The University of Kansas Health System has developed a tool to monitor note sharing by providers as part of its compliance efforts under the information blocking rule, said Christine Hogan-Newgren, chief compliance and internal audit officer.[1] The screenshot shows some findings for one period of time. The numerator represents all the notes that were shared, and the denominator represents all the notes that should have been shared, with the tool therefore showing the percentage of total notes shared. Below it is a tip sheet developed by the compliance team at The University of Kansas Health System to help its providers, clinical staff and ancillary staff comply with shared notes/information blocking requirements. Contact Hogan-Newgren at chogan-newgren2@kumc.edu and Terri Thompson, system director of privacy and privacy officer, at tthompson3@kumc.edu.
Frequently asked questions and answers are given to provide additional information to staff about the Open Notes initiative.
Implementation
What is the timeline for implementation of open notes?
Default shared notes launched in ambulatory encounters on 10/1/2020 and for Inpatient/Emergency Department (IP/ED) discharge summaries on 10/29/2020. Open notes will expand to most IP/ED note types on 4/1/2021 to prepare for stricter and broader federal requirements approaching in 2022.
Provider Experience
Are shared note numbers trackable?
The number of shared notes is trackable. Understanding the practice of sharing and declining to share notes will allow appropriate support for departments that are struggling with this transition.
Will someone be monitoring these numbers?
The number of notes shared and rate of patient viewership is critical for open notes to meet its primary objectives of patient engagement and provider transparency. IT will review composite numbers to identify overall trends. The goal is to be transparent with our patients. With some time, we hypothesize that the expectation by patients will be that notes are provided.
Will open notes increase my medicolegal risk (malpractice claims)?
Early adopters of open notes have noted a decrease in such claims due to improved patient satisfaction established with greater transparency with open notes.
Will shared notes work for my specialty?
A growing body of literature has examined open notes in a number of medical, surgical, and procedural specialties. Please consider entering “open notes” or “shared notes” and your specialty into Pubmed or your preferred citation database.
How do providers handle sensitive issues/sensitive notes?
Any notes that are marked as sensitive will NOT be shared. Marking a note as sensitive is only available to certain users.
When is a note visible to the patient in MyChart?
Notes are not shared/visible to the patient in MyChart until:
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Ambulatory: The encounter is signed/closed.
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IP/ED: The note is signed (and co-signed, if applicable).
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Encounter addendum: The note is signed.
Will a patient see a note I deleted?
No. Patients do not see deleted notes in MyChart even if they are showing as shared in O
Are proxies able to view a patient’s notes in MyChart?
Yes, if the proxy has full proxy access to the patient’s MyChart, notes can be viewed. Proxies with limited access do not have access to a patient’s notes. View the MyChart Proxy Access tip sheet for additional proxy definitions and how to view a patient’s proxy status.
How do I unshare a note for a specific patient? How do I request all notes of a certain type not be shared?
It is only acceptable to not share notes when it is in compliance with HIPAA (Reviewable and Unreviewable Grounds for Denial of Access), 42 C.F.R. § 2 (Substance Use Disorder Program), or the Information Blocking Exceptions (privacy and harm, namely). A provider, nurse or clinician can unshare an individual note at any time; however, this does not prevent the patient from viewing the note with a release of information (ROI) request. Unsharing activity will be monitored to ensure health system compliance with the Cures Act. For more information about unsharing a note, review the Open Notes tip sheet.
To restrict a note from being produced with an ROI request, a provider, nurse or clinician may request a Release Restriction be placed by calling the Health Information Management (HIM) Release of Information Manager at 913-588-7788. If there is a request for that record, the provider will be contacted. When the licensed health care professional would like to remove the Release Restriction, call the HIM Release of Information Manager at 913-588-7788 to request the removal. This process is outlined in the Viewing Denial of Access policy.
If an entire category of note, such as a particular note type within a particular department, should never be shared with any patient due to patient safety or privacy/security concerns, a provider can request an exception to the automatic sharing of that note type. Visit the Cures Act and Open Notes hub for details on requesting exceptions.
How can I see if a patient has viewed a shared note?
When viewing the note in Chart Review, the bottom of the note contains information whether it was shared with the patient and if/when the patient viewed it. View the Open Notes tip sheet for details.
Patient Experience
Are notes/encounters shared to MyChart for patients who are deceased?
Postmortem documentation encounters are not visible in MyChart.
What does a patient see when a provider decides NOT to share a note (e.g., Do they see a shell of a note but no content, or is it just absent altogether?)
The view by the patient in MyChart has not changed with default shared notes. Each encounter has a tab for after visit summary (AVS) and notes. The notes section is empty in encounters without shared notes. The Open Notes tip sheet shows the patient view in MyChart. Please note that patients can get a copy of their notes at any time through HIM.
What percent of notes are opened by patients?
Currently, 15%-20% of shared notes are reviewed by patients. With broader launch of open notes and engagement with patient advocacy, a read rate of 20%-30% is expected.
What percent of notes do patients ask the provider about?
Total queries on shared notes is low with much less than 1% of shared notes leading to a patient portal message. Studies have shown that shared notes better prepare patients for their next visit, and the open notes work group hopes that such review will broaden and deepen the conversation during subsequent encounters.
What percent of notes do patients request that the provider edit?
Correction queries are rare, constituting well under 1% of shared notes. HIM will monitor queries and address strictly clerical and nonclinical adjustments. The open notes work group and the health system are attuned to provider work burden stress and are working diligently to limit the impact of open notes on stressed provider time.
