Federal Rules on Interoperability and Information Blocking, and open notes
According to HealthIT.gov, as of April 5th, 2021, Cures Act’s information blocking provision will be in affect. In short, the the program rule on Interoperability, Information Blocking, and ONC Health IT Certification, which implements the 21st Century Cures Act, is designed to give patients and their healthcare providers secure access to health information.
The following participants in health care will need to follow the law:
health care providers,
health IT developers of certified health IT, and
health information networks/health information exchanges.
Through the Cures Act, Congress defined “information blocking” and established penalties for those who engage in practices that interfere with the access, exchange, or use of “electronic health information” (EHI). The law excludes practices required by applicable law(s) or if they meet an “exception” established by the HHS Secretary.
What are the information blocking exceptions?
On behalf of HHS, ONC has defined eight exceptions that offer actors (i.e.,
health care providers, health IT developers, health information networks (HINs)
and health information exchanges (HIEs)) certainty that, when their practices
with respect to accessing, exchanging, or using electronic health information
(EHI) meet the conditions of one or more exceptions, such practices will not be
considered information blocking.
What Notes Must Be Shared?
The eight (8) types of clinical notes that must be shared are outlines in the United States Core Data for Interoperability (USCDI) and include:
Consultation notes
Discharge summary notes
History & physical
Imaging narratives
Laboratory report narratives
Pathology report narratives
Procedure notes
Progress notes
Clinical notes to which the rules do not apply:
Psychotherapy notes that are separated from the rest of the individual’s medical record and are recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session. Note: All clinicians and organizations are required to share medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Information compiled in reasonable anticipation of, or use in a civil, criminal or administrative action or proceeding.
What is the timeline for when these new rules go into effect?
Under this new rule, clinical notes must be shared by health systems by April 5, 2021, and shared with a patient’s 3rd party application (“app”) that may be downloaded to a smart phone or other device by October 6, 2022.
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