Activity Description

Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.

Objective & Validation Documentation

Objective: Utilize a program or process that provides an open exchange of necessary patient information between care teams and patients to guide patient care.

Validation Documentation: Evidence of full access to patient information (between care team and patient) to guide patient care. Required clinical documentation from a medical record available in a patient portal using United States Core Data for Interoperability (USCDI) standards, including consultation, as relevant to each patient. Medical records that are not required to be available include psychotherapy notes that are separated from the rest of the individual’s medical record and information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding.

Information: The federal rule on ‘Interoperability and Information Blocking’ mandates that U.S. healthcare providers give patients access to all the health information in their electronic medical records “without delay” and without charge. Information on the Cures Act Final Rule and Information Blocking ‘Actors’ can be found here: https://www.healthit.gov/topic/information-blocking; information on the OpenNotes initiative can be found here: https://www.opennotes.org