The Cures Act: What Nursing Professionals Need to Know

The Cures Act: What Nursing Professionals Need to Know
In December 2016, President Obama signed the 21st Century Cures Act (“Cures Act”) into law, and the US Department of Health and Human Services published the final rule on May 1, 2020. The act has several elements of interest to healthcare providers, including regulations designed to
facilitate sharing of data for research purposes, thereby accelerating drug and device development, and those designed to improve interoperability so that patients have easier access to their health information.

However, the act has the potential to create difficulties for both patients and healthcare providers. Nurse practitioners, registered nurses, and other nursing professionals need to understand the act, its benefits and potential risks, and how to protect themselves against legal action.

What is the Cures Act?
One of the Cures Act’s goals is to speed development of new treatments through a variety of methods, including data sharing. The act also promotes patients’ ready access to information in their electronic health record. Although patients already have the right to access their information under the Health Insurance Portability and Accountability Act (HIPAA), the Cures Act focuses on quick, free access to electronic health information (EHI), including consultation notes, discharge and summary notes, history and physical, imaging narratives, lab report narratives, pathology report narratives, procedure notes, and progress notes. The act requires organizations to have a secure “application programming interface” so patients can access this information via apps on their personal devices.

Failure to provide patients with access can result in penalties related to “information blocking.” The act defines information blocking as practices “likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information,” which includes delays in giving access.

The Office of the National Coordinator for Health Information Technology has issued eight exceptions that will not result in penalties for information blocking:
• preventing harm
• privacy
• security
• infeasibility
• health information technology (IT) performance
• content and manner
• fees
• licensing.

The “preventing harm” exception is of particular interest to healthcare providers and states: “Itm will not be information blocking for an actor [healthcare provider] to engage in practices that are reasonable and necessary to prevent harm to a patient or another person, provided certain conditions are met.” It’s beyond the scope of this article to review each exception and its associated conditions; more information can be found at

The deadline for compliance with most of the act’s parameters that directly impact healthcare
providers was April 5, 2021; full compliance with all information-blocking provisions will be
required on October 6, 2022.

What are the potential risks?
Although providing patients with access to information is a worthy goal, that access can create problems. For example, a patient with slight chest discomfort who is waiting in the ED to see a provider may access their lab results via their smartphone app and incorrectly assume they don’t have a problem because no test is marked “abnormal.” The patient may then leave without seeing the provider, but later return with serious heart damage. Or a patient accessing their health record could object to terms or labels used, such as seeing that a nurse listed “male-to-female transgender” as a “health issue” in their record. Issues such as these can affect the clinician- patient relationship between nurses and their patients, and even result in lawsuits.

Another challenge is balancing access with privacy protection. There has been confusion as to what is meant by EHI and how it relates to electronic “protected health information (PHI)” listed under HIPAA. The definition of EHI in the final rule is aligned with the information in HIPAA, so it’s important that nurses review what falls under PHI (see Protected health information).

How can nurses protect themselves?
Nurses, other healthcare providers, administrators, and IT personnel should understand the act’s requirements, particularly as they relate to information blocking, including the eight exceptions that will not result in penalties for information blocking, listed above. Before proceeding with acting under an exception, nurses should consult with a risk manager. It’s also important to know nurses still need to adhere to state requirements for sharing EHI. If, for example, a state law prohibits sharing certain EHI, nurses should follow the law. And, of course, nurses need to adhere to HIPAA requirements, which include PHI in paper, electronic, and verbal formats.

More data may prompt patients to ask more questions. Therefore, it’s a good time for nurses to remember to document patient counseling fully in the health record so they are protected in case of legal action.

Meeting information needs
As awareness of the act increases, more patients are demanding access to their EHI. Nurses need to ensure that this access is available, while remembering that it’s up to them to help patients interpret that information correctly and to document education and counseling efforts completely in the health record to protect themselves from liability.

Protected health information
HIPAA specifies that PHI is “individually identifiable health information” that relates to the person’s past, present, or future physical or mental health or condition; the provision of healthcare to the person; or the past, present, or future payment for the provision of healthcare to the individual. It refers to information transmitted in any form (verbal, paper, electronic).
Here are items that could be used to identify a person, so they are included under PHI:
• Names (full or last name and initial)
• Geographical identifiers smaller than a state, except for the initial three digits of a zip code
(but only under specific conditions)
• Dates (other than year) directly related to an individual
• Email addresses
• Phone, fax, medical records, account, certificate/license, and Social Security numbers
• Health insurance beneficiary numbers
• Device identifiers and serial numbers
• Vehicle identifiers
• Web Uniform Resource Locators (URLs)
• Internet Protocol (IP) address numbers
• Biometric identifiers, including finger, retinal, and voice prints
• Full-face photographic images and any comparable images
• Any other unique identifying number, characteristic, or code except the unique code
assigned by the investigator to code the data.

