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Hagström J, Hägglund M, Holmroos M, Lähteenmäki P, Hörhammer I. Minors' and guardian access to and use of a national patient portal: A retrospective comparative case study of Sweden and Finland. Int J Med Inform 2024; 187:105465. [PMID: 38692233 DOI: 10.1016/j.ijmedinf.2024.105465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/21/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Approaches to implementing online record access (ORA) via patient portals for minors and guardians vary internationally, as more countries continue to develop patient-accessible electronic health records (PAEHR) systems. Evidence of ORA usage and country-specific practices to allow or block minors' and guardians' access to minors' records during adolescence (i.e. access control practices) may provide a broader understanding of possible approaches and their implications for minors' confidentiality and guardian support. AIM To describe and compare minors' and guardian proxy users' PAEHR usage in Sweden and Finland. Furthermore, to investigate the use of country-specific access control practices. METHODS A retrospective, observational case study was conducted. Data were collected from PAEHR administration services in Sweden and Finland and proportional use was calculated based on population statistics. Descriptive statistics were used to analyze the results. RESULTS In both Sweden and Finland, the proportion of adolescents accessing their PAEHR increased from younger to older age-groups reaching the proportion of 59.9 % in Sweden and 84.8 % in Finland in the age-group of 17-year-olds. The PAEHR access gap during early adolescence in Sweden may explain the lower proportion of users among those who enter adulthood. Around half of guardians in Finland accessed their minor children's records in 2022 (46.1 %), while Swedish guardian use was the highest in 2022 for newborn children (41.8 %), and decreased thereafter. Few, mainly guardians, applied for extended access in Sweden. In Finland, where a case-by-case approach to access control relies on healthcare professionals' (HCPs) consideration of a minor's maturity, 95.8 % of minors chose to disclose prescription information to their guardians. CONCLUSION While age-based access control practices can hamper ORA for minors and guardians, case-by-case approach requires HCP resources and careful guidance to ensure equality between patients. Guardians primarily access minors' records during early childhood and adolescents show willingness to share their PAEHR with parents.
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Affiliation(s)
- Josefin Hagström
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, 752 37 Uppsala, Sweden; MedTech Science & Innovation Centre, Uppsala University Hospital, 751 85 Uppsala, Sweden.
| | - Maria Hägglund
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, 752 37 Uppsala, Sweden; MedTech Science & Innovation Centre, Uppsala University Hospital, 751 85 Uppsala, Sweden.
| | - Mari Holmroos
- Kela, Nordenskiöldinkatu 12, 00250 Helsinki, Finland.
| | - Päivi Lähteenmäki
- Department of Women's and Children's Health, Karolinska Institute, 171 77 Stockholm, Sweden; Department of Pediatrics and Adolescent Medicine, Turku University, and Turku University Hospital, Kiinamyllynkatu 4-8, 20521 Turku, Finland.
| | - Iiris Hörhammer
- Department of Computer Science, Aalto University, Konemiehentie 2, 02150 Espoo, Finland.
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van Kessel R, Ranganathan S, Anderson M, McMillan B, Mossialos E. Exploring potential drivers of patient engagement with their health data through digital platforms: A scoping review. Int J Med Inform 2024; 189:105513. [PMID: 38851132 DOI: 10.1016/j.ijmedinf.2024.105513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/11/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Patient engagement when providing patient access to health data results from an interaction between the available tools and individual capabilities. The recent digital advancements of the healthcare field have altered the manifestation and importance of patient engagement. However, a comprehensive assessment of what factors contribute to patient engagement remain absent. In this review article, we synthesised the most frequently discussed factors that can foster patient engagement with their health data. METHODS A scoping review was conducted in MEDLINE, Embase, and Google Scholar. Relevant data were synthesized within 7 layers using a thematic analysis: (1) social and demographic factors, (2) patient ability factors, (3) patient motivation factors, (4) factors related to healthcare professionals' attitudes and skills, (5) health system factors, (6) technological factors, and (7) policy factors. RESULTS We identified 5801 academic and 200 Gy literature records, and included 292 (4.83%) in this review. Overall, 44 factors that can affect patient engagement with their health data were extracted. We extracted 6 social and demographic factors, 6 patient ability factors, 12 patient motivation factors, 7 factors related to healthcare professionals' attitudes and skills, 4 health system factors, 6 technological factors, and 3 policy factors. CONCLUSIONS Improving patient engagement with their health data enables the development of patient-centered healthcare, though it can also exacerbate existing inequities. While expanding patient access to health data is an important step towards fostering shared decision-making in healthcare and subsequently empowering patients, it is important to ensure that these developments reach all sectors of the community.
