Division of Pediatric Gastroenterology, Hepatology, and Nutrition at Nationwide Children's Hospital, Columbus, OH.
Division of Clinical Informatics at Nationwide Children's Hospital, Columbus, OH.
J Pediatr Gastroenterol Nutr. 2021 May 1;72(5):700-703. doi: 10.1097/MPG.0000000000003117.
The information blocking (IB) prohibition component of the 21st Century CURES Act (21CCA) comes into effect April 5, 2021, which gives patients and their families near-instant access to almost all clinical notes, lab results, and health data. Exceptions to IB prohibition include risk of harm and patient privacy, but violations can be punished by a fine of up to $1,000,000.00. A committee of pediatric gastroenterologists reviewed the 21CCA regulation and compared local practice policies. Pediatric practitioners need to understand how age will affect local information release policies and to know which note types are released, paying special consideration to trainee notes and confidential information. Extraneous detail should be removed from notes, emotional labeling be avoided, and objective statements be made when referring to the care of other providers. Awareness of the 21CCA provides pediatric gastroenterologists with the opportunity to adapt their medical documentation practices to accommodate the new law.
《21 世纪治愈法案》（21CCA）中的信息阻断（IB）禁令部分将于 2021 年 4 月 5 日生效，这使得患者及其家属几乎可以立即获得所有临床记录、实验室结果和健康数据。IB 禁令的例外情况包括对患者造成伤害的风险和患者隐私，但违规行为可能会被处以最高 100 万美元的罚款。一组儿科胃肠病学家审查了 21CCA 法规，并比较了当地的实践政策。儿科医生需要了解年龄将如何影响当地信息发布政策，并了解哪些类型的记录被发布，特别要注意学员记录和机密信息。记录中应删除多余的细节，避免情感标签，并在提及其他提供者的护理时做出客观陈述。了解 21CCA 为儿科胃肠病学家提供了调整其医疗文档实践以适应新法律的机会。