Nurses should keep PHI information confidential and only share with the patient’s authorization.
Failing to adhere to privacy standards may result in significant penalties, as well as legal action.

Sources: U.S. Department of Health and Human Services. Summary of the HIPAA Privacy Rule. OCR Privacy Brief. 2013.; What is protected health information? HIPAA J. 2018.

By: Georgia Reiner, MS, Senior Risk Specialist, Nurses Service Organization (NSO)
Aebel ES, Newlon AJ. Increased patient access under the 21st Century Cures Act: what it means
for providers. Trennan Law. 2020.
Ambulatory Surgery Center Association. 2020 Cures Act final rule. 2020.
Federal Register. 2020;85(85). 45 CFR Parts 170 and 171.
Majumder MA, Guerrini CJ, Bollinger JM, Cook-Deegan, R, McGuire AL. Sharing data under
the 21st Century Cures Act. Genet Med. 2017;19(12):1289-1294.
Posnack S. Pssst…information blocking practices, your days are numbered…pass it on.
HealthIT Buzz. 2020.
Primeau D, James J. Game planning the information blocking final rule. J AHIMA. 2020.
Office of the National Coordinator for Health Information Technology. Cures Act final rule.
Information blocking exceptions.

US Department of Health and Human Services. 21st Century Cures Act: interoperability,
information blocking, and the ONC Health IT Certification Program. 2020.
US Department of Health and Human Services. Summary of the HIPAA privacy rule. OCR
Privacy Brief. 2013.
What is protected health information? HIPAA J. 2018.
Disclaimer: The information offered within this article reflects general principles only and does not
constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable
standards of professional conduct. Readers should consult with an attorney if they have specific concerns.
Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is
applied in practice or for the accuracy of this information.
This risk management information was provided by Nurses Service Organization (NSO), the nation's
largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976.
The individual professional liability insurance policy administered through NSO is underwritten by
American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without
permission of the publisher is prohibited. For questions, send an e-mail to or call 1-800-



Live-Remote Proctoring Test Administration Available for the NAWCO WCC Exam

NAWCO now offers the option to take the WCC exam by live-remote proctoring (LRP) with testing vendor Examity. Candidates who are interested in taking the exam via LRP should review the information and administration requirements in this document and contact NAWCO at to receive availability and scheduling information.

The following FAQs provide specific information about LRP test administrations. Candidates must review the WCC candidate handbook for full certification program policies and information.

The WCC exam will still be offered via computer-based testing at PSI test centers and via paper and pencil at select sites as is detailed in the WCC Candidate Handbook available on the NAWCO web site.

What is live-remote proctoring (LRP)?

LRP is a mode of test administration that allows approved candidates the ability to take the certification exam at a location and time of their choosing using the candidate’s own computer. The administration is monitored in real time by a remote proctor who observes the candidate and enforces the exam administration rules throughout the exam.

What are the benefits of LRP?

LRP allows candidates the flexibility to select the date, time, and location that is best for them. Pending available appointments, the exam may be taken 24/7 in a candidate’s own home or office. Note – individuals other than the approved candidate may not be in the same room as the candidate at any point during the exam administration. Therefore, candidates should plan to take the exam in a private room where they will not be disturbed at any point during testing.

What are the technology requirements for testing via LRP?

Candidates must meet the following technology requirements in order to take the exam via LRP:

  1. Device: Desktop computer, laptop, or Chromebook required.  Tablets and cell phones will not meet the requirements.
  2. Operating System: Windows 7 or later, Mac OS X 10.8 or later, Chrome OSA 
  3. Internet Connection: 2 Mbps or better for upload and download speed
  4. Hardware: 2GB or more of RAM, Microphone, Speakers, and Webcam 
  5. Web Browser: Google Chrome, IE/Edge, Firefox, and Safari

Sitting for the WCC exam will involve connecting to a site outside of your network security settings and requires software download. If you are planning to take the exam at work, please speak to your IT Department to confirm the download is permitted and ask them to open ports 80, 443 and 1935. 

Candidates can perform their own systems check by going to and clicking on “Open Portal” and then clicking on “My Profile”. Candidates can set up their security profile and check compatibility.

Candidates may also contact the LRP testing vendor, Examity, at to arrange a system check with the support system prior to the exam appointment.

What are the examination rules?

Candidates must adhere to all exam day rules as detailed in the WCC Candidate Handbook and those listed below. Violation of these rules will result in termination of the exam session and/or cancellation of exam scores and may prohibit the candidate from taking the WCC exam in the future. No refunds will be given to a candidate whose exam is terminated for violation of the exam day rules.

