Note Transparency Requirements: Risk Management Considerations

New rules against “information blocking” are designed to increase transparency and protect patient rights, but many healthcare providers are dealing with the unintended consequences of note transparency. To avoid unnecessary confusion or burden, new risk management strategies are needed.

The Implications of Note Transparency

The 21^st Century Cures Act and the 2020 Cures Act Final Rule, as of April 5, 2021, give patients the right to access their electronic health information (EHI) without delay. Starting October 6, 2022, additional categories of EHI will be accessible to patients.

Healthcare providers are likely familiar with these requirements, but they may still be grappling with the implications. First, there’s the risk of expensive penalties – The Office of the National Coordinator for Health Information Technology received 429 possible claims of information blocking between April 5, 2021, and July 31, 2022. Perhaps more importantly though is the potential impact on patient communication and provider processes.

Risk #1: Patients May See Their Results Before Their Provider

Patients have the right to access their medical records without delay. As a consequence, they may see their results before their provider has a chance to review them.

Consider a situation in which a patient is undergoing a biopsy to determine whether cells are cancerous. If the results indicate that the patient has cancer, the provider would want to convey this information if not in person, at least over the phone. However, with the new requirements for access to records, patients may see these results before the provider.

This means a patient could learn of a life-changing diagnosis by reading a lab report.

One only has to look at the situation from the patient’s point of view to see how this could result in distress and confusion. Patients will likely have questions, but because their provider will not be present, they will not be able to receive answers immediately.

Risk #2: Patients May Not Understand Their Records

Healthcare providers often use medical terms and abbreviations that the average patient is unlikely to know. This could lead to confusion. For example, if a doctor writes “S.O.B.” for shortness of breath, the patient may assume the doctor meant something else entirely.

Risk #3: Increased Confusion Could Create More Work and Liability

Note transparency is much more than just an IT issue. As healthcare providers adjust to the new requirements, they may have concerns about how note transparency could lead to turmoil in their processes, for example:

• Patients who are alarmed may call, increasing call volume.
• Providers may need to avoid medical shorthand and must therefore devote more time to writing notes in plain language.
• Increased note transparency may result in more requests for amendments to records.
• When treating minors, conflicts regarding confidentiality and note transparency may occur.
• Increased transparency and related problems may result in additional liability.

Risk Management and Best Practices

Concerns regarding note transparency are valid. However, many of the issues may simply be growing pains. According to Open Notes, research has found that patient access to notes does not increase note length, time spent writing notes, or documentation workload.

Once providers become used to writing plain language notes, note transparency should not be overly time consuming, and it can improve communication with patients. Being aware of possible risks and taking steps to address them can help minimize potential issues.

Documentation Tips

Providers need to write notes with the assumption that patients will be reading them, possibly without provider guidance. They should consider how the information will be interpreted and aim for both clarity and compassion by:

• Sticking to standard abbreviations. Do not invent your own abbreviations.
• Avoiding excessively complex medical jargon. Use plain language whenever possible; for example, “kidney stones” instead of “nephrolithiasis.”
• Avoiding extraneous, biased, or subjective statements in favor of factual statements. For example, avoid describing a patient as drug-seeking or alcoholic.
• Refraining from professional bickering in records. Including these types of comments in records may alarm the patient and increase liability.
• Remembering to be kind and supportive to the patient, even in the notes.

Special Considerations for Radiologists and Pathologists

Adapting to these requirements may be especially difficult for radiologists and pathologists because they do not typically have as much direct interaction with patients as other medical professionals. Whereas they previously wrote reports just for a medical audience, they now have to write with patients in mind.

There are a few ways radiologists and pathologists can adapt to note transparency:

• Start the notes with a short summary intended specifically for the patient and follow with more detailed information and medical terms for members of the healthcare team.
• Accommodate patient requests to delay reports on a case-by-case basis. If a patient asks for a life-changing report to be delayed until provider review, document this request.
• Draft clinical notes and laboratory results pending confirmation are examples of data that may not be appropriate to disclose or exchange until they are finalized.
• Remember that providers may not be required to notify the patient that an EHI report is available by text or email.
• Be consistent and strategic with phone interactions. Radiologists and pathologists may not be required to accept phone calls. It may be smart to come up with a script directing patients to the referring clinician.

For more helpful tips, see the American College of Radiology page on Information Blocking and the American College of Pathologists Cures Act Fact Sheet. 

Minors’ Rights

Minors, especially teens, may not want their parents to access certain information in their health records, such as results for sexually transmitted diseases or pregnancy testing.

State laws regarding this issue vary significantly. In some states, minors over a certain age may have the right to access certain types of care without a parent’s consent. Therefore, depending on the state laws, it may be necessary to separate the documents that are available to the parents from those available to the minors.

Amendment Requests

Under HIPAA, patients have the right to request amendments to their records if they think the information is inaccurate. According to the Department of Health and Human Services, covered entities have 60 days to act on a request.

As access to documents increases, requests may also increase. You should establish procedures for amendment requests. For instance, to avoid issues, requests should be made in writing. Proactively educate patients about the process.

Patient Education

Healthcare providers aren’t the only ones who may need training on note transparency – patients also need to know what to expect.

• Set expectations for reports. Explain what you’re looking for in the results.
• Ask patients if they want results to be delayed. Explain that reports may be available to them before their provider has had a chance to review them.
• Let patients know what to do if they are upset, alarmed, or confused about their records. Whom should they contact?

Engaging the Team

Note transparency is here to stay, and additional portions of medical records will become available to patients soon. Getting everyone on board is essential for success.

This article was based, in part, on the Coverys presentation “21st Century Cures Act: Patient Perspective and Best Practices,” presented by Heather Marchegiani, MBA, and Marlene Icenhower, BSN, JD, CPHRM.