Starting this month, clinical notes will be among electronic information that must not be blocked and must be made available free of charge to patients. The change implements the 21st Century Cures Act, which requires that healthcare providers grant patients access without charge to all the health information in their electronic medical records “without delay.” There are eight types of clinical notes that must be shared: (1) consultation notes, (2) discharge summary notes, (3) history and physical (4) imaging narratives, (5) laboratory report narratives, (6) pathology report narratives, (7) procedure notes, and (8) progress notes.
The rule does not apply to psychotherapy notes that are separate from the rest of the patient’s medical record. This means that information recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. The rule also does not apply to information compiled in reasonable anticipation of or use in a civil, criminal, or administrative action or proceeding.
This new practice innovation —known as ‘open notes’ has actually been around for over 50 years. The idea behind the philosophy is that allowing clinician notes to be openly available by patients will allow them to know what specific health issues are observed by physicians. According to OpenNotes, this practice will help empower patients and their families, better inform patient caregivers, and improve the quality and safety of patient care.
Providers reluctant to engage in the open notes philosophy have expressed that clinician notes can be confusing to patients or damage the patient-provider relationship. The apprehension seems to stem from the notion that notes are not standardized documentation within the Electronic Health Record (EHR). Another cause for hesitation is that clinician’s notes often include formal medical terminology which may confuse patients or offend them. However, after UC Health providers had positive experiences with open notes— and other providers across the country had positive experiences as well— it became clear that open notes will provide a necessary information source for patients.
Research from 2020 showed that 96% of patients accessing their open notes understood the notes that were shared. Of the remaining 4% of patients who only understood some of their open notes, most of them sought help to further understand what was being stated in those notes. Some data has shown that patient access to clinician notes can improve patient safety. Some patients who had access to their clinician notes have been able to report potential note errors, which has, in some cases, resulted in changes that protect and improve the continuity and quality of care. We are looking to learn so much more over the next year as healthcare providers roll this out at their various practices and organizations.
We would love to hear your thoughts on the CURES Act.
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Sources:
opennotes.org
opennotes.org
patientengagementhit.com
johnahartford.org