Exam Day Rules

  1. The candidate must present a valid, US government-issued photo identification to the web-cam for validation by the proctor during the authentication process. The name and photo on the identification must match the candidate and the authorization provided by NAWCO. Examples of acceptable identification include driver’s license, passport, military ID card, or other state-issued ID. Unacceptable identification includes an employment ID, student ID, etc.
  2. No one other than the candidate is permitted in the candidate’s testing room (including children) at any time during the check-in or exam administration.
  3. Candidates may not have coats, cell phones, books, notes, or other unauthorized materials beyond the computer on their examination desks. Candidates should remove cell phones and other devices from the testing room before beginning the administration.
  4. Candidates will be required to conduct a room scan for unauthorized content as part of the check-in procedures with the test proctor. During this scan, the candidate must present the entire room, desk and behind the monitor/camera.
  5. Candidate breaks are not authorized during the exam administration. The exam time allotted is 2 hours. An additional 5 minute authentication process will take place before the exam begins. Candidates should plan accordingly. Unscheduled breaks will result in the termination of the exam session which will require the candidate to apply to retake the exam and pay the reexamination fee.
  6. NAWCO and its testing partners maintain test administration and test security standards that are designed to ensure all candidates are provided the same opportunity to demonstrate their abilities. Before, during and after examination, all candidates are expected to conduct themselves in an ethical manner.
    • To take the examination via live-remote proctoring, candidates must download monitoring software as prompted by the testing vendor. The testing computer’s cache is deleted before testing and after testing. Candidate key strokes and behavior are monitored, and irregular behavior may result in termination of the exam or cancellation of exam scores.
    • If the proctor observes the candidate violating the exam day rules, the candidate will be immediately notified. If irregular behavior continues after a warning from the proctor, is extreme, or indicates cheating, the exam session will be immediately terminated and the incident reported to the NAWCO. LRP administrations are continuously monitored by the proctor and are recorded and stored.
    • Incidents of reported cheating will be investigated by the NAWCO®. If a candidate is found to have cheated, that candidate’s exam will not be scored, and the candidate will be barred from taking any further NAWCO® examinations indefinitely.

Can a candidate request a special testing accommodation for a LRP administration?

To request a special testing accommodation for a documented disability, candidates must complete the “Request for Special Accommodations” and “Documentation of Disability Needs” forms found in the WCC Candidate Handbook. Accommodations requests must be received at least six weeks prior to the requested examination date. The request must be specific as to the nature of the disability. The applicant is responsible for demonstrating that the request should be granted.

When extra time is an approved special testing accommodation for a candidate testing via LRP, this will be provided by the testing vendor. Other special testing accommodations, if authorized by NAWCO, must be provided by the candidate. In some instances, the specific testing accommodation requested may not be able to be granted due to the inherent nature of the LRP administration. In cases where an otherwise approved special testing accommodation may not be available for a LRP administration, the candidate may take the exam in one of the other available administrations offered to WCC candidates.

NAWCO will reply to each candidate requesting a special testing accommodation with the decision.

What is the policy for rescheduling or cancelling an exam appointment?

Candidates who arrive late for the examination may not take the examination. If a candidate fails to appear for the examination, the entire examination fee is forfeited.

Candidates may cancel or reschedule the exam appointment up to 48 hours before the scheduled attempt.

Waivers of exam fee forfeiture will be considered in the case of medical emergencies. Requests for such waivers must be made in writing and supported by appropriate physician documentation. Requests must be received within three weeks following the scheduled examination. They will be reviewed on a case-by-case basis.

How are exam results communicated to candidates testing via LRP?

Candidates are required to complete a brief survey about their testing experience. Once the survey has been completed and submitted, candidates will receive exam results.  Exam results will indicate pass/fail status. Unsuccessful candidates will receive score information by content area as detailed in the WCC candidate handbook.

Successful candidates may begin using the “WCC®” credential immediately and will be able to print their WCC® Certification Certificate, wallet ID card and congratulations letter within 2 weeks of the examination date. No candidate exam results will be given by telephone or facsimile for any reason. Exam results are released ONLY to the candidate.

Can candidates retaking the exam test via LRP?

Candidates who are retaking the exam may select LRP as the mode of administration if they were unsuccessful via LRP on the first attempt. Paper and pencil testing at select locations or computer-based testing at PSI test centers will also be available for those candidates retaking the exam.

How do WCC candidates register to take the exam via LRP?

Candidates interested in testing via LRP should contact NAWCO at to select LRP as the mode of test administration and to receive information for scheduling the exam.

Examity recommends that candidates allow a minimum of 14 working days from the date of registration to ensure exam appointment availability.