21st Century Cures Act and Patient Experience

Premier Pulse     September 2023

1659546505By Lakmali Ranathunga, MD, chief medical officer, Miami Valley Hospital North and Upper Valley Medical Center

The 21st Century Cures Act's "Open Notes Rule" became effective on April 5, 2021, mandating that health care organizations grant patients immediate access to their electronic medical records, including clinical notes, lab results, medication lists, operative reports, and referral information. This rule encompasses a range of health care providers like hospitals, skilled nursing facilities, nursing homes, home health entities, long-term care facilities, and health care clinics.

Following in-person or telehealth visits, medical professionals, including doctors, nurses, and other care providers, compose “Open Notes” summarizing crucial patient details. These notes integrate into a patient's medical record, and upon sharing with patients, they transform into "open notes." While patients understand that clinical notes serve as a conduit for care coordination among clinical teams and aren't framed in layperson's terms, they expect that these notes accurately and genuinely represent their health status. Exceptions aside, clinical notes must remain accessible. Non-compliant organizations and providers risk potential fines, sanctions, or other adverse consequences arising from their failure to adhere to The Cures Act; the act, however, permits a comprehensive list of well-defined exceptions. For instance, a note could be withheld if a provider deems its viewing poses a substantial risk to the physical safety of a patient or another individual.

The silver lining is that our choice of words and phrases can empower and humanize our patients, fostering a healing connection with them and their families.

Furthermore, open notes yield a positive impact on patient engagement and comprehension. Patients affirm that reading these notes helps them better grasp and assert control over their health care journey. They also note a sense of trust in their health care provider.

Health care professionals frequently counsel patients to jot down their notes during clinical visits or enlist friends or family for assistance, given that a significant portion of conveyed information is often forgotten. For better or worse, patients can swiftly access their provider's notes within their electronic medical records (EMRs) to recall the specifics of their health care interactions.

Patients are observant of our notations and bedside manner. Specifically, our use of templated physical examination descriptions must be tailored to reflect the actual bedside assessment. We've encountered instances where patients discovered a comprehensive exam documented in the chart without a corresponding physical examination. On one occasion, a patient reached out to us, highlighting a consistent age discrepancy across the records—73 instead of 33. This discrepancy originated from a provider's error and propagated through various notes. Similarly, vigilance is required in documenting time-based information.

In addition, our choice of language must be sensitive, avoiding terms like alcohol addiction, frequent flyer, pain seeker, addict, or alcoholic, which can inadvertently come across as judgmental and offensive. For instance, substituting "alcohol use disorder" for "alcohol addiction" is more considerate. Rather than describing a patient as "non-compliant" and a "frequent flyer," we can depict a "73-year-old female with a history of diabetes mellitus who struggles with adhering to her diabetes regimen, resulting in multiple readmissions." These nuances in phrasing can either foster a stronger patient-provider connection or erect barriers to its formation.

Requests for medical record amendments vary in legitimacy and complexity. While some adjustments are straightforward, others involve removing material that patients find embarrassing, even if factually accurate. A surge in amendment requests could further burden providers with administrative tasks. Some of these appeals might not befeasible, necessitating careful conversations with patients and written responses to rejected requests. Such interactions might not always go smoothly, potentially causing stress for patients and providers, and tarnishing the provider's reputation due to negative online reviews.

Let's focus on the positives of this practice to cultivate connection, nurture trust, and ultimately enhance patient health care outcomes. Patients have harnessed open notes to better comprehend and adhere to treatment instructions. Addressing valid concerns or miscommunications in these notes has allowed patients to resolve issues promptly. Beyond a mere administrative burden, open notes present an avenue to refine documentation, enhance patient-provider relationships, and bolster patient safety. By promoting patient compliance with treatment plans, open notes can elevate patient experience and provider satisfaction.

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