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Affiliation(s)
- Robin van Kessel
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom; Department of International Health, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands; Digital Public Health Task Force, Association of School of Public Health in the European Region (ASPHER), Brussels, Belgium.
| | | | - Michael Anderson
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom; Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom.
| | - Brian McMillan
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom.
| | - Elias Mossialos
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom; Institute of Global Health Innovation, Imperial College London, London, United Kingdom.
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Chu S, Sisk BA, Kolmar A, Malone JR. Open Notes Experiences of Parents in the Pediatric ICU. Pediatrics 2024; 153:e2023064919. [PMID: 38584584 PMCID: PMC11035162 DOI: 10.1542/peds.2023-064919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 04/09/2024] Open
Abstract
OBJECTIVE We examined how parents experience and navigate open access to clinical notes ("open notes") in their child's electronic health record and explored their interactions with clinicians during an ICU admission. METHODS We performed a qualitative analysis using semistructured interviews of English-speaking parents who accessed their child's clinical notes during a pediatric ICU (general or cardiac) admission. We included patient-parent dyads with an ICU admission ≥48 hours between April 2021 and December 2022, note access by proxy timestamp during the ICU course, and either patient age <12 years or incapacitated adolescent ages 12 to 21 years. Purposive sampling was based on sociodemographic and clinical characteristics. Phone interviews were audio-recorded, transcribed, and analyzed using inductive thematic codebook analysis. RESULTS We interviewed 20 parents and identified 2 thematic categories, outcomes and interactions, in parents accessing clinical notes. Themes of outcomes included applied benefits, psychosocial and emotional value, and negative consequences. Themes of interactions included practical limitations and parental approach and appraisal. The ICU context and power dynamics were a meta-theme, influencing multiple themes. All parents reported positive qualities of note access despite negative consequences related to content, language, burdens, and lack of support. Parents suggested practice and design improvements surrounding open note access. CONCLUSIONS Parental experiences with open notes reveal new, unaddressed considerations for documentation access, practices, and purpose. Parents leverage open notes by negotiating between the power dynamics in the ICU and the uncertain boundaries of their role and authority in the electronic health record.
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Affiliation(s)
- Selby Chu
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bryan A. Sisk
- Washington University School of Medicine, St Louis, Missouri
- St Louis Children’s Hospital, St Louis, Missouri
| | - Amanda Kolmar
- Washington University School of Medicine, St Louis, Missouri
- St Louis Children’s Hospital, St Louis, Missouri
| | - Jay R. Malone
- Washington University School of Medicine, St Louis, Missouri
- St Louis Children’s Hospital, St Louis, Missouri
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Chung RJ, Lee JB, Hackell JM, Alderman EM. Confidentiality in the Care of Adolescents: Technical Report. Pediatrics 2024; 153:e2024066327. [PMID: 38646698 DOI: 10.1542/peds.2024-066327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 04/23/2024] Open
Abstract
Confidentiality is a foundational element of high-quality, accessible, and equitable health care. Despite strong grounding in federal and state laws, professional guidelines, and ethical standards, health care professionals and adolescent patients face a range of complexities and barriers to seeking and providing confidential care to adolescents across different settings and circumstances. The dynamic needs of adolescents, the oftentimes competing interests of key stakeholders, the rapidly evolving technological context of care, and variable health care billing and claims requirements are all important considerations in understanding how to optimize care to focus on and meet the needs of the adolescent patient. The following assessment of the evolving evidence base offers a view of the current state and best practices while pointing to numerous unmet needs and opportunities for improvement in the care experiences of youth as well as their health outcomes.
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Affiliation(s)
- Richard J Chung
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Janet B Lee
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jesse M Hackell
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Elizabeth M Alderman
- Division of Adolescent Medicine, Department of Pediatrics, Albert Einstein College of Medicine and The Children's Hospital at Montefiore, Bronx, New York
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Hagström J, Blease C, Scandurra I, Moll J, Cajander Å, Rexhepi H, Hägglund M. Adolescents' reasons for accessing their health records online, perceived usefulness and experienced provider encouragement: a national survey in Sweden. BMJ Paediatr Open 2024; 8:e002258. [PMID: 38460965 DOI: 10.1136/bmjpo-2023-002258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/25/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND Having online access to electronic health records (EHRs) may help patients become engaged in their care at an early age. However, little is known about adolescents using patient portals. A national survey conducted within the Nordic eHealth project NORDeHEALTH provided an important opportunity to advance our understanding of adolescent users of patient portals. The present study explored reasons for reading the EHRs, the perceived usefulness of information and functions in a patient portal and the association between frequency of use and encouragement to read the EHR. METHODS Data were collected in a survey using convenience sampling, available through the Swedish online health portal during 3 weeks in January and February 2022. This study included a subset of items and only respondents aged 15-19. Demographic factors and frequencies on Likert-style questions were reported with descriptive statistics, while Fisher's exact test was used to explore differences in use frequency based on having been encouraged to read by a healthcare professional (HCP). RESULTS Of 13 008 users who completed the survey, 218 (1.7%) were unique users aged 15-19 (females: 77.1%). One-fifth (47/218, 21.6%) had been encouraged by HCPs to read their records, and having been encouraged by HCPs was related to higher use frequency (p=0.018). All types of information were rated high on usefulness, while some functions were rated low, such as blocking specific clinical notes from HCPs and managing services for family members. The main reason for reading their health records online was out of curiosity. CONCLUSIONS Adolescents who read their records online perceive it to be useful. Encouragement by HCPs can lead to increased use of patient portals among adolescents. Findings should be considered in the future design of patient portals for adolescents.
