As reported in the Sept. 27 edition of the Common Ground, the 21st Century Cures Act was enacted to improve our patients’ ability to personally engage in their care. Electronic Health Information has historically been available to patients through an HIM request. With the new regulatory rules prescribed by the act, EHI will be made more readily and immediately available to patients through MyChart and other apps. Empowering and engaging patients with their own health information is good for clinical care, however, it is important to be prepared for how this change may impact your practice.
Providers should continue to document as medically appropriate when composing a clinical note. Heightened awareness that the patient may also read the note could alter the tone the author uses. For example, consider how documenting “morbid obesity” might be viewed by a patient when this diagnosis has not been discussed with them.
Another area to consider is that the default ROS and physical exam findings documented are aligned with the visit.
Also having clear and proactive discussions with your patient when ordering imaging studies or sending specimens to pathology will help them to understand what potential results to expect. Patients generally appreciate these discussions starting even before the result has arrived.
Our 12-17 year old patients who have granted proxy access to their EHI will not see changes to our current information blocking policy. This age groups’ clinical notes are not currently shared with proxies. Additionally, a process is being developed to allow for proxy sharing for adolescents with diminished capacity.
As previously mentioned, we will continue to provide updates through the Common Ground as we approach the go live date with this work on Nov. 2, 2020. For additional information and links, please see the Sept. 27 Common Ground article.