21st Century Cures Act: Implementation Without Understanding Implication?

Navigating the Complexities of Brain Metastases Management

The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.

Establishing priorities for implementation of large language models in pathology and laboratory medicine

Artificial intelligence and machine learning have numerous applications in pathology and laboratory medicine. The release of ChatGPT prompted speculation regarding the potentially transformative role of large-language models (LLMs) in academic pathology, laboratory medicine, and pathology education. Because of the potential to improve LLMs over the upcoming years, pathology and laboratory medicine clinicians are encouraged to embrace this technology, identify pathways by which LLMs may support our missions in education, clinical practice, and research, participate in the refinement of AI modalities, and design user-friendly interfaces that integrate these tools into our most important workflows. Challenges regarding the use of LLMs, which have already received considerable attention in a general sense, are also reviewed herein within the context of the pathology field and are important to consider as LLM applications are identified and operationalized.

Information transparency with immediate release: Oncology clinician and patient perceptions

INTRODUCTION

As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients. In this study, we sought to evaluate clinician and patient perceptions regarding this immediate release.

METHODS

After surveying 33 clinicians and 30 patients, semi-structured interviews were conducted with a subset of the initial sample, comprising 8 clinicians and 12 patients. Open-ended questions explored clinicians' and patients' perceptions of immediate release of EHI and how they adjusted to this change.

RESULTS

Ten themes were identified: Interpreting Results, Strategies for Patient Interaction, Patient Experiences, Communication Strategies, Provider Limitations, Provider Experiences, Health Information Interfaces, Barriers to Patient Understanding, Types of Results, and Changes due to Immediate Release. Interviews demonstrated differences in perceived patient distress and comprehension, emphasizing the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.

CONCLUSIONS

Clinicians and patients have unique insights on the role of immediate release. Understanding these perspectives will help improve communication and develop patient-centered tools (glossaries, summary pages, additional resources) to aid patient understanding of complex medical information.

Taking It to the States: Adapting Information Blocking Legislation to Oncology

Oncologists have successfully pushed for new state laws on how we release life-changing test results

Unsolicited Patient Complaints Following the 21st Century Cures Act Information-Blocking Rule

Importance

The 21st Century Cures Act includes an information-blocking rule (IBR) that requires health systems to provide patients with immediate access to their health information in the electronic medical record upon request. Patients accessing their health information before they receive an explanation from their health care team may experience confusion and may be more likely to share unsolicited patient complaints (UPCs) with their health care organization.

Objective

To evaluate the quantity of UPCs about physicians before and after IBR implementation and to identify themes in UPCs that may identify patient confusion, fear, or anger related to the release of information.

Design, Setting, and Participants

This retrospective cohort study was conducted with an interrupted time-series analysis of UPCs spanning January 1, 2020, to June 30, 2022. The data were obtained from a single academic medical center, Vanderbilt University Medical Center, at which the IBR was implemented on January 20, 2021. Data analysis was performed from January 11 to July 15, 2023.

Exposure

Implementation of the IBR on January 20, 2021.

Main Outcomes and Measures

The primary outcome was the monthly rate of UPCs before and after IBR implementation. A qualitative analysis was performed for UPCs received after IBR implementation. The Wilcoxon rank-sum test was used to compare monthly complaints between the pre- and post-IBR groups. The Pearson χ2 test was used to compare proportions of complaints by UPC category between time periods.

Results

The medical center received 8495 UPCs during the study period: 3022 over 12 months before and 5473 over 18 months after institutional IBR implementation. There was no difference in the monthly proportions of UPCs per 1000 patient encounters before (median, 0.81 [IQR, 0.75-0.88]) and after (median, 0.83 [IQR, 0.77-0.89]) IBR implementation (difference in medians, -0.02 [95% CI, -0.12 to 0.07]; P =.86). Segmented regression analysis revealed no difference in monthly UPCs (β [SE], 0.03 [0.09]; P =.72).

