November 2017

In this Issue: Improving Care of Mental Health Conditions
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Optimizing Benefits for Mental Health OpenNotes

Feature Article

Little is known about the benefits and harms of the OpenNotes initiative, which provides Veterans electronic access to their medical records through MyHealtheVet. An area of special controversy pertains to mental health notes, which often contain sensitive information. It has been suggested that OpenNotes use by patients receiving mental health treatment may have unique negative consequences. On the other hand, OpenNotes has the potential to help patients feel more informed about their health and more engaged in care. This ongoing study (2015-2017) will:

• Examine benefits and unintended negative consequences of OpenNotes use as perceived by Veterans receiving VA mental healthcare – and by mental health clinicians; and
• Develop and evaluate prototype web-based training programs designed to help Veterans and clinicians use OpenNotes in ways that optimize Veteran-clinician collaboration and minimize unintended consequences.

In Phase 1 of this ongoing study (2015-2016), investigators conducted interviews with approximately 30 Veterans treated by mental health clinicians, and who had used MyHealtheVet in the prior year. They also conducted interviews with approximately 30 VA Portland mental health clinicians. Interviews explored perspectives, experiences, and preferences with regard to OpenNotes. The investigators also administered a preliminary brief clinician survey to all VA Portland mental health clinicians and nurses to gather perspectives, impacts, and concerns about OpenNotes. Five Veterans and three clinicians were invited to consult with the research team over the course of the project. In Phase 2 of this study (2016-2017), investigators recruited and enrolled Veterans receiving mental healthcare and who were MyHealtheVet users. The Veteran cohort and their mental health clinicians participated in the web-based courses, then completed study surveys at baseline, 4 and 8 months

Preliminary findings show that in a survey of 208 VA Portland mental health clinicians and nurses, just over half agreed that making mental health notes available is a good idea. Most believed that their patients would better remember the plan of care, but most also felt that patients would worry more. In addition, the investigators found that OpenNotes is having substantial impacts on how clinicians perceive, document, and provide care for patients.

In interviews with Veterans, respondents reported that feelings of trust were crucial to the therapeutic process. For some, reading notes strengthened their trust in their clinicians, but for others, it strained trust. Also, patient perceptions of transparency and respect in notes served to strengthen and maintain trust in their clinicians

Impact: This project is providing important and timely information about impacts of OpenNotes on Veterans, clinicians, and care; the courses will be designed to optimize Veteran-clinician interactions – and to minimize unintended negative consequences.

Principal Investigator:  Steven Dobscha, MD, is Director of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.

Publications:

Denneson L, Cromer R, Williams H, Pisciotta M, and Dobscha S. A qualitative analysis of how online access to mental health notes is changing clinician perceptions of power and the therapeutic relationship. Journal of Medical Internet Research. June 14. 2017;19(6):e208.

Cromer R, Denneson M, Pisciotta M, Williams H, Woods S, and Dobscha SK