OpenNotes, the effort to provide patients with online access to their clinical notes through a portal, has gotten mixed reviews from Veterans Health Administration mental health clinicians who perceive it as both challenging and beneficial.
Some clinicians view OpenNotes as an opportunity to better partner with patients, while others say they believe that it has the potential to undo their therapeutic relationships with patients, according to results of a recent study. In addition, many clinicians say they are uncomfortable with OpenNotes and acknowledge that this discomfort could affect documentation practices.
For the study, researchers interviewed 28 VHA mental health clinicians and nurses at the VA Portland Health Care System to get their perspectives on the use of OpenNotes in behavioral healthcare through the VA’s MyHealtheVet patient portal.
“Findings from this study suggest that online patient access to their mental health progress notes is changing how VHA mental health clinicians think about and document care—in both positive and negative ways,” conclude researchers writing in the Journal of Medical Internet Research.
“Clinicians perceive a shift in the balance of power between clinicians and patients, primarily resulting from reduced clinician control over the flow of information pertinent to the therapeutic relationship and process,” they observed.
“Clinicians often view this as a shift toward more patient-centered care, but many find the change uncomfortable. This discomfort may result in improved documentation and conversations with patients, or could lead to some unintended negative consequences such as reducing what they document.”
According to Steven Dobscha, MD, director of the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System, overall a majority had mixed feelings about patients using OpenNotes.
“The VA has been using OpenNotes for all patients, including patients receiving mental healthcare, since January 2013, and as far as I can tell, there are no efforts underway to change that,” says Dobscha. “It’s pretty clear that patients value the access to the notes, even though sometimes they can be upsetting or confusing, and think that it’s helpful. We know that the notes are critical to the veterans in terms of developing trust with clinicians.”
Dobscha contends that OpenNotes challenges the “power dynamics” in the clinician-patient relationship. “Who are the notes being written for? Who controls the flow of information?—those are important questions,” he observes.
In the study, many clinicians perceived the increase in patient control over their health information as a shift in power. Some clinicians viewed this shift as a move toward patient-centered care, creating better opportunities for collaboration with patients and encouraging patient engagement. At the same time, however, a few clinicians said they believed that patients could use OpenNotes to dictate to clinicians on how to write their notes as well as direct their care.
As a result, researchers concluded that future studies should continue to monitor the impact of OpenNotes in the VA’s mental health settings and identify ways to reduce negative effects and strengthen the benefits.
“Consistency between what’s written in a note and what’s discussed in a session between clinician and patient is important,” advises Dobscha. “When something shows up in a note like a new diagnosis that wasn’t discussed in a session, that’s sometimes where patients have trouble. If a clinician is going to put a diagnosis in the record, then they should discuss it with their patient.”
At the same time, he recommends including in the notes a “pat on the back” for patients, recognizing the progress that they are making in mental health treatment. “Documentation of patient strengths and efforts is pretty easy to do in a note, and that can help—most of the patients we work with are working pretty hard to feel better and get better.”
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