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Affiliation(s)
- Josefin Hagström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- MedTech Science & Innovation Centre, Uppsala University Hospital, Uppsala, Sweden
| | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jonas Moll
- School of Business, Örebro University, Örebro, Sweden
| | - Åsa Cajander
- Department of Information Technology, Uppsala University, Uppsala, Sweden
| | - Hanife Rexhepi
- School of Informatics, University of Skövde, Skövde, Sweden
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- MedTech Science & Innovation Centre, Uppsala University Hospital, Uppsala, Sweden
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Hoopes AJ, Cushing-Haugen KL, Coley RY, Fuller S, White C, Ralston JD, Mangione-Smith R. Characteristics of Adolescents Who Use Secure Messaging on a Health System's Patient Portal. Pediatrics 2023; 152:e2022060271. [PMID: 37271795 PMCID: PMC10312232 DOI: 10.1542/peds.2022-060271] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVES To determine adolescent characteristics associated with patient portal secure messaging use within a health system. METHODS This study analyzed monthly data from individuals aged 13 to 17 who met study eligibility criteria from 2019 to 2021. The primary outcome was any secure messages sent from an adolescent's account during each observed month. Unadjusted and adjusted associations between adolescent characteristics and secure messaging use were assessed using generalized estimating equations with log link and binomial variance. RESULTS Of 667 678 observed months, 50.8% occurred among males who were not transgender, 51.5% among those identifying as non-Hispanic white, and 83.3% among the privately insured. The adjusted relative risks of secure messaging use were significantly higher for individuals with female sex and transgender identities (female sex, not transgender: adjusted relative risk [aRR] 1.41, 95% confidence interval [CI] 1.31-1.52; male sex, transgender: aRR 2.39, CI 1.98-2.90, female sex, transgender: aRR 3.01, 95% CI 2.63-3.46; referent male sex, not transgender), those with prior portal use (aRR 22.06, 95% CI 20.48-23.77; referent no use) and those with a recent preventive care visit (aRR 1.09, 95% CI 1.02-1.16; referent no recent visits). The adjusted relative risks of portal secure messaging use were significantly lower among those with public insurance (aRR 0.58, 95% CI 0.50-0.67; referent private). CONCLUSIONS Adolescents who sent patient portal secure messages differed from those who did not. Interventions to encourage secure messaging use may require tailoring based on patient characteristics.
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Affiliation(s)
- Andrea J. Hoopes
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - R. Yates Coley
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Cicely White
- Kaiser Permanente Washington, Seattle, Washington
| | - James D. Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Carlson JL, Pageler N, McPherson T, Anoshiravani A. Providing Online Portal Access to Families of Adolescents and Young Adults with Diminished Capacity at an Academic Children's Hospital: A Case Report. Appl Clin Inform 2023; 14:128-133. [PMID: 36792056 PMCID: PMC9931492 DOI: 10.1055/s-0043-1760847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND For caregivers of adolescents and young adults with severe cognitive deficits, or "diminished capacity," access to the medical record can be critical. However, this can be a challenge when utilizing the electronic health record (EHR) as information is often restricted in order to protect adolescent confidentiality. Having enhanced access for these proxies would be expected to improve engagement with the health system for the families of these medically complex adolescents and young adults. OBJECTIVES To describe a process for granting full EHR access to proxies of adolescents with diminished capacity and young adults who are legally conserved while respecting regulations supporting adolescent confidentiality. METHODS The first step in this initiative was to define the "diminished capacity" access class for both adolescents and young adults. Once defined, workflows utilizing best practice alerts were developed to support clinicians in providing the appropriate documentation. In addition, processes were developed to minimize the possibility of erroneously activating the diminished capacity access class for any given patient. To enhance activation, a support tool was developed to identify patients who might meet the criteria for diminished capacity proxy access. Finally, outreach and educations were developed for providers and clinics to make them aware of this initiative. RESULTS Since activating this workflow, proxies of 138 adolescents and young adults have been granted the diminished capacity proxy access class. Approximately 54% are between 12 and 17 years with 46% 18 years and older. Proxies for both age groups have engaged with portal functionality at higher rates when compared to institutional rates of use by proxies of the general pediatric population. CONCLUSION With this quality improvement initiative, we were able to enhance EHR access and engagement of families of some of the most complex adolescent and young adult patients without inadvertently compromising adolescent confidentiality.
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Affiliation(s)
- Jennifer L. Carlson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Natalie Pageler
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Tom McPherson
- Information Services, Stanford Medicine Children's Health, Palo Alto, California, United States
| | - Arash Anoshiravani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
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Hagström J, Blease C, Haage B, Scandurra I, Hansson S, Hägglund M. Views, Use, and Experiences of Online Access to Pediatric Electronic Health Records for Children, Adolescents, and Parents: Scoping Review (Preprint). J Med Internet Res 2022; 24:e40328. [DOI: 10.2196/40328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
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Stubbe DE. Confidential Communication: Addressing Challenges of Open Electronic Health Records for Youths and Families. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:210-214. [PMID: 37153137 PMCID: PMC10153502 DOI: 10.1176/appi.focus.20220040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Dorothy E Stubbe
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
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Hagström J, Blease C, Haage B, Scandurra I, Hansson S, Hägglund M. Use and Experiences of Online Access to Electronic Health Records for Parents, Children, and Adolescents: Protocol for a Scoping Review (Preprint). JMIR Res Protoc 2022; 11:e36158. [PMID: 35704386 PMCID: PMC9244655 DOI: 10.2196/36158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/10/2022] [Accepted: 05/29/2022] [Indexed: 12/17/2022] Open
Abstract
Background As patient online access to electronic health records becomes the standard, implementation of access for adolescents and parents varies across providers, regions, and countries. There is currently no international compilation of evidence to guide policy decisions in matters such as age limit for access and the extent of parent proxy access. Objective This paper presents the protocol for a scoping review of different stakeholders’ (including but not limited to end users) perspectives on use, opinions, and experiences pertaining to online access to electronic health records by parents, children, and adolescents. Methods This scoping review will be conducted according to the Arksey and O’Malley framework. Several databases will be used to conduct a literature search (PubMed, CINAHL, and PsycInfo), in addition to literature found outside of these databases. All authors will participate in screening identified papers, following the research question: How do different stakeholders experience parents’, children’s, and adolescents’ online access to the electronic health records of children and adolescents? Data abstraction will include but will not be limited to publication type, publication year, country, sample characteristics, setting, study aim, research question, and conclusions. The data to be analyzed are from publicly available secondary sources, so this study does not require an ethics review. Results The results from this scoping review will be presented in a narrative form, and additional data on study characteristics will be presented in diagrams or tabular format. This scoping review protocol was first initiated by Uppsala University in June 2021 as part of the NordForsk-funded research project NORDeHEALTH. The results are expected to be presented in a scoping review in June 2022. The results will be disseminated through stakeholder meetings, scientific conference presentations, oral presentations to the public, and publication in a peer-reviewed journal. Conclusions This is, to our knowledge, the first study to map the literature on the use and experiences of parents’ and adolescents’ online access to the electronic health records of children and adolescents. The findings will describe what benefits and risks have been experienced by different stakeholders so far in different countries. A mapping of studies could inform the design and implementation of future regulations around access to patient-accessible electronic health records. International Registered Report Identifier (IRRID) DERR1-10.2196/36158
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Affiliation(s)
- Josefin Hagström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Charlotte Blease
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Barbara Haage
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | | | - Scharlett Hansson
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Schapiro NA, Mihaly LK. The 21st Century Cures Act and Challenges to Adolescent Confidentiality. J Pediatr Health Care 2021; 35:439-442. [PMID: 33865680 DOI: 10.1016/j.pedhc.2021.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/21/2021] [Accepted: 03/21/2021] [Indexed: 11/16/2022]
Abstract
Confidentiality is an important part of adolescent health care, providing a safe arena for young people to address sensitive health concerns and develop independent relationships with their providers. State and federal laws support a range of adolescent confidentiality protections. However, the full implementation of the 21st Century Cures Act, with the release of all medical records to patients and caregivers, may endanger this expectation of privacy. This policy brief reviews implications of the open notes requirement of the Cures Act, suggests strategies to improve care for adolescent patients, and recommends advocacy to improve the 2020 Final Rule implementation.
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