The program rule on Interoperability, Information Blocking, and ONC Health IT Certification, which implements the 21st Century Cures Act passed in 2016, requires patients be provided access to all the health information in their electronic medical records without charge by their healthcare provider beginning April 5, 2021.
OpenNotes is invested in the Cures Act because clinical notes are among the information that must not be blocked—and thus be made available to patients.
The eight (8) types of clinical notes that must be shared are outlined 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 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 and that are separated from the rest of the individual’s medical record. Note: 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.
To read the rest of this article, please click here: https://www.opennotes.org/onc-federal-rule-interoperabilty-information-blocking-and-open-notes/