The compliance deadline for the federal Open Notes mandate, a key component of the 21st Century Cures Act, has been postponed until April 5, 2021. However, at UVA Health, key changes have already been made to ensure compliance by the original November 2, 2020 deadline.
UVA Health has worked diligently over the past year to overcome minor technological barriers and establish new protocols that makes this process seamless for providers and their patients via the EpicCare electronic medical record system. As of early November, the health system is releasing 95% of clinical notes and 97% of test results.
“I think we’re in good shape,” says Sherry McCarty, communications specialist for the Open Notes project. “Our result release timeframes are now within guidelines. Test results are released to MyChart one to two days after finalization rather than 14 days later, which is a big difference. In addition, a majority of clinical notes auto release as soon as they’re signed.”
In addition to getting a jump on the mandate, McCarty believes this effort will be a significant patient satisfier. “Care coordination from one provider to the next is a big benefit. There is also the potential to strengthen the patient-provider partnership,” she says. “When a patient goes back and reads notes and sees that the information is represented accurately, there is more trust built there and more transparency, which increases engagement in care plans.”
Making patients aware that this information is easily accessible will make this collaboration more likely. At UVA, patients are currently only accessing their clinical notes around 7% of the time, according to McCarty. That number will likely increase as word gets out about change in practice, and providers shouldn’t hesitate to make their patients aware.
“This was a culture shift for us, but it hasn’t changed much in our day-to-day business,” says McCarty. “There was concern that notes sharing may increase patient calls, but we haven’t seen any of the big impacts we might have expected.”
Tips for Providers on Open Notes Compliance
As you work within the parameters of the new regulations, McCarty recommends that you educate yourself on the process to prevent notes or results release and when it is appropriate, such as in the case of potential harm. “Providers have discretion to make that decision. But if you do decide to prevent a release, be sure to document your reason,” she says. “If there’s ever an allegation of information blocking, this is the number one thing providers can do to be sure to avoid liability.”
Another important reminder: brush up on your clinical note etiquette. “These notes are shared with patients, so it’s important to follow best practices for clinical documentation. Stick to the facts,” says McCarty.
UVA providers can also get training on steps to prevent note or result release, and updates to our resident note release process on the UVA MyChart Support intranet site.