EHR Documentation Time Unaffected by Cures Act Patient Access Rule

The 21st Century Cures Act final rule mandating patient access to clinical notes has not meaningfully impacted clinician time on EHR documentation, according to a study published in JAMIA.

This finding opposes the concern that the policy could have an unintended consequence on EHR work as clinicians may feel the need to adapt their documentation practices in light of their notes being accessible to patients.

Researchers analyzed a national longitudinal dataset of all ambulatory care physicians and advance practice providers using an Epic EHR. The study found decreases in note length and documentation time after the final rule went into effect, though the effect sizes are minuscule.

“Our results are consistent with studies on clinicians that opted into patient access to notes through the OpenNotes initiative, which found most clinicians had a positive impression of patient note access,” the authors wrote.

The authors noted that while EHR time and note length did not increase, note quality may have decreased, or clinicians may have had to otherwise alter their documentation practices due to the new policy.

“Future research should evaluate the longer-term impact of policy on EHR burden to better understand how policy impacts clinician work, productivity, and well-being,” the researchers said.

The study has several limitations, the authors said.

“First, our results are an average treatment effect of the policy implementation—some individual clinicians or groups may have experienced increased documentation burden even if the policy did not have an impact on the average clinician,” they wrote.

Second, the study evaluates the policy change mandating patient access to clinical notes rather than the impact of patients viewing the notes. Additionally, the study authors said that some organizations may have implemented patient access before the policy deadline of April 5, 2021.

“However, in plotting our dependent variables over time, we do not see an uptick in documentation burden in the months leading up to the policy change, which suggests even if this were the case we do not observe an increase in documentation burden,” the researchers wrote.

Additionally, the results could be biased since ONC implemented the policy change during COVID-19.

“However, our findings on time spent in notes are similar to prepandemic data, and previous research has found that the disruptive impact of COVID on clinician EHR use had reached a steady state by August 2020,” the study authors said.

Fourth, due to data limitations, the researchers could only evaluate the immediate impact of the policy change.

“While our data are able to address our main research question as to whether the implementation of the policy increased EHR documentation time and length, future studies should evaluate long-term impacts on other aspects of documentation as clinician behavior can change slowly,” they said.

Finally, patient access to notes may impact other forms of EHR work outside clinical documentation, such as increased patient messages that the study’s data did not capture.

“Policymakers and health system leaders interested in addressing EHR burden should continue to investigate other drivers of documentation work to address the impacts of EHRs on clinician well-being,” the authors concluded.