Conclusions and Relevance

In this cohort study, implementation of the Cures Act IBR was not associated with an increase in monthly rates of UPCs. These findings suggest that review of UPCs identified as IBR-specific complaints may allow clinicians and organizations to prepare patients that their test and procedure results may be available before clinicians are able to review them and respond.

Impact of the Immediate Release of Clinical Information Rules on Health Care Delivery to Patients With Cancer

PURPOSE

The 21st Century Cures Act mandates the immediate release of clinical information (IRCI) to patients. Immediate sharing of sensitive test results to patients with cancer might have serious unintended consequences for patients and providers.

METHODS

A 22-question REDCap survey was designed by the Association of American Cancer Institutes Physician Clinical Leadership Initiative Steering Committee to explore oncology providers' opinions on IRCI policy implementation. It was administered twice in 2021 with a 3-month interval. A third survey with a single question seeking providers' opinions about their adaptation to the IRCI mandate was administered 1 year later to those who had responded to the earlier surveys. The data were analyzed using descriptive statistics such as chi-squared or Fisher's exact tests for categorical variables. The survey was sent to all Association of American Cancer Institutes cancer center members. In the first or second administration, 167 practitioners answered the survey; 31 responded to the third survey.

RESULTS

Three quarters of the providers did not favor the new requirement for IRCI and 62% encountered questions from patients about results being sent to them without provider interpretation. Only half of the hospitals had a plan in place to deal with the new IRCI requirements. A third survey, for longitudinal follow-up, indicated a more favorable trend toward adoption of IRCI.

CONCLUSION

IRCI for patients with cancer was perceived negatively by academic oncology providers after its implementation. It was viewed to be associated with higher levels of patient anxiety and complaints about the care delivered. Providers preferred to discuss test results with patients before release.

Laboratory Results Release to Patients under the 21st Century Cures Act: The Eight Stakeholders Who Should Care

A major aim of the 21st Century Cures Act is to support patients' access to their electronic health data and to prevent information blocking practices by health care organizations and health information technology developers. Prior to the Cures Act, significant variation existed in patient access to laboratory test results, key pieces of health data which enable timely self-management and engagement in care. Although many health care systems began releasing test results immediately through patient portals because of the Cures Act, implementation remains challenging due to variations in state regulations around electronic results release, local interpretations of allowable exceptions to Cures information blocking, concerns about privacy of sensitive laboratory results, and technological limitations. This paper outlines the eight stakeholder groups involved in implementation of electronic laboratory result release to patients and describes recommendations for these groups to consider in achieving the Cures Act goals to support a patient's access to their health information and control of their health care.

Telehealth, Social Media, Patient Empowerment, and Physician Burnout: Seeking Middle Ground

The digital revolution is an ongoing process that has nevertheless profoundly affected century-old medical practice. Digitalization has many facets, ranging from telehealth to social media and even new instant communication devices, each of which affect both patients' and physicians' realities. Although the benefits of developments such as telehealth and novel applications of social media to medicine are more easily perceived by all stakeholders, they still have their own hurdles and risks, such as coldness and impersonal treatment in telehealth, and misinformation on social media. The widespread digitalization of health records has greatly facilitated patient access to health information, becoming a major patient empowerment tool; however, some forms of unrestricted access, such as to test results-in particular, prior to consultations-have unclear benefits to patients with cancer and have also become a hurdle for care teams. In addition, the advent of instant messaging, which is revolutionizing personal communication in many cultures, is gradually affecting patient-physician communication and, combined with unrestricted patient access to test results, is creating new challenges for physicians. How these transformations are affecting patients themselves and physicians' well-being and mental health are matters addressed in this text. Last, to address potential biases in an article written by two oncologists, and in line with this year's ASCO presidential theme of including a diversity of voices, we decided to give voice to patients with cancer by collecting the opinions of high-profile patient advocates about the controversial topics addressed in this text.