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Posted on 04.16.2021

New Rule Provides Access to Health Visit Notes

Health care providers routinely take notes as part of in-person or tele-health visits. Though those notes become part of a patient’s medical record, they have typically not been shared with – or even made accessible to – the patient. As of April 5, 2021, that’s all changed.

The 21st Century Cures Act’s counterintuitively named Information Blocking Final Rule is set up to prevent actions that interfere with access to patient health information – including clinical notes.

The rule applies to three categories of what it calls “actors.” Actors include health care providers (defined broadly in this fact sheet from HealthIT.gov), health information networks or exchanges and health IT developers of certified Health IT.

The rule banning information blocking specifies eight types of clinical notes that now must be made available to patients, including:

  • Consultation notes
  • Discharge summary notes
  • History and physical notes
  • Imaging narratives
  • Laboratory report narratives
  • Pathology report narratives
  • Procedure notes
  • Progress notes

 

It’s worth noting there are certain exceptions including psychotherapy notes as defined by the HIPAA Privacy Rule.

Transparency Matters

OpenNotes is a nonprofit organization that represents an international movement committed to spreading and studying the effects of transparent communication among patients, families and clinicians. It was launched by clinicians from Beth Israel Deaconess Medical Center and Harvard Medical School in 2010. Funded by non-commercial grants, philanthropy and supporters, OpenNotes faculty, scholars, and collaborators from a wide variety of settings have studied the impact of open visit notes on patients, caregivers and clinicians.

“Time and again, studies show that open, transparent communication through visit notes are a good thing, across all demographics, and the majority of clinicians with experience with open notes feel it is a good idea and would recommend it to colleagues,” the organization says.

OpenNotes has documented benefits of open visit notes that include:

Accuracy. Studies find almost 10% of patients find errors in their records. And 25% of physicians who have offered open notes for more than a year report that patients found errors that the doctors themselves felt were serious.

Adherence. In a 2019 study, one out of six patients reported open notes led them to adhere to their medication regimen more closely. Most patients reported open notes improved their understanding of why and how to take their medications.

Empowerment. One study reported 77-87% of patients said accessing their notes made them feel more in control of their health care. Notes also remind patients of what was discussed during their visit and can help increase adherence to medications and care plans.

Support. Many patients share access to their patient portal with family and other caregivers. Reviewing notes can help them provide better support to the patient and can reduce their stress.

Satisfaction. In numerous studies, 93-99% of patients surveyed reported that reviewing their notes made them feel the same or better about their doctor. More than half of participating physicians said sharing notes led to improved patient satisfaction and trust.

Go Deeper

There’s a lot to explore about this new landscape. Resources abound at OpenNotes.org. HealthIT.gov provides access to the final rule and offers resources for patients, health providers and health IT developers.

Read about the implementation of open visit notes by Johns Hopkins Physicians in OpenNotes: Bonus or Burden?

Physicians at the University of Colorado Hospital, Aurora, published results in JAMA of their efforts to share electronic health record information in real time with patients. Despite issues and barriers anticipated rom both caregivers and patients, concerns decreased in all groups.

The Information Blocking Final Rule creates considerable communications challenges for health care providers and organizations. Please contact us at Lovell Communications for assistance in helping your clinicians, staff, patients and other stakeholders understand this new era of transparency.

 

This blog  features content from OpenNotes.org, available under a Creative Commons Attribution 4.0 International license, and HealthIT.gov.

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