As part of the Department of Veterans Affairs’ efforts to enhance patient-physician communication, the VA has been sharing clinicians’ mental health notes online with patients to improve the transparency of their medical records.

However, the practice of providing patients with online access to all of their clinical notes through an electronic health record portal has gotten mixed reviews from patients at the VA medical center of Steven Dobscha, MD, director of the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System.

A new study of veterans who receive VA behavioral health treatment, published in the journal Psychiatric Services, reveals how so-called OpenNotes may be affecting patients’ relationships with their mental health clinicians.

“As we analyzed the data, the emerging theme had to do with trust in clinicians and how important trust was to the overall patient-physician relationship,” says Dobscha. “OpenNotes could either reinforce trust or could diminish trust. It really could go either way depending on certain elements in the record.”

Steven Dobscha, MD

The study, involving interviews with 28 patients using OpenNotes, included men and women veterans of various ages, who had diagnoses ranging from depression and PTSD to bipolar disorder and schizophrenia. What researchers found was that “respondents consistently reported that patient-clinician relationships—feelings of trust in particular—are critical to the therapeutic process and that reading clinical notes strengthens or strains patients’ trust in mental health clinicians,” states the article.

While patients in the study strongly believed that the patient-clinician relationship is important to their care and that OpenNotes can help foster this relationship, they reported “strained trust” when they perceived low transparency and when they noticed incongruities between sessions and notes, including the absence of information discussed in sessions; outdated copied and pasted sections; mistakes, such as incorrect age or gender; and details that didn’t line up with a patient’s recollection of a session.

In particular, many patients in the study said they were upset to see diagnoses in the physician notes that hadn’t been discussed with them during a session, and that served to significantly erode their trust.

“Notes need to reflect what happens in the sessions and not really surprise people,” says Dobscha, who acknowledges that sometimes clinicians overtly discuss diagnoses with patients, while at other times they do not because they worry that it will have a negative impact on their patients.

“Communicating openly and transparently about observations, interpretations and diagnoses may help mitigate surprises when patients read their notes,” recommend researchers in the article. “Second, we encourage clinicians to use documentation that highlights the individuality of the patient and that includes patient strengths. Our findings suggest that including unique details from each session could help patients feel heard and understood by their clinicians; also, documentation highlighting patient progress could be therapeutically motivating.”

Dobscha’s research team has been exploring the use of OpenNotes in mental healthcare through the VA’s legacy electronic health record system, the Veterans Health Information Systems and Technology Architecture (VistA), and the MyHealtheVet patient portal. Patients access their physicians’ notes and other health information through the Blue Button feature in the MyHealtheVet personal health record.

In January 2013, the VA nationally became one of the first health systems in the country to offer OpenNotes access to its patients, according to Dobscha. “At that time, all notes became available to veterans through the MyHealtheVet patient portal,” he adds. “There are no restrictions in the VA. Some institutions and providers have opted out from mental health notes. But, the VA didn’t do that.”

Currently, more than 10 million patients nationwide have access to their doctors’ notes online. To increase the number of OpenNotes participants to 50 million patients nationally, several foundations have committed $10 million to the effort to dramatically scale up the initiative on a national level.

Also See: 50 million patients to access clinical notes under $10M effort

Going forward, Dobscha says his team has developed some web-based courses for veterans and clinicians, based on the study’s qualitative interviews, to help them optimize use of mental healthcare OpenNotes while avoiding any negative consequences.

“One of the things we’re doing in the web-based courses is including some information for clinicians on how they might more easily share diagnoses with patients,” he concludes. “Those courses are currently being evaluated here at VA Portland.”

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