News: Patients now have access to their clinical notes, test results, imaging

CDI Strategies - Volume 15, Issue 14

While the 21st Century Cures Act had previously been delayed by the Department of Health and Human Services (HHS) to provide additional time to allow healthcare systems to focus on COVID-19 response, it is now officially implemented. This means that, as of April 5, 2021, patients now have access to read clinical notes, test results, and imaging.

The 21st Century Cures Act states that “the implementation of these provisions will advance interoperability and support the access, exchange, and use of electronic health information.” Included in electronic health items patients should be granted access to are consultations, discharge summaries, history notes, physical exam findings, imaging narratives, laboratory and pathology report narratives, and procedure and progress notes.

While there is concern that giving patients immediate access could leave them confused or alarmed, causing increased workload for providers as they tailor notes for patient consumption, there is also the possibility that patient access to clinical notes can lead to better doctor-patient communication as well as allowing patients to play a more active and aware role in their health. In fact, according to a 2020 study in the Journal of the American Medical Association, 20% of patients identified errors in their own electronic records.

Even with the newly effective rule, note that the new rule permits information being withheld if there is clear evidence that withholding will “…substantially reduce the risk of harm” to patients.

Such transparency may very well be yet another reason for CDI expansion into outpatient and specialty office settings to help physicians get the clearest, most accurate information into the medical record the first time, every time. Physician documentation isn’t just for coders and clinicians now, it’s also for patients.

Editor’s note: The 21st Century Cures Act can be found here. Previous ACDIS coverage of the Cares Act can be found here.

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