New Federal Rules Increase How Much Information a Patient Can Access
A law was passed in November of last year to give patients access to reading their health records, which is different from the access with HIPAA that can take longer to obtain. This law enables immediate access to the patient’s notes, which increases transparency but may take providers by shock. This new level of transparency warrants a reassessment and improvement to charting, with special emphasis on how to do so clinically and in a way that patients will understand and appreciate.
It’s time to start thinking about how you chart. When charting, consider that patients will read those notes. Keep things clinical and to the point, and avoid harsh notes. Make sure you note progress within the notes where applicable.
Federal Rules on Interoperability and Information Blocking
This web page is not official technical or legal advice. State laws around data release may not be superseded by the 21st Century Cures Act. Consult with your organization’s Health Information Management, compliance, legal, finance, and public affairs teams to find out how it applies to you.
The program rule on Interoperability, Information Blocking, and ONC Health IT Certification, which implements the 21st Century Cures Act passed in 2016, requires patients be provided access to all the health information in their electronic medical records without charge by their healthcare provider beginning April 5, 2021.
OpenNotes is invested in the Cures Act because clinical notes are among the information that must not be blocked—and thus be made available to patients.
What notes must be shared?
The eight (8) types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI), and include:
- consultation notes
- discharge summary notes
- history & physical
- imaging narratives
- laboratory report narratives
- pathology report narratives
- procedure notes
- progress notes
Clinical notes to which the rules do not apply:
- Psychotherapy notes 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 and that are separated from the rest of the individual’s medical record. Note: Clinicians and organizations are required to share medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
- Information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding.
What is the timeline for when these new rules go into effect?
Under this new rule, clinical notes must be shared by health systems by April 5, 2021, and shared with a patient’s 3rd party application (e.g., downloaded to a smart phone) by October 6, 2022.
Are there any exceptions to the Rules?
There are complex situations in which information can be blocked—and these are called Exceptions. Unless one of the Exceptions applies, clinical notes must not be blocked.
A group called actors are referred to throughout the rule. Actors include:
- Health care providers
- Health information networks or health information exchanges
- Health IT developers of certified health IT (e.g., electronic health record vendors)
Featured below are the exceptions outlined by the final rule, which fall into two categories (source).
More Information
- New for health professionals in 2021, extra great information about documentation by Open Notes
- Open Notes are Delayed Until April by Med Page
- Riverside Psychiatric Medical Group settles with HHS OCR to resolve a potential HIPAA Right of Access violation. The $25,000 settlement is the tenth of the OCR patient access initiative by Health IT Security: the consequences of delaying a person’s access to their medical records.
- Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects by The American Journal of Medicine
- What Providers Must Know About Patient Access to Clinical Notes by Patient Engagement Hit
