For most of the EMR era, a progress note was a document written by clinicians for clinicians, and a lab result reached the patient only after someone decided to release it. That changed with the federal information blocking rules, which treat unreasonable delays in giving patients access to their electronic health information as a violation. In practice, notes and results now appear in the patient portal as soon as they are final, often before the ordering clinician has seen them. This article covers what that means for charting and how practices have adapted.
What changed and why
The 21st Century Cures Act directed the Office of the National Coordinator for Health IT to define information blocking, and the resulting rules took effect in stages beginning in 2021. The scope initially covered a defined set of data classes and expanded in October 2022 to all electronic health information in a designated record set. The rules apply to providers, health IT developers, and health information exchanges. For providers, the practical effect is that a policy of holding results or notes for a fixed period, or requiring a clinician to click "release" before a patient can see anything, is difficult to justify unless it fits one of the defined exceptions.
Enforcement for providers runs through appropriate disincentives established by HHS, which for clinicians in the Merit-based Incentive Payment System includes losing credit for the Promoting Interoperability performance category. Health IT developers and exchanges face civil money penalties.
Writing notes patients will read
Open notes did not require anyone to write differently, but many clinicians found that they wanted to. The most common adjustments are small and mostly improve the note for other readers too.
- Replace shorthand that reads badly out of context. "SOB" and "pt denies" are precise to a clinician and jarring to a patient; "shortness of breath" and "the patient reports no" cost a few characters.
- Describe behavior rather than labeling it. "Did not take medication as prescribed on three days this week" carries the same information as "non-compliant" with less friction.
- Write the assessment as if explaining it in the room. Patients who read a clear plan follow it more often, which is the point of the plan.
- Keep the note honest. Difficult findings still belong in the record; the change is in how they are phrased, not whether they are documented.
Templates and open notes: Auto-populated normal exams and copied-forward history look worse to a patient than to a colleague, because the patient knows what was actually examined. Immediate release is a good reason to trim templates to what was done.
Results that arrive before the call
The larger workflow shift is results. Pathology, imaging, and abnormal labs now reach the patient portal when the result is final, which can be evenings, weekends, or minutes after signing. Patients may read a cancer diagnosis on their phone before anyone has spoken to them. Practices have responded in several ways, none of which involve holding results.
| Approach | How it works |
|---|---|
| Set expectations at ordering | Tell the patient results will appear in the portal, possibly before the clinician reviews them, and how follow-up will happen |
| Pre-result outreach for high-stakes tests | Schedule the results conversation when the biopsy is ordered, not after the result posts |
| Result comments | Add a short portal-visible comment when releasing or reviewing, so the patient sees context alongside the number |
| Same-day review queues | Route critical and abnormal results to a covering clinician so patients are contacted within hours, not days |
When delaying release is allowed
The rules include exceptions, and understanding them prevents both over-restriction and over-release. The preventing harm exception permits withholding when a clinician determines, on an individualized basis, that access is reasonably likely to endanger the life or physical safety of the patient or another person; it does not cover general emotional distress. The privacy exception covers situations such as a state law that restricts release, or a minor's confidential information. Other exceptions address infeasibility, security, and health IT performance. Every exception has conditions, and blanket delays applied to whole categories of results generally do not meet them. If your EMR still has a default hold configured, confirm it maps to an exception or remove it.
Workflow adjustments that help
Practices that adapted well share a few habits. They updated the EMR result-release configuration once and documented the reasoning. They gave nurses and medical assistants standing orders to communicate normal results and route abnormal ones, so the ordering clinician is not the bottleneck. They added a portal message template for common abnormal results, such as mildly low vitamin D or a borderline A1c, that explains what the number means and what will happen next. And they trained front-desk and phone staff on the new reality, because the first call about a scary result often lands there.
The upside clinicians report
Surveys of both patients and clinicians since open notes became standard have found more benefit than harm. Patients report better understanding of their plan, better recall of medications, and greater trust. Clinicians report that the feared flood of questions mostly did not arrive, and that the notes they now write are shorter and clearer. The adjustment is real, but it is an adjustment to how the chart is written and how results are communicated, not a threat to either.
Common questions
Do I have to release every result immediately?
The information blocking rules prohibit practices that unreasonably interfere with a patient's access to their electronic health information. Results should be available when they are final unless a specific exception applies to that patient and that result. A fixed delay applied to all results of a type generally does not fit an exception.
Can I withhold a result until I can call the patient?
Only if the preventing harm exception applies, which requires an individualized determination that access is reasonably likely to endanger life or physical safety. Anticipated distress from bad news does not meet that standard. The better approach is to plan the conversation before the result is expected.
Do psychotherapy notes have to be released?
Psychotherapy notes as defined by HIPAA, meaning a therapist's separate process notes kept apart from the record, are excluded from the definition of electronic health information and from the patient's right of access. Ordinary behavioral health progress notes in the chart are not excluded.
What if the EMR was configured with a release delay years ago?
Review the configuration against the current rules. If the delay does not correspond to a documented exception, remove it. Keep a record of the review and the change so the practice can show it evaluated its settings.