Does allowing patients quick and easy access to the information in their medical record improve patient care? Yes—but simple adjustments can maximize the benefits of full information sharing.
Fans of the hit 1990s sitcom, Seinfeld, regularly say its brilliance and success came from its ability to point out the humor in the events of our everyday lives. In 1996, just after the Health Insurance Portability and Accountability Act (HIPAA) was enacted, character Elaine Benes takes a sneak peek at her medical chart while her doctor is out of the room to find that someone had written she was “difficult” after a previous a visit.
Elaine confronts her physician, Doctor Stern, and pleads her case trying to explain why she wasn’t being difficult when she refused to wear a gown at the appointment four years previous.
“I wore a tank top,” she says. “Specifically so I wouldn’t have to wear a gown. Cause, you know, they’re made of paper.”
Her doctor smiles and nods. “Well, that was a long time ago. Why don’t I just erase it,” he says as he takes his pencil eraser to her chart.
“But it was in pen,” Elaine says. “You fake erased.”
Doctor Stern takes his pencil and writes in her chart, but doesn’t allow her to see it. She transfers physicians, and makes attempts to steal her chart at the new practice to see their comments about her. But she never succeeds in getting a hold of her patient notes.
Elaine would have appreciated the Information Blocking Rule of the 21st Century Cures Act.
Old practice, new caveats
Providing patients access to visit summaries is nothing new. Engaging patients not just during their visit, but immediately following it, is more likely to improve health outcomes by encouraging them to take an active role in follow-up care and monitor any issues identified. In fact, according to one study, many patients immediately forgot about half of the information communicated during an appointment. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36 percent recalled with a prompt; 15 percent were recalled erroneously or not at all.1
Recently, the final rule on Interoperability, Information Blocking, and ONC Health IT Certification (“Information Blocking Rule”), part of the 21st Century Cures Act, nationally mandates that patients be granted access to all of the information in their medical records, electronically and without charge or delay, and through patient portals or, to the extent possible, through third-party smartphone applications (apps).
In particular, the requirement stating that patients must be able to access information in their electronic health records “without delay” has raised many questions pertaining to physician note taking and practice management.
You may find yourself asking: Does a patient really get access to all of the information I record about them? How much extra time will this require of me? What if a patient takes issue with how I say something? What if they don’t understand a clinical summary or have questions about lab results, etc.?
In fact, however, there are many valuable note taking strategies that support transparency, quality, and—most of all—improved patient outcomes.
Transparency builds trust
According to MSMS Legal Counsel, Kathleen Westphal of Kerr, Russell & Weber, the increased transparency afforded under the Information Blocking Rule aligns well with the Open Notes concept.
“Initially, there were questions about logistics and concerns regarding how compliance with the Information Blocking rule will impact a physician’s practice,” says Westphal. “Over time, we’re seeing that with increased transparency with patient notes, there is more opportunity for improved communication regarding a patient’s treatment, better engagement by patients, and an overall strengthening of the physician-patient relationship. This generally leads to fewer complaints and better outcomes.”
Some physicians worry that the direct tone of their note-taking, or recording sensitive subjects, such as patients not following care instructions, will offend. Others worry that the clinical nature of their notes will be inaccessible, misconstrued, or lead to further worries about a diagnosis. In fact, studies show that many patients feel better about their provider after reading their visit notes. Positive effects on the patient-provider relationship may be most significant among vulnerable patients, such as those with fewer years of formal education.2 In the same study, among doctors, 26 percent anticipated documentation errors and 44 percent thought patients would disagree with notes. After a year, however, 53 percent believed patient satisfaction increased, and 51 percent thought patients trusted them more.
Many physicians are using the mandated release of patient data electronically as an opportunity to help patients assume greater involvement in their own health journeys—which is proving to result in better health outcomes.
Info blocking should not be viewed as ‘black or white’; it is okay to consider your patient’s needs while thinking about compliance. Physicians should strike a balance between strict regulatory compliance and exercising his/her independent professional judgment—guided by personal and professional beliefs—as to what is in the best interests of patients, the profession, and the community.
American Medical Association³
According to the American Medical Association, patients who read their physician’s notes say they:
- Feel more in control of—and engaged in—their health care
- Recall their care plans more accurately
- Are better prepared for visits
- Have a better understanding of their medical conditions and medications
- Are more likely to adhere to their treatment plans
- Can identify clinically important errors in their notes
- Are not more worried or offended after reading their notes
- Have more successful conversations and stronger relationships with their doctors
During the worst of the COVID pandemic, numerous public opinion surveys showed that doctors were the most trusted source of information, topping government agencies, politicians, and the news media.4 While there are always certain to be outliers, it’s evident that access to clear, concise information builds patient trust and understanding.
