To the Editor:
Implementation of the 21st Century Cures Act took effect in April 2021, specifying that clinical notes are among electronic information that must not be blocked and must be made available free of charge to patients.1 Despite the laudable intentions of the Cures Act, we believe its implementation is already causing unintended consequence for clinical care or research procedures. These regrettable consequences stem from patients’ misunderstanding of the medical record. To illustrate, let us reflect on the following example.
Early in April 2021, we provided anesthesia care for a young woman whom we considered to be clinically unremarkable with a history significant only for anxiety and who underwent a minor procedure. A size 3 laryngeal mask airway was placed and removed because of unacceptable air leak, at which point blood was noted and the laryngeal mask airway was replaced uneventfully with an endotracheal tube and without desaturation. The patient did well during the case, and after an uneventful recovery she was briefed by the attending anesthesiologist before discharge on the blood and intubation. On the third postoperative day the attending received an email from the patient requesting a phone call to personally explain the anesthesia notes because, according to her, she was not processing the medical terms.
This led to a 20-min consultation with the attorney of the institution’s risk management office whose advice was to return the patient’s call request. The attorney also advised that the discussion be limited to one brief phone conversation and, if further dialogue is still necessary, to invite the patient to come for an in-person meeting with the attending and a witnessing colleague. Unfortunately, the phone conversation was not constructive. The patient had many questions about technical details such as laryngeal mask airway sizing, medication dosing, and the decision to intubate. Her upset emotional state only seemed to cloud any attempts to clarify information and allay her already apparent mistrust of the medical profession. Indeed, she was convinced that during the procedure she did not receive adequate oxygen, that her blood pressure was too low, that we harmed her, and that we were trying to hide the truth from her. This prompted an additional attorney consultation of 13 min, which advised to document the conversation and enter the email into the electronic medical record system of the institution.
Ultimately, this patient left with a false and distressing feeling that she was physically injured when in fact she was not. This psychologic unease can be severe, and its consequences can be serious, difficult to measure, but nonetheless real. These unintended consequences can be amplified in cases of psychiatric illness. All sorts of tragedies can potentially spiral from misjudgments of information.2
This new act has certainly introduced some unfamiliar perioperative considerations to our specialty. At the time of the follow-up phone call, we did not realize that the patient was forming her interpretation based on the partial medical record—she only had access to the notes archive, which we later realized does not include the intraoperative anesthetic record. In light of the Cures Act, closer consideration should be given to how a single piece of medical information may be easily misinterpreted on its own outside the context of the rest of the record. Clinical documentation has typically been written to address an audience of clinicians. This mindset is now a changing paradigm as our audience will inevitably involve more nonclinical readers. This is a problem, given the technical nature of anesthetic records that can sometimes be difficult to understand, even for clinicians outside of anesthesiology. We anticipate that the extent of our documentation will evolve and that more time will now be spent on documentation. We hope that the example above helps to appreciate some of the additional costs incurred in the new open system—costs that are ultimately incurred by patients and payers. We are also concerned that more patients will opt to share and discuss their medical record on social media. These platforms can be destructive to the process of seeking truth from facts.
The authors declare no competing interests.