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SPOTLIGHT and time that we haven ’ t budgeted for and are not reimbursed for .”
Preparing Patients
Knowing that patients will soon be privy to a massive amount of data , clinicians are now trying to determine the best ways to prepare their patients for the information dump .
“ As a benign hematologist , I do a lot of blood tests , and results can take anywhere from a few hours to a week to come back ,” Dr . Morton said . “ I explain to the patient that I will look at the results as they come in , and if there is anything concerning to me , I will connect with them immediately . Otherwise , I let them know that I will call once the results are all back .”
So far , most patients have been satisfied with that because the expectation is set ahead of time , she said . “ I still get some questions via the patient portal , but they are fewer and easier to manage .”
At Texas Children ’ s Hospital , Dr . Stevens prepares patients and their families to what might be coming to their portal , but also encourages them to reach out if they have questions after reviewing the results . “ I would rather field the extra calls than have patients and parents feeling anxious if they see something bad or see an unexpected change ,” Dr . Stevens said , acknowledging that this places an increased burden on health care providers .
She added that she has not yet seen a great difference in the workflow at her practice , but the hospital is discussing whether front desk staff will be trained to address calls from families who are anxious about early test results . The implementation of the information blocking rules also brings up concerns about adolescent privacy , inclusion of notes related to end-of-life discussions or chaplain ’ s notes , and other sensitive information .
At Rush , Dr . Shammo said that they are still determining the best way to handle the release of test results .
“ We have been sharing notes and lab test results for quite some time , but we are always thinking of ways to perfect our system ,” she said . Ideally , test results that are indicative of a malignancy are blocked until the physician can sit with the patient to discuss . A delay like this would fall under the Cures Act ’ s patient harm exception because the clinician would be worried about “ unreasonable risks of harm ” to the patient .
An Open Note Test
Another area of potential concern is the increased access to physician notes . Although some institutions have already moved to an “ open access ” platform for physician notes , many still require patients to request these records . Under the new ONC rule , patients will have complete access .
“ Much of the information captured in notes is in medical language that is necessary to document the diagnosis and convey vital information accurately , so that other physicians can look at the chart and know exactly what the diagnosis is ,” Dr . Morton said . Patients may not be able to interpret the language , which leads to questions , but the information often cannot be put into lay language .
“ If we start writing notes differently to make them understandable to patients , the chart may lose some of the important medical information that we need to convey to other providers ,” she said .
Dr . Shammo also worries that changing the way notes are written could cause physicians to inadvertently conceal some of the reality of what is going on in the patient encounter . “ For example , if I know that a patient is going to see the notes , I may not write that a patient is obese . Although technically correct , I may have to find a more polite way of saying that ,” she explained .
In similar situations , Dr . Connors has started to use patients ’ body mass index , rather than the term ‘ obese ,’ as a workaround .
“ If we start writing notes differently to make them understandable to patients , the chart may lose some of [ what ] we need to convey to other providers .”
— Colleen T . Morton , MBBCh
Other clinical scenarios do not have such an easy solution . Dr . Stevens offered the example of communicating sensitive information around drug-seeking behaviors or noncompliance .
“ In our current era , awareness has increased about unconscious bias or insensitivity ,” she said . “ It is important that we are careful with how we communicate about these issues to families and recognize their value .”
Clinicians are often charting until midnight as it is just to meet the bare minimum of what needs to be recorded , Dr . Stevens noted . Having extra eyes on notes and charts will add to that burden .
“ To add the step of now considering how the information will be read or interpreted by patients and their caregivers is challenging ,” she said . “ If you care about the families and the therapeutic alliance , it adds another layer of complexity .”
The transparency mandated by the Cures Act could also have consequences for billing and coding , according to Dr . Morton . As of January 1 , 2021 , physicians must select an evaluation and management ( E / M ) code based on the total time spent on the date of the patient encounter or medical decision making , per new guidelines from the American Medical Association .
With that in mind , Dr . Morton explained , “ if a patient has a life-threatening disease , we would code it at a higher level , because we have to document the significance of the diagnosis in more detail . I wonder whether we might end up putting more concerning language in our notes for coding purposes ,” she said . “ I might not want to emphasize to a patient how life-threatening a diagnosis like immune thrombocytopenia could be , because most people do fine , but from a coding standpoint , I have to document it as such if the patient ’ s platelet count is very low .”
Theory Versus Practice
The providers who spoke with ASH Clinical News agreed that the intention of the ONC ’ s Cures Act rule on interoperability and information blocking is admirable and it could benefit patients and providers . Still , real-world implementation introduces several new predicaments .
“ When [ patient questions about early test results ] come up , we have to go through all the patient messages , look at their chart , and provide an explanation about the significance or lack of significance of a result ,” Dr . Connors said . “ Patients having this immediate access has added to physician workload . It needs to be addressed .”
Dr . Shammo has also witnessed a disruption to her workflow since access to health records has increased . Recently , a single patient sent 15 emails about complete blood count results sent prior to a telehealth visit , she recalled .
“ It would be great if someone gathered data to better understand the magnitude of additional time that physicians are spending on addressing patients ’ concerns and questions outside of a clinic visit as a result of the implementation of this rule ,” she said . “ How will this impact our productivity , our livelihood , our burnout levels , our job satisfaction , and the time we spend with our families ?”
“ The concept behind open access for families and patients is important ,” Dr . Stevens added , “ but I think there are definitely some issues with its implementation .” — By Leah Lawrence
References
1 . U . S . Food and Drug Administration . 21st Century Cures Act . Accessed January 5 , 2021 , from https :// www . fda . gov / regulatory-information / selected-amendmentsfdc-act / 21st-century-cures-act .
2 . Health and Human Services . HHS Extends Compliance Dates for Information Blocking and Health IT Certification Requirements in 21st Century Cures Act Final Rule . October 29 , 2020 . Accessed January 5 , 2021 , from https :// www . hhs . gov / about / news / 2020 / 10 / 29 / hhs-extends-compliance-dates-informationblocking-health-it-certification-requirements-21st-century-cures-actfinal-rule . html .
3 . The Office of the National Coordinator for Health Information Technology . ONC ’ s Cures Act Final Rule . Accessed January 5 , 2021 , from https :// www . healthit . gov / curesrule /.
4 . The Office of the National Coordinator for Health Information Technology . New Applicability Dates included in ONC Interim Final Rule . Accessed January 6 , 2021 , from https :// www . healthit . gov / cures / sites / default / files / cures / 2020-10 / Highlighted _ Regulatory _ Dates _ All . pdf .
5 . HealthIT . gov . Clinical Notes . Accessed January 6 , 2021 , from https :// www . healthit . gov / isa / uscdi-data / clinical-notes # uscdi-v1 .
6 . The Office of the National Coordinator for Health Information Technology . Cures Act Final Rule . Information Blocking Exceptions . Accessed January 6 , 2021 , from https :// www . healthit . gov / cures / sites / default / files / cures / 2020-03 / InformationBlockingExceptions . pdf .
20 ASH Clinical News March 2021