exchange key information with other systems

– At least one of 4 clinical decision support rules

– Report hospital quality measures to CMS/state

– Electronic copies to patients on request

– Provide clinical summaries for patients for each office visit

– Protect electronic health information

9 
Background - Meaningful Use 11

• Objective 

– Provide clinical summaries for patients for each 

office visit

• Measure

– Clinical summaries provided to patients for 

more than 50% of office visits within 3 days

• Additional parameters

– May be provided through PHR, website, secure 

messaging, or printed copy

10
Background - Meaningful Use 11 

• Clinical Summary Content from CMS

– Patient’s name

– Providers name, visit location and date and contact 

information 

– Updated medication list

– Updated vitals, reason for visit

– Procedures and instructions

– Updated problem list

– Upcoming appointments

– Laboratory and test orders

– Laboratory and other test results

11
Background - VA and Meaningful Use

• VA seeking meaningful use certification12

– "We're going to try to get certified on everything 

for inpatient and outpatient," said Dr. Theresa 

Cullen, director of health informatics for the VHA. 

– "If you look at what's required in certification, all 

of it benefits patient care. Striving for meaningful 

use will help us deliver better care for the 

veterans."

12
AVS Development

Purpose of the After Visit Summary (AVS) 

• Promote patient-centered, outpatient care

• Summarize medications, appointments, tests, patient 

education material and other instructions

• Enhance communication 

• Engage patients in their care

• Improve recall of medical instructions

• Meets electronic health record meaningful use criteria

 

13
AVS Development Project Goals

 

• For outpatient visits

– Provide patients with relevant information about 

their office visit in a clinical summary

– Develop patient-friendly language and format

– Minimize work for the provider by automatically 

populating AVS with data from VistA 

– Provider user options

– Save, print and upload to VistA Imaging and 

MyHealtheVet

14
AVS Development

• 2009 VHA Innovations Grant 

• Requirements gathering through patient and clinician 

focus groups

• Contractor developed software framework

• VA Loma Linda Healthcare System (VALLHCS) IT 

developer refined software

• Pilot testing in VALLHCS clinics

• Close collaboration with Informatics Team and clinicians

15
AVS Development 

• Clinician and Innovations input at VALLHCS

• Pharmacy Benefits Management (PBM) National 

Medication Reconciliation Workgroup

– Add remote medications

– Medication descriptions

• Region 1 Development Team

– Changed from using a network service account to an 

application programming interface (API)

– VistA service accounted changed to Application Proxy

16
AVS Features

• Web-based, launched from the CPRS toolbar

• Imports data VistA/CPRS, Remote Procedure Calls 

(RPC’s) 

• Clinical Context Object Workgroup (CCOW)

• Auto refresh and manual refresh button

• Print, store VistA Imaging as PDF, stub note in CPRS

• Integration with Krames-On-Demand Patient 

Education 

• Optionally saves and locks changes between users

17
AVS Features

• Technical

– Java/J2EE with web-based front end

– RPC’s through national software (VistALink) 

–No custom RPC’s or MUMPS code

– Small Delphi client for CCOW

–Hosted at Denver Regional Data Center

18
AVS Features - AVS Workflow

• Provider

– Completes orders

– Completes encounter

• Data

– Automatically uploaded to AVS

– Auto-refresh every 3 minutes, manual refresh available

• Additional instructions

– Free text instructions

– Krames-on-Demand Education Sheets

• Completed AVS

– Printed to Windows printer or VistA printer 

– Stub note created in CPRS

– PDF copy uploaded to VistA Imaging 

19
AVS Features - Launch 

20

Launched from the CPRS 

Tools menu, the AVS uses 

CCOW, changing patients with 

CPRS, therefore requiring only 

one launch per clinic. 
AVS Features - View of AVS at Launch

21
AVS Features – Visit Selection

22
AVS Features – Header 

23
AVS Features - Data from VistA/CPRS 

24
AVS Features - Data from VistA/CPRS 

25
AVS Features - Data from VistA/CPRS 

26
AVS Features - Data from VistA/CPRS 

27
AVS Features - Data from VistA/CPRS 

28
AVS Features - Data from VistA/CPRS 

29
AVS Features - Footer

30
AVS Features - Instructions 

31
AVS Features - Instructions 

32
AVS Features - Editor 

33
AVS Features - Editor 

34
AVS Features - Clinical Services Information

35
AVS Features-Clinical Services Information

36
AVS Features - Clinical Services Information

37
AVS Features - Font Size

38
AVS Features - Lab Results

39
AVS Features - Lab Results

40
AVS Features - Clinical Charts

41
AVS Features - Clinical Charts

42
AVS Features - Sections Displayed

43
AVS Features - Integration with Krames-on-Demand 

44
AVS Features - Integration with Krames-on-Demand 

45
AVS Features - Integration with Krames-on-Demand 

46
AVS Features - Integration with Krames-on-Demand 

47
AVS Features - Integration with Krames-on-Demand 

48
AVS Features - Integration with Krames-on-Demand 

49
AVS Features - Integration with Krames-on-Demand 

50
AVS Features - Printing Functions

51
AVS Features - Printing Functions

52
AVS Features - Printing Functions

53
AVS Features - Printing Functions

54
AVS Features - Printing Functions

55
AVS Features - Note Creation 

56
AVS Note Creation 

CPRS 57

VistA Imaging
AVS Features - PDF Generation

58
AVS Features - PDF Generation

59
AVS Features - Administrative Functions

60
AVS Administrative Functions

61
AVS Features - Administrative Functions

62
AVS Features - Administrative Functions

63
Poll Question

• As a patient, what information on the AVS would be most 

important to you? (Pick your top 3)

– Providers name, visit location and date and contact information

– Updated medication list

– Medication physical descriptions

– Updated vitals

– Reason for visit

– Procedures and instructions

– Updated problem list and diagnoses

– Upcoming appointments

– Laboratory and test orders

– Laboratory and other test results

– Clinical data charts

– Patient education material

– Large font size 64
Lessons Learned 

• Software Development Plan

• Positives

– Rapid development

– Small development team, local programmer

– Feedback directly from users

– Informal, not bureaucratic

– Flexibility 

65
Lessons Learned

• Challenges 

– Feature creep/Scope bloat

– Users are testers

– Software bugs

– Class III status 

– Class I approval process

• Software changes for class I compliance

– Requirements analysis might have missed 

things like medication reconciliation

– Consistency with other patient-facing software

66
AVS - Current Status 

• Presented to VHA Innovations Selection Board 

for possible funding for class I development 

(October 2013)

• Veterans Points of Service 

– Possible funding (September 2013)

• VA OI&T Region 1 approval for testing

– September 2013

• San Diego

– October/November 2013

• Long Beach, West LA, Las Vegas, Cleveland 67
AVS Evaluation

• Veterans Assessment and Innovation 

Laboratory (VAIL) Patient-Aligned Care Team 

(PACT) Demonstration Lab

– $10,000 grant (September 2013)

• Evaluation Plan

– Randomly select ~ 150 patients in primary care 

clinics 

• Patient satisfaction survey

• Survey self-assessed knowledge of treatment plan

68
AVS Evaluation

• VAIL Grant

– Collect usage statistics from primary care modules

• Number of providers using AVS

• Use of optional features

• Saving and printing 

– Provider preferences for using AVS

• Patient self-assessed health status on survey

• Provider focus group

69
Contact Information

• John M. Byrne, D.O.

• Associate Chief of Staff for Education

• VA Loma Linda Healthcare System

• 11201 Benton Street

• Loma Linda, CA 92357

• 909-583-6004

• john.byrne3@va.gov 

70
References • 1. Kessels, RPC. Patients memory for medical information. Journal of the Royal Society of Medicine, May 2003; 96: 219-223.

• 2. McGuire, LC. Remembering what the doctor said: organization and adults’ memory for medical information. 1996;22(4): 

403-428.

• 3. Tang PC, Newcomb, C. Informing patients: a guide for providing patient health information. JAMIA 1998;5(6): 563-570.

• 4. Coulter A. Patient engagement – what works? J Ambulatory Care Manage.2012; 35(2): 80-89.

• 5. Archer N, Fevrier-Thomas U, Lokker C, McKibbon KA, Straus SE. Personal health records. A scoping review. JAMIA 2011; 

18:515-532.

• 6. VHA Support Service Center (VSSC). 

https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fSecureMessaging%2fSM_Penetration&rs

:Command=Render , Accessed October 31, 2013

• 7. Ralston JD, Carrell, D, Reid R, Anderson M, Moran M, Hereford J. Patient web services integrated with a shared medical 

record: patient use and satisfaction. JAMIA 2007; 14:798-806.

• 8. Throop C, The Ix After-Visit Summary (AVS), Center for Information Therapy. October 2009

• 9. Jha AK, et al A progress report on electronic health records in US hospitals . Health Affairs 2010: 29(10): 1951-1957

• 10. Centers for Medicare and Medicaid Services, Stage 2, Eligible Professional, Meaningful Use Table of Contents, Core and 

Menu Set Objectives, https://www.cms.gov/Regulations-and Guidance/Legislation/EHRIncentivePrograms/downloads/EPMU-TOC.pdf 

• 11. Centers for Medicare and Medicaid Services, Stage 2, Eligible Professional, Meaningful Use Core Measures, Measure 8 of 

17, October, 2012. http://www.cms.gov/RegulationsandGuidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_8_ClinicalSummaries.pdf , accessed November 

5, 2013.

• 12. Conn J. Modern Healthcare. October 25, 2012. 

http://www.modernhealthcare.com/article/20121025/NEWS/310259956, accessed May 2013

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Appendix: AVS Example

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AVS Example

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AVS Example

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AVS Example

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AVS Example

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AVS Example

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