Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following:
- Participate in a Health Information Exchange if available; and/or
- Use structured referral notes.
ObjectiveUtilize a program or process that provides an open exchange of necessary patient information between care teams and patients to guide patient care.
Evidence of exchange of patient information (between care team and patient) to guide patient care. Include at least one of the following elements:
1) Participation in a Health Information Exchange (HIE) – Confirmation of participation in a health information exchange (e.g., email confirmation, screenshots demonstrating active engagement with HIE); OR
2) Utilization of OpenNotes – Clinical documentation from a medical record available in a patient portal.
If an eligible clinician is using a patient portal for bidirectional patient-client communication without employing Open Notes, they may find IA_BE_4, “Engagement of patients through implementation of improvements in patient portal” an applicable improvement activity to attest to.