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 health care organizations to grant patients immediate access to their electronic medical records, including lab results, medication lists, operative reports, referral information, and clinical notes. Organizations and providers that are non-compliant in adhering to the Open Notes Rule risk potential fines, sanctions, or other adverse consequences.

This is the perfect time to reflect on the wise adage, that words matter. Just as we are careful in what we say to our patients, we also need to be mindful of what we write about our patients in their medical files. Our choice of language must be sensitive, avoiding terms like alcoholic, frequent flyer, pain seeker, or addict, which can come across as judgmental and offensive.

Perhaps it is more sensitive to write alcohol use disorder instead of alcoholic. Rather than describing a patient as non-compliant or 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 phrasing nuances can foster a stronger patient-provider connection, or our words can build barriers.

A positive aspect of the Open Notes Rule is that our words can positively impact patient engagement and comprehension. Patients affirm that reading these notes helps them have more control over their health care journey. They also express a deeper trust in their health care provider. Open notes present an avenue to refine documentation and bolster patient safety.

Let's focus on these positive facets of the Open Notes Rule to ultimately elevate patient experience and provider satisfaction. The silver lining is that our choice of words and phrases can empower and humanize our patients, fostering an additional healing connection with them and their families. 

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