Beginning April 5, 2021, providers must give patients immediate access to their health data free of charge. This includes a laundry list of data types: Consultation notes, discharge summary notes, history and physical, imaging narratives, laboratory report narratives, pathology report narratives, procedure notes, and progress notes. It’s all thanks to the Final Interoperability Rule released by the Office of the National Coordinator for Health IT. The rule, which is part of the 21st Century Cures Act, prohibits information blocking, including blocking access to patient data.
There are several exceptions to the new rule. For example, providers may withhold psychotherapy notes or notes for which the provider has reasonable assumption could be used in a civil or criminal court case or administrative proceeding. Another example is when the provider anticipates that releasing the information would cause harm to the patient.
What’s important about the new federal mandate is the immediacy of access to clinical notes. Under HIPAA, patients can request copies of their medical records, but they don’t have the same level of ongoing accessibility that the mandate requires.
The new rule essentially requires providers to adopt the OpenNotes philosophy—one rooted in patient engagement—that has existed for the last 50 years, says Deb Wachenheim, assistant director of the OpenNotes dissemination team.
“Many physicians say that when patients read their own notes, they’re more engaged,” says Wachenheim. “They come better prepared for their next visit, and some physicians say it even saves time.”
The OpenNotes movement officially began in 2010 when Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in rural Pennsylvania, and Seattle’s Harborview Medical Center launched an exploratory study funded by the Robert Wood Johnson Foundation to examine the effects on patients and doctors of sharing clinical notes. Results of that study were overwhelmingly positive. Today, 53 million patients have access to their clinical notes with a growing body of research that supports fully transparent medical care.
Several important themes have emerged over decades of OpenNotes-related research. On the patient side, providing access to clinical notes enables people to better manage their own health care, be more effective caretakers for others, and feel better equipped to follow medication regimens. It also has patient safety benefits. Patients who read their own notes may find critical errors that, if not corrected, could lead to adverse events.
“On the patient side, it has been very positive in terms of their experience,” says Wachenheim.
Physician experiences have been largely positive, though some physicians have been leery of sharing their notes because they think that doing so will spur an increase in patient questions. In reality, that doesn’t happen, says Wachenheim, because patients are more likely to simply research topics on their own or come better prepared with questions for the next visit.
Others have been concerned that it will take them longer to document. In some cases, that may be true, but it’s not necessarily a bad thing, says Wachenheim, because it may result in a more thoughtful clinical note from which patients and other clinical providers alike can benefit.
Still, it’s a culture change. “Physicians are accustomed to writing for other physicians—not for patients,” she adds.
The good news is that practices that embrace the mandate can reap the rewards of better patient engagement, says Wachenheim. Consider these five strategies:
- Obtain physician buy-in. Refer physicians to research that supports the OpenNotes philosophy so they understand how the mandate can be helpful in terms of patient engagement and improved outcomes.
- Educate physicians. Provide physician education around how to document with patients in mind. OpenNotes doesn’t require a major documentation overhaul, says Wachenheim. It’s more about subtle language shifts or being more mindful of clinical jargon (e.g., enlarged heart rather than cardiomyopathy) and abbreviations (e.g., spell out ‘shortness of breath’ instead of using the acronym SOB), she adds.
For example, use direct language to help reinforce instructions. Document ‘Start taking lisinopril and check your blood pressure twice a week,’ rather than, ‘Initiated lisinopril and instructed to check her blood pressure twice a week.’
Likewise, directly and respectfully address concerns. For example, if a physician is concerned about a patient’s mental health, they might consider the following documentation: ‘Increased feelings of worthlessness and thoughts of self-harm. No active suicide plan and willing to seek care if thoughts worsen. Your grandchildren remind you of reasons to live. Check in tomorrow with your counselor and don’t forget the crisis line number.’
- Educate patients. For example, consider creating a one-page explanation of the new federal mandate and what it means for patients that the practice can distribute upon check-in. Other ideas include a waiting room poster, exam room tear-off sheet, press release, or social media campaign.
- Include patients in the note-writing process. For example, physicians can turn the EHR screen to face to the patient as they type, or they could dictate the clinical note in front of the patient so the patient can overhear it.
- Encourage patients to read their notes. Physicians can say, ‘This note will be posted in a couple of days. When you receive the alert that it’s available, I want you to log on and read it.’ Similarly, when reminding patients of an upcoming appointment, practices can remind them to read the notes from their last visit as well.
Practices that embrace this new federal mandate using a thoughtful approach will undoubtedly see higher levels of patient engagement in the form of medication adherence, improved outcomes, and more. During a time when many practices continue to rebuild in the wake of COVID-19, the mandate presents an opportunity to attract and retain patients as well as build trust through greater transparency.
To learn more about patient preferences and satisfaction around communication, download the recent guide on COVID's impact on patient communication.