Statement on 21st Century Cures Act Final Rule Information Blocking Compliance

Developed by: Committee on Informatics and Information Technology
Original Approval: October 23, 2024

Summary of Recommendations: Anesthesia records that are part of a patient’s electronic health information (EHI) should not be released to patients or proxies until the draft anesthesia record is finalized by the anesthesiologist of record, unless specifically requested by the patient or caregiver through relevant consent forms or during a preoperative discussion.

Anesthesiologists should familiarize themselves with how and when perioperative EHI is currently released at the healthcare facilities where they practice.

As part of preoperative discussions with patients and caregivers, we encourage including a discussion of what patients or caregivers may expect to see in a patient's EHR portal during the perioperative period. In this discussion, anesthesiologists may set reasonable expectations for when additional context and discussion can occur, which may be after anesthetic care has been completed for the patient.

Information about immediate EHI release in the perioperative period for caregivers could be included in relevant consent forms to provide additional context about this topic.

Each healthcare institution/anesthesiology group should consider the implications of differential timing in records release and how conforming to a standard will help provide consistency for patients and caregivers. 

Background: The 21st Century Cures Act Final Rule stipulates that all electronic health information be shared with patients (e.g. clinical notes, lab results, etc.) in a timely fashion, otherwise penalties may be applied to entities who have engaged in information blocking. The Final Rule was first published May 1, 2020, but its deadline for go-live was extended to April 5, 2021. Subsequently, the definition of EHI was expanded, and sharing requirements with third party applications was added on October 6, 2022. Thus, the entirety of an anesthetic record meets the requirement for sharing with patients.

Formal recommendations from professional societies on strategies for release of anesthesia records for patients completing anesthesia care are currently lacking. This has led to inconsistent interpretation by anesthesia groups, hospitals, healthcare systems, and their respective legal teams. The American Society of Anesthesiologists Committee on Informatics and Information Technologies has authored this statement which discusses recommendations to improve transparency of anesthesia records with patients and families while minimizing anxiety due to misinterpretation of non-finalized draft data during a patient’s anesthetic. In the same way that a patient’s outpatient clinic note halfway-drafted by their provider would not be released mid-draft, partial or non-finalized portions of the anesthesia record should not be released in what are essentially a “mid-draft” state.

The time around anesthesia can be a very stressful period for patients and families. Anesthesia providers are responsible for vigilantly caring for their patients while at the same time balancing the need to document their care. Receiving anesthesia can be a very dynamic and potentially dangerous time for patients. It may be the case that a life-threatening event occurs during anesthesia, in which case the anesthesiologist will focus on the patient and documentation will not be the priority. During these events, real-time documentation may be inaccurate or incomplete. Labs and tests obtained in the intraoperative phase may be inaccurate, or have extreme values, for a number of reasons. Anesthesiologists are also unavailable during these periods to answer medical questions as their focus is on the anesthetized patient.

This is particularly pertinent in the daily practice of pediatric anesthesiology in which a child’s parent, guardian, or care proxy can monitor the flow of EHI in real-time during a child’s anesthetic. There have been cases of parents who have become distressed due to partial or non-finalized information (e.g. labs, procedure notes) being displayed in their child’s patient portal account during anesthesia. We recommend that the timing of anesthesia record release conform to a single standard of “finalized” so that all anesthesiologists can focus on patient safety during the anesthetic and then follow up with the patient and/or their proxy to contextualize the anesthetic record once the anesthesia record is finalized. 

Guiding Principles:

1. Anesthesiologists support the improved transparency and interoperability that the Cures Act Final Rule brings about for patients, families, and their care teams.
2. Although patient EHI may be distributed to patients and their caregivers during the perioperative period based on local policy, patients and caregivers should be notified during the preoperative period that the data does not constitute a finalized anesthesia record until sign-off by the anesthesiologist, and thus may not have sufficient context for a patient/caregiver to interpret.
3. When crafting local policy, anesthesiologists should be familiar with guidance provided by the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (hereafter ASTP). Among other clinical scenarios, ASTP regulatory guidance on sequestering non-finalized EHR, patient access to data, and clinical circumstances related to the release of data should be consulted
4. We also emphasize that any putative delay in release of information to the patient while a patient is anesthetized is mooted by the fact of the patient being in an anesthetized state. The impact of our position with respect to release of anesthesia information would be to putatively delay release of information to proxies ("authorized representatives"). The rule does not explicitly prohibit (or permit) blocking access to family or proxies. It does not address this scenario. Our statement clarifies that the intent behind this putative delay of release is to be consistent with timely release of finalized medical records/information and would not fall under the definition of information blocking.
5. This statement is intended to be agnostic of anesthesia information management system (AIMS) vendors available. There are many AIMS systems available: some are sub-components of enterprise all-in-one electronic health record (EHR) solutions, others are stand-alone AIMS that export an anesthetic record that can be included in a patient’s EHR. Either way, different AIMS vendors may have different workflows for when a record is considered “finalized.” 
6. This statement does not apply to paper anesthetic records. 

What does an anesthesia record encompass?

The American Society of Anesthesiologists has defined and routinely updates its Statement on Documentation of Anesthesia Care, which outlines the components of documentation that an anesthesiologist is responsible for. This Statement is intended to complement the other by discussing the timing of release of the components of the anesthesia record. One of the challenges with enterprise EHR systems is that what previously may have been solely documented in the paper anesthetic record is now available across multiple clinical domains and EHR components for the benefit of interdisciplinary care in a complex health system. For some AIMS vendors, this may be difficult to separate out. For others, if the AIMS is completely separate from the hospital’s EHR system, the anesthesia record may be easy to separate.

Components of the anesthesia record that are not “finalized” until reviewed and signed off by the anesthesiologist of record may include, but are not limited to, the following:

1. Pre-anesthesia evaluation note*
2. Physiologic monitoring data
   1. Anesthetic vitals grid and granular vital signs components, including all components of monitoring documentation that might be automatically or manually documented
   2. Anesthesia machine data including ventilator settings and ventilator data
3. Anesthetic technique(s) used.
4. Additional anesthesia procedures performed and associated documentation*
5. Medications administered: dose, time, route, response (where appropriate)
6. Documentation of fluid or product administration, output types and amounts (e.g., blood loss, urine output, blood products).
7. Unusual or noteworthy events during surgery and anesthesia care.
8. Patient status at transfer of care to staff in a Postanesthesia Care Unit (PACU) or an area which provides equivalent post-anesthesia care.
9. Post-anesthesia evaluation note (documenting physiologic condition and presence/absence of anesthesia related complications or complaints)*

* - Depending on the AIMS implementation, preoperative, intraoperative, and postoperative notes may be "signed" independent of the signature on the anesthesia record by the attending anesthesiologist or other anesthesia provider. 
** - "Perioperative" is defined, for the purposes of this statement, as the time period between (a) intake of the patient into the perioperative environment to be prepared for surgery and (b) the discharge of the patient from the post-anesthesia care unit or equivalent recovery unit, or the handoff of care to an intensive care unit team, as appropriate.

When is an anesthesia record considered “finalized”?

An anesthesia record is “finalized” when the responsible provider has fully reviewed the contents of the chart and signs the record. This may correspond to the following non-exhaustive list of actions depending on the AIMS vendor:

1. Closing the anesthetic encounter,
2. Signing the anesthesia post-evaluation note to sign the last component of the anesthetic record,
3. Attestation of the chart.

A potential catch-all way to determine if the anesthetic record is “finalized” is if it is fully ready to be sent over for billing to review.

Notably, it is the anesthesiologist’s responsibility to finalize documentation in a timely fashion. Local institutional policy may dictate the timeliness with which documentation must be finalized.

References:

1. Office of the National Coordinator. “Cures Act Final Rule.” https://www.healthit.gov/topic/oncs-cures-act-final-rule, https://www.govinfo.gov/content/pkg/FR-2020-05-01/pdf/2020-07419.pdf 
2. Ramaswamy P, Chin D, Robinowitz D. Open Anesthesia Records: Guidance for Anesthesia Providers on Implementing the Cures Act. ASA Monitor February 2021, Vol. 85, e3–e4. https://pubs.asahq.org/monitor/article/85/2/e3/115119/Open-Anesthesia-Records-Guidance-for-Anesthesia 
3. Ramaswamy P, Xie J, Marsiglio AM, et al. Keeping an open mind about open notes: sharing anesthesia records with patients. Anesth Analg. 2022;135(4):697-703. https://pubmed.ncbi.nlm.nih.gov/36108183/  
4. American Society of Anesthesiologists Committee on Quality Management and Departmental Administration. “Statement on Documentation of Anesthesia Care.” October 18, 2023 (original approval: October 15, 2003). https://www.asahq.org/standards-and-practice-parameters/statement-on-documentation-of-anesthesia-care