Introduction
The Office of the National Coordinator for Health Information Technology (ONC) officially enabled the information blocking provisions that cover healthcare providers, certified health IT developers, and health information exchanges (HIEs). ONC’s information blocking provisions mandate enacted in 2021 enables patients access to eight kinds of EHR notes consultation, discharge, history, imaging, laboratory tests, pathology, procedures, and progress (Wheeler, 2021). The ONC Final Rule establishes rules prohibiting healthcare providers from information blocking techniques. Information blocking occurs where practices are likely to interfere with accessing, exchanging, or using electronic health information (Wheeler, 2021). The ONC information blocking rule is a part of the 21st Century Cures Act that seeks to increase choice and access for patients and providers. The Cures Act includes clauses designed to improve interoperability and lessen the regulatory constraints of using electronic health records.
Impact on System Implementation
Information blocking rule does not create data sharing requirements; thus, organizations must negotiate the rule in the context of existing regulations and privacy practices. Organizations can deny data requests where privacy issues exist, preventing harm, infeasibility, and health IT performance exceptions. The second option entails procedures for fulfilling requests regarding content and manner, fees, and licensing exceptions. Organizations will comply with the ONC final and interoperability rules that address admissions, discharge, and transfer (ADT) notifications. Any healthcare facility admitting, discharging, or transferring a patient from another hospital must provide direct electronic notification to the patient’s physician. HIEs can help enable this by integrating their ADT notifications mechanism within the HIE service.
Impact on Clinical Care
There are numerous risks and benefits to patients’ access to electronic health records for both healthcare providers and patients. Nelson (2022) improved patient access to clinical notes and may lower malpractice claims by accelerating diagnoses, minimizing medical errors, and fostering better patient-physician interactions. The influence of patient access to clinical notes may extend to other aspects of EHR work, such as increased patient messages. Access to EHR data may increase patient and caregiver participation in the diagnosis and treatment processes, potentially lowering the likelihood of delays and missed diagnoses (Nelson, 2022). According to the law, a finding of patient injury is necessary before determining malpractice culpability. Patients who disclose mistakes in their medical records could potentially stop doctors from using inaccurate information, resulting in subpar diagnosis or treatment decisions and legal consequences.
Additionally, EHR clinical note access may make it simpler for people to get legal counsel concerning potential malpractice cases. However, there is no correlation between the policy and clinician time on EHR documentation, where health practitioners may feel the need to adapt their documentation practices due to their increased accessibility. The documentation quality may change if physicians alter the contents of their clinical notes, leading to increased litigation.
Policies and Procedures
The healthcare organization will provide clinicians with resources to help ensure efficient documentation while maintaining accuracy, clarity, and sensitivity to patients’ needs. Training should be availed to clinicians who may feel uncomfortable having patients view the clinical notes and to manage discontent constructively. In addition, patients need to be trained on how to use their portals and report documentation errors to health practitioners. This necessitates using contemporary computing standards and APIs that enable patients to access their health information and utilize the tools they want to use to shop for and manage their treatment on their smartphones.
Conclusion
Patients’ authority over electronic health records is a key component of the law. It will fuel the burgeoning healthcare IT industry and enable apps to offer patient-specific price and product transparency. Consultants are vital as they will enable organizations to comply with the interoperability rule.
References
Nelson, H. (2022). Potential risks, benefits of patient access to EHR clinical notes. EHRIntelligence. Web.
Wheeler, R. (2021). The Cures Act fact sheet. TempDev. Web.