16 michigan MEDICINE® | Sept / Oct 2022 In most cases, a patient’s immediate access to their complete medical records including test results will lead to quality and satisfaction for all parties. A learning curve will be present for some patients, and it’s wise to share with them how to contact your office in the case they don’t understand something or believe an entry may be incorrect. “Some physicians have expressed concerns about a patient misunderstanding their notes or misinterpreting test results and the potential impact to the patient,” says Westphal. “In these circumstances, physicians should talk with their patients and let them know how they can ask questions or obtain clarification regarding their notes or test results, whether at the patient’s next visit, or for more urgent concerns, calling the office or using the practice’s patient portal.” Be familiar with what the patient has the right to ask, what you can grant and/or refuse, and how to amend information in their medical record, including: • Patients have the right to request amendments to their medical records: The Health Insurance Portability and Accountability Act (HIPAA) requires a signed, dated request from the patient regarding what they want changed and why. • Providers have the right to determine whether the requested amendment will be made: The provider must respond, in writing, within 60 days of receipt of the patient’s request. • Common reasons to deny a patient’s request include that the provider who received the request did not create the record entry, or that the medical record is accurate as is. • The patient’s request and the provider’s response both become part of the patient’s medical record.6 The OpenNotes organization has communication resources available for use instructing patients how to understand their medical records and ask for clarifications as needed, such as posters for patient waiting areas or exam rooms, and printed communications that can be mailed or provided at appointment check-ins.7 Interoperability and continuing requirements Legislators put these rules in place to increase collaboration between health care providers and their patients, allowing for better quality health care, but it could come at a cost to those who have outdated technology, according to the The Doctors Company: A stumbling block to reaching true interoperability is when electronic health record (EHR) vendors closely guard data, which harms the transparency and open communication aspect of getting information directly to patients. The ultimate goal of the Cures Act is to support patient care by addressing health information technology hurdles across the continuum of care, and information blocking is strongly discouraged. Additionally, open notes are becoming even more, well…open. Starting in 2023, patients will be able to see task notes from staff members in their record, which includes items like reminders from staff members to the provider to return a call from the patient. If they are not doing so already, staff members should begin composing task notes as if the patient can see them—because soon, that will be the reality. “It’s important that physicians implement and enforce information sharing policies and protocols that will work within their practice,” she says. “Physicians should also talk with their EHR vendors to confirm compliance and ways to provide more seamless access to patient notes.” “A stumbling block to reaching true interoperability is when electronic health record (EHR) vendors closely guard data, which harms the transparency and open communication aspect of getting information directly to patients. The ultimate goal of the Cures Act is to support patient care by addressing health information technology hurdles across the continuum of care, and information blocking is strongly discouraged.” THE DOCTORS COMPANY
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