What is the CURES Act?
Fully enacted on April 5, 2021 the Cures Act requires that all healthcare providers give patients immediate access to their health information, free of charge. If you receive a request for patient information from a patient or another provider, you are required to provide the information within an allotted time frame. This information includes EHR, images, charts, notes, and lab reports and they must be electronically available.
With the 21st Century Cures Act, complete and accurate patient documentation becomes a critical and often patient-facing aspect of the care you provide. The Cures Act ensures that patients have immediate access to their records. Since the rule went into effect, patients have been able to access more of their medical data, which means patients are potentially more engaged in their own care. In fact, new studies indicate patients who have access to their medical data are more compliant with their treatment plans. How can you use this to empower your patients to follow your treatment plans more closely and improve their outcomes? How can you track these outcomes in your EHR system in order to write more effective notes?
What is the CURES Act trying to accomplish?
The Main Goal of the Cures Act pushes for interoperability by providing secure and free access to patient health information to patients and other healthcare providers and to promote transparency.
Health information includes:
- Electronic health records (EHR) information
- Consultation notes
- Discharge summary notes
- Digital Images
- Images
- Laboratory reports
- Medical history
- Paper Charts
- Pathology reports
- Procedure notes
- Progress notes
- Paper Charts
While these are the intended outcomes of the law, there are many benefits stemming from these requirements such as more diligent note requirements from practitioners, patient awareness, and clear communication between providers resulting in a more unified treatment plan. Furthermore, the requirement to ensure all this information is available electronically likely means the adoption of an electronic medical record system is necessary. In order to meet the Cures Act accessibility requirement of providing patient information electronically, practitioners must have a means of transferring paper notes to electronic notes. Further, by allowing patients more access to their health data, the system is allowing for what many complimentary providers hope to support in their clinics: proactive efforts from patients. In order to truly empower your patients however, you’ll need complete, consistent, and accurate notes. ForTheRecord Magazine highlights the importance of notes in the role of patient care:
“Providers need to be held accountable for documentation that accurately captures the patient’s story not only for the patient to be able to read and understand but also for other health care providers to base treatment on,” says Stacy Lehto, CHDS, AHDI-F, who is also the senior health care documentation quality analyst for Spectrum Health’s Business Service Center. “Basing treatment on erroneous information charts the course for patient safety concerns and potential risk to patient care. Ultimately, the ability for patients to access their medical records is a blessing and a curse,” she continues. “The best provider, the best facility in the world will lose all credibility when documentation is done poorly and riddled with inaccurate or inconsistent information.”
How can my SOAP Notes create an impact for my patients?
Fortunately, many EHRs are up to the task and have been evolving in order to help practitioners improve their note taking and track patient outcomes. In a recent study published in May of 2021, the Journal of General Internal Medicine found that providers reported patients took more action and better care of themselves when given access to their charts. We broke it down below:
So how do you make sure your notes are clearly written and communicate goals for your patients? Start by reviewing your notes. Are consistent, accurate charts that outline the patient’s subjective notes clearly already part of your workflow? Does your suggested treatment plan take both you and your patient’s goals into consideration? Clearly outlined notes provided to your patient empowers them to continue to take the steps necessary to maximize their treatment outcomes.
But how do you improve your documentation while in the midst of seeing patients? It can be difficult to write down what you think throughout your busy day. Thankfully, many EHR systems offer templates and smart texting features so you can quickly create comprehensive notes that are eligible for your patients. Create consistency not only in how you chart, but when you chart and be sure that you are signing your notes on the day of treatment. Prioritizing the best practices that help you create complete and accurate charting will not only streamline your appointments, but will also ensure consistency in your notes, encourage patient understanding and transparency, and develop overall clarity on treatment plans and recommendations. Utilizing an EHR that provides the flexibility and ease of use you need to achieve these goals is paramount in the quest for optimal patient communication and adherence to the CURES Act.
Work with your patients on how and why to access their notes:
When you as a medical professional give patients more information about their health, you are not only empowering them to improve their outcomes, but you are also building trust with your patients. Patients who can clearly understand the steps and the outcomes of these plans are more likely to stick to their treatment plans. If you specifically call out actions required by the patient, you’re providing more context around the treatment plan, and are giving your patients guidance to help ensure more successful outcomes and more accurate timelines of results. This can help create realistic expectations on the patient’s part of how they are able to impact their own health outcomes and the importance of sticking to their treatment plan.
We know you care deeply about your patients and want to provide recommendations that are effective and appropriately utilized. It is not always easy to ensure your patients take the next steps, but we believe this is a step in the right direction. Empower your patients, provide them with the information they need to move forward, and create trust and transparency along the way. Clear notes create transparency and build trust. This relationship can improve patient outcomes.
