Open Notes Law For Mental Health and Behavioral Health Professionals
Over the years, the mental healthcare space has witnessed a movement toward transparency, connectivity, and interoperability. Just as the 1990s ushered in HIPAA protections and saw the rise of the Electronic Health Record (EHR), the 2010s were marked by the development of the Open Notes initiative.
In 2016, Congress passed the 21st Century Cures Act which requires health providers to provide patient records immediately, directly, and free of charge to patients. This law came into effect in April 2021. Failure to comply with the 21st Century Cures Act may result in being identified as an “information blocker,” someone who prevents lawful access to health records. This can carry a hefty fine, up to one million dollars. ClinicTracker understands that while these policies promise many positives for patients, in the short term this creates uncertainty for clinics that do not have the resources to implement Open Notes seamlessly.
Open Notes Requirements and Exceptions
Part of the complexity of Open Notes law that mental health professionals need to deal with comes in finding the line between openness and other interests. To begin with, mental health information must be made available to patients including:
- Functional status
- Treatment plans
- Progress notes
Psychotherapy notes, which may include the therapists’ private observations and analysis, are excluded from the requirement as well as information collected for legal reasons. Open Notes law says mental health professionals may also exclude a progress note if they believe sharing it could put someone in danger, or expose the information of a third party.
Sharing experiences regarding these judgment calls will help us all build best practices. Though providing the correct and appropriate amount of access to patients immediately and seamlessly represents an ongoing challenge, it provides substantial benefits that we should work toward together.
Benefits of Open Notes
Apart from the legal requirements, sharing Open Notes comes with proven benefits to patients and clinicians. This video follows a patient and captures her experience on how Open Notes has helped her care for her diagnosis. Other benefits include:
- Improved Patient Interactions – After their session, your patient may review their plan on the Patient Portal, supporting their memory with a written reminder of what was discussed. This leads to more effective conversations and better outcomes.
- Provide a Sense of Control – Having access to their own records can give patients insight and understanding of their health and mental health conditions. This encourages more participation in their own care and encourages them to take better care of themselves.
- Improve Medication Adherence – Patients who are able to read their notes take their medications as prescribed more regularly. Part of this effect can be explained by the patient’s better understanding of the care they receive. For example, after reading their notes, 67% of patients with SMI (Serious Mental Illness) felt they better understood why medications had been prescribed.
Selecting an EHR that Supports Open Notes
To unlock the benefits of Open Notes law and avoid being identified as “information blockers,” behavioral health professionals today need to rely on technology and training. Electronic Health Record systems are not all built the same. Choosing the right EHR will affect the ease and success of your Open Notes implementation.
Evaluate whether a potential EHR will comply with federal record-sharing laws. Confirm that it allows you to easily share the required records on a patient portal. Check that it is highly configurable. Can you exclude a specific type of note or an individual note that should stay private? You want to select an EHR with a reputation for reacting quickly to changes like ClinicTracker, one that will keep pace with new regulations and support your clinic’s evolving needs.
Preparing Your Staff for Open Notes
Before your patients can fully benefit from Open Notes law, mental health and behavioral health staff need related training to calm their nerves and answer their questions. It may be helpful to share Open Note resources and training materials from your EHR. Clinicians may be nervous at the thought of sharing the progress notes they’ve written. They may worry that they’ve included terms that patients don’t understand or that may accidentally offend. Prevent this with simple changes to the writing, such as eliminating abbreviations and avoiding judgmental terms. Also, be sure to provide clear context, and be mindful of sensitive topics in progress notes.
Preparing Your Patients for Open Notes
Once you have the right technology ready and your staff has been trained, let your patients know that their notes have been made available on their patient portal. They too need to be trained on how best to use Open Notes. We recommend sending a portal message and email providing step-by-step instructions on how to access Open Notes. Include an explanation of the benefits of doing so. Discussing Open Notes with individual patients in their sessions will surely help with the rollout. Encouraging patients to stay current with and engage with their Open Notes will lead to better understanding and communication. Make Open Notes an integrated and invaluable part of their care.
We understand you want to find ways to better serve your communities by fully complying with the Cures Act. With ClinicTracker EHR at their side, our clinic leaders have ways to help their staff achieve this. Reach out to your ClinicTracker representative with questions about implementation, ideas you have for development or simply to brainstorm best practices for using a patient portal.
Not currently working with ClinicTracker? Schedule a free demonstration. We’d love to help get your clinic from an information blocker to an information sharer!