May 19, 2021
Brief Summary: The "Open Notes" requirement inthe CURES act has direct impact on documentation in the electronicHealth Record (EHR). Hear from our IT specialist Dr. KristianFeterik, a hospitalist and implementer of EHR documentation tipsand tricks, how to maximize your impact in providing optimalpatient care in the "Open Notes” era. Learn how real timeaccessibility of "Open Notes” can empower patients and familiestowards better health awareness with EHR best practices.
Learning Objectives:
- Detail the importance of "Open notes" brought about by“information blocking” and the Cures act
- Illustrate recent changes in clinician responsibilities whendocumenting in the medical record
- Explain why certain approaches to the EHR are better thanothers.
- Describe how clinicians can empower patients’ health awarenessthrough “Open notes”
CME Questions:
- The OpenNotes movement started as a pilot program in 2009 atBeth Israel Deaconess Medical Center, Harvard Medical School, andGeisinger Health System. The resulting study, published in Annalsof Internal Medicine, found that:
- Virtually all patients wanted the practice to continue, withmore than 80 percent of patients reading their notes and a largemajority reporting clinically relevant benefit.
- There was significant disruption of clinical workflow in allparticipating study sites.
- Many patients were alarmed by what they read and there was anincrease in telephone encounters.
- Most practitioners reported changing their clinicaldocumentation style.
- Majority of patients agreed that they should have the option ofapproving the content of clinical documentation generated by thepractitioner.
Correct answer: A
Reason: Nearly 99% of patient respondents at Beth IsraelDeaconess Medical Center (BIDMC), Harvard Medical School (HMS), andGeisinger Health System (GHS) wanted continued access to theirvisit notes, and 86% at BIDMC, 87% at GHS, and 89% at HMC agreedthat open notes would be a somewhat or very important factor inchoosing a future doctor or health plan.
Reference: Debanco T et al. “Inviting patients to read theirdoctors' notes: a quasi-experimental study and a look ahead.”Annals of internal medicine vol. 157,7 (2012): 461-70.doi:10.7326/0003-4819-157-7-201210020-00002
- The Cures Act was passed with bipartisan support in 2016,became law in 2020 and went into effect on April 5, 2021. Theofficial name of the “Open Notes” rule is the "InformationBlocking" provision of the Cures Act. The provision pertains toeight types of clinical notes: consultation, discharge summary,history and physical, imaging, lab report and pathology narrative,procedure note, and progress note. Please select a correctstatement:
- It is permissible to delay radiology and pathology reports fora range of 4 to 14 days (about 2 weeks) before releasing them tothe patient portal.
- Emergency department documentation has been excluded from theCures Act.
- Clinical notes listed above should be made available topatients electronically immediately after completion.
- The Cures Act requires only ambulatory notes to be shared withpatients.
Correct answer: C
Reason: Under the Information Blocking rule of the 21st CenturyCures Act, clinical notes must be shared by health systems by April5, 2021, and shared with a patient’s 3rd party application (“app”)that may be downloaded to a smart phone or other device by the endof 2022. In other words, the rule requires that healthcareproviders give patients access without charge to all the healthinformation in their electronic medical records “withoutdelay.”
Reference: Information Blocking FAQs. https://www.healthit.gov/curesrule/resources/information-blocking-faqsAccessed, May 17, 2021
Reference: Federal Rules Mandating Open Notes. https://www.opennotes.org/onc-federal-rule/Accessed, May 17, 2021
- In general, patientsdo notexpect doctors to writenotes in layperson language. They are notbothered by termsthey don’t understand and report researching terms, preparingbetter questions for clinicians, and in general feeling fortunateto have a window into more information about their health.Nevertheless, the following suggestions may help you maximize theeducational potential of notes - select all that applies:
- Incorporate a summary of lab or study results into your notesto give patients the full picture.
- Include an official Medline definition if you use jargon or amedical term.
- Be mindful of sensitive topics, and remember patients alwayshave rights under HIPAA to access their record.
- Include educational materials or links to trusted content foryour patients.
- A, B, C
Correct answer: E
Reason: Reading the notes helps patients remember treatmentplans. Patients also say note reading helps them take theirmedications as prescribed. Many patients say they email or calltheir health professionals less because they answer questions byreading their notes. Furthermore, both health professionals andpatients report that engaging with notes helps set the agenda,makes the visit more efficient, and helps both parties feel moresatisfied with the visit and ongoing relationship. To make yournotes more patient friendly, avoid use of acronyms and potentiallyjudgmental language. While it is helpful to include a briefdefinition of a medical term, there is no need to cite an officialMedline source.
Speakers:
-Kristian Feterik, MD, MBA, Clinical Associate Professor ofMedicine, eRecord Medical Director, Clinical Informatics, AssociateMedical Director, Clinical Documentation Integrity, University ofPittsburgh Medical Center, Pittsburgh, PA
-Julie McCausland, MD, MS, Associate Professor of EmergencyMedicine and Medicine, Program Director, Transitional YearResidency Program, Co-Chair, UPMC GME Professional DevelopmentSubcommittee, University of Pittsburgh Medical Center, Pittsburgh,PA
Course Directors:
-Greg Bump, MD, Associate Dean, UPMC GME, DesignatedInstitutional Official (DIO), Associate Professor, InternalMedicine, University of Pittsburgh Medical Center, Pittsburgh,PA
-Melinda Hamilton, MD, MS, Associate Professor of Critical CareMedicine and Pediatrics, Program Director Pediatric Critical CareMedicine Fellowship, Co-Chair, UPMC GME Professional DevelopmentSubcommittee, University of Pittsburgh Medical Center, Pittsburgh,PA
-Julie McCausland, MD, MS, Associate Professor of EmergencyMedicine and Medicine, Program Director, Transitional YearResidency Program, Co-Chair, UPMC GME Professional DevelopmentSubcommittee, University of Pittsburgh Medical Center, Pittsburgh,PA
Moderator:
-Julie McCausland, MD, MS, Associate Professor of EmergencyMedicine and Medicine, Program Director, Transitional YearResidency Program, Co-Chair, UPMC GME Professional DevelopmentSubcommittee, University of Pittsburgh Medical Center, Pittsburgh,PA
CME Accreditation and Credit Designation
In support of improving patient care, the University ofPittsburgh is jointly accredited by the Accreditation Council forContinuing Medical Education (ACCME), the Accreditation Council forPharmacy Education (ACPE), and the American Nurses CredentialingCenter (ANCC), to provide continuing education for the healthcareteam.
The University of Pittsburgh designates this enduring activityfor a maximum of 0.5 AMA PRA Category 1 Credit[s]™. Physiciansshould claim only the credit commensurate with the extent of theirparticipation in the activity.
No members of the planning committee, speakers, presenters,authors, content reviewers and/or anyone else in a position tocontrol the content of this education activity have relevantfinancial relationships with any entity producing, marketing,re-selling, or distributing health care goods or services, used on,or consumed by, patients to disclose.
Instructions for receiving CME credit
Click here to receive CME credit, https://cce.upmc.com/gmecastehrbestpractices#group-tabs-node-course-default4you will be required to login and complete the courseevaluation. If you are a new user, click “Register” in thetop left corner to create a new account.