The editing process: or lack thereof
One of the biggest changes to the rules that govern dissemination of information to patients electronically is the immediacy required. The rule now in effect says that patients must be able to access information in their medical records “without delay.”
While there is no requirement for adapting notes to the ‘open note’ style, many physicians are choosing to use less ‘medical speak,’ including fewer abbreviations and technical terms, so that patients are readily able to understand and digest the information provided to them.
One of the hardest pieces of getting used to this open-format communication style is how to address sensitive topics, such as diagnoses of serious illness, weight management, and/or mental health concerns. Surprisingly, some patients have reported that they appreciated direct language used in their notes, and that it helped them take their health more seriously. Clinicians in one study found that when some patients read visit notes about obesity or substance abuse, they were more motivated to attempt difficult behavioral changes. Some patients reported that “seeing it in black and white” made it more real.5
In most cases, a patient’s immediate access to their complete medical records including test results will lead to quality and satisfaction for all parties. A learning curve will be present for some patients, and it’s wise to share with them how to contact your office in the case they don’t understand something or believe an entry may be incorrect.
“Some physicians have expressed concerns about a patient misunderstanding their notes or misinterpreting test results and the potential impact to the patient,” says Westphal. “In these circumstances, physicians should talk with their patients and let them know how they can ask questions or obtain clarification regarding their notes or test results, whether at the patient’s next visit, or for more urgent concerns, calling the office or using the practice’s patient portal.”
Be familiar with what the patient has the right to ask, what you can grant and/or refuse, and how to amend information in their medical record, including:
- Patients have the right to request amendments to their medical records: The Health Insurance Portability and Accountability Act (HIPAA) requires a signed, dated request from the patient regarding what they want changed and why.
- Providers have the right to determine whether the requested amendment will be made: The provider must respond, in writing, within 60 days of receipt of the patient’s request.
- Common reasons to deny a patient’s request include that the provider who received the request did not create the record entry, or that the medical record is accurate as is.
- The patient’s request and the provider’s response both become part of the patient’s medical record.6
The OpenNotes organization has communication resources available for use instructing patients how to understand their medical records and ask for clarifications as needed, such as posters for patient waiting areas or exam rooms, and printed communications that can be mailed or provided at appointment check-ins.7
Interoperability and continuing requirements
Legislators put these rules in place to increase collaboration between health care providers and their patients, allowing for better quality health care, but it could come at a cost to those who have outdated technology, according to the The Doctors Company:
A stumbling block to reaching true interoperability is when electronic health record (EHR) vendors closely guard data, which harms the transparency and open communication aspect of getting information directly to patients. The ultimate goal of the Cures Act is to support patient care by addressing health information technology hurdles across the continuum of care, and information blocking is strongly discouraged.
Additionally, open notes are becoming even more, well…open. Starting in 2023, patients will be able to see task notes from staff members in their record, which includes items like reminders from staff members to the provider to return a call from the patient. If they are not doing so already, staff members should begin composing task notes as if the patient can see them—because soon, that will be the reality.
“It’s important that physicians implement and enforce information sharing policies and protocols that will work within their practice,” she says. “Physicians should also talk with their EHR vendors to confirm compliance and ways to provide more seamless access to patient notes.”
Recommended Resources
More information on successfully complying with the Information Blocking Rule:
- OpenNotes – https://www.opennotes.org/
- AMA Sharing Clinical Notes with Patients Toolkit – http://MSMS.org/AMASharingNotes
- AMA Patient Access Playbook (pdf) – http://MSMS.org/AMAPatientRecordsPlaybook
- Information Blocking Resource Center – https://infoblockingcenter.org/
- AMA Information Blocking Part 1 – http://MSMS.org/AMAInfoBlocking
- AMA Information Blocking Part 2 – http://MSMS.org/AMAInfoBlockingCompliance
- MSMS Legal Alert: ONC Cures Act Information Blocking Final Rule – http://MSMS.org/ONCCuresAct
REFERENCES
- https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191940
- https://qualitysafety.bmj.com/content/26/4/262
- https://www.ama-assn.org/system/files/2020-11/info-blocking-compliance.pdf
- https://chrt.org/wp-content/uploads/2020/07/CoverMichigan_COVIDInfoAndTrust_Final-.pdf
- https://www.ama-assn.org/system/files/2021-04/sharing-clinical-notes-with-patients-toolkit.pdf
- https://www.thedoctors.com/articles/open-notes-in-healthcare-the-good-the-bad-and-the-ugly-of-the-cures-act/
- https://www.opennotes.org/communications/
