O2007: Potential Areas of Unintended Disclosure in the EHR: Pediatric Care Implications of the 21st Century Cures Act Based on Charting Practices at a Large Integrated Healthcare System

Background: Over the past two decades, there has been a trend in healthcare to adopt electronic patient portals and increase transparency of the medical record for patients and their proxies. Though beneficial, Pediatric providers must maintain a careful balance of information sharing with protection of confidential information. The need to increase access to electronic health information (EHI) via patient portals has only been accelerated by the 21st Century Cures Act, yet current EHR infrastructure fails to completely address the complexity of patient care delivery for children and adolescents related to information access and privacy protection. As the enforcement of information blocking provisions expand beyond the USCDI data elements, it will be important for institutions to proactively consider where medical information is stored and where it may need to be protected.

Methods: An evaluation of areas of EHI charting elements in pediatric care was completed in a two-stage process at a large integrated healthcare system: 1) survey of charting practices for pediatric care workflows that covered inpatient, outpatient, primary care, medical specialty, and surgical specialty patient encounters, and 2) appraisal of information entered in identified EHR charting tools on pediatric patients. Workflows were assessed from June to September of 2021 and a cross-sectional data extraction of EHI elements was completed in November 2021. Charting tools, excluding note documentation, were categorized based on use and type of data entered (ie discrete, free text), and evaluated for potential disclosure of sensitive items if information was released on the patient portal.

Results: The assessment of charting workflows reviled common documentation tools across EHR encounter types (eg problem list, visit diagnosis, medical history, patient instructions) and specialty specific/uncommon tools (eg social history, questionnaires). Additionally other EHI elements like medications, imaging and laboratory results, and care teams were often overlooked areas of the chart. The 75,611 charts evaluated, corresponded to 1439 providers across 400 departments. Regarding the problem list, 504 children, older than 3 years, had an active problem list item related to perinatal-entered maternal history (eg illicit drug use, hepatitis C exposure), and over 20 children had family history of a genetic cancer risk noted (eg BRCA). Within the free-text social history section of the chart, more than 300 patients had a positive sexual or drug use experience documented. This area of the chart was often inconsistently updated, and included inaccurate information related to the patient’s current living arrangements and family dynamics.

Conclusion: Pediatric EHI possess unique concerns related to information sharing/blocking. Health care institutions of all sizes and types should evaluate their charting and standard patient portal sharing practices to accommodate these concerns. Individual providers should be aware of these additional EHR charting areas that can result in unintended disclosure.