My husband often says that to fix something, you need the right tools. This is true in all aspects of life, but most of all in healthcare. To help people be active participants in their healthcare, they need the information to understand the rationale in their plan of care and make decisions that align with their goals.

A new Federal Rule went into effect on April 5, 2021, focused on ¬†Interoperability, Information Blocking, and ONC Health IT Certification. This is part of the 21st Century Cures Act, requiring healthcare providers to give patients access without charge to all the health information in their electronic medical records “without delay.”

The 21st Century Cures Act was signed into law in December 2016 with the goal is to ensure the patient is at the center of their care. Among the various aspects of the Cures Act, there is a mandate to providers to ensure patients have access to their medical records through smartphones, computers, patient portals, and other applications to provide them with more transparency and choices in their health care.

The new rules hold the promise of increased clinical collaboration between patients and their doctors, allowing for informed and better health care decision-making.

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 that do not apply

Psychotherapy notes that are separated from the rest of the individual’s medical record and are 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.

What does this mean for patients and for the healthcare team?

This is an important time for patients as well as professionals at the point of care. With greater access to their medical records, patients and their families will have a way to better participate in their own care. By having access to their doctor’s office notes, they can read the note to understand what the doctor said after they leave the appointment. They can share the note with their caregiver, a nurse, or other trusted person who is part of thier care team. Have access to these notes will allow them to read firsthand what the patient was told.

Research shows that when patients are informed, they take part in their care by asking questions, allowing them to make choices that meet their goals. Patients and family members who are caregivers need help in keeping their records so that when they meet a new doctor or are hospitalized, they can produce records that helps their team better understand what has been done and how things are working. Having information to share improves care coordination, decreases fragmentation, duplication, and waste, which helps to lower healthcare costs. Having access to their medical records is a transformational step in engaging people in their health and healthcare.

Now that the Rule is in place, providers are working to ensure their systems allow patients access to their records. Patients should ask their doctors about how they provide access. As a nurse, patient/health advocate, please inform your patietns of this rule and help them through the process.

Resources:

Here are some links that will help patients, caregivers, and healthcare team members understand the new Rule.

  1. Here is a video of a patient who is excited to have access to his records and how this has helped him be an active member in his care. https://youtu.be/V41bhSWtQbI
  2. The Society for Participatory Medicine has been an advocate to help make this Rule come into practice.
  3. Open Notes: OpenNotes is an international movement committed to spreading and studying the effects of transparent communication among patients, families, and clinicians. They are motivated by evidence indicating that when health professionals offer patients and families ready access to clinical notes, the quality and safety of care improves. To learn more, visit their website at https://www.opennotes.org
  4. Health and Human Services Finalize Historic Rules to Provide Patients with More Control of their Health Data. https://www.cms.gov/newsroom/press-releases/hhs-finalizes-historic-rules-provide-patients-more-control-their-health-data

As a nurse, I am excited to see this new Rule come to fruition as it will allow people to be active members of the care team.

As a patient, I am excited as the new Rule allows me to access the doctor’s progress notes to review the information so I better understand my plan of care.

If you have had success in accessing and saving your medical records, please drop me a note as I am interested in how this is working.

Thanks for reading Nurse Advocate, have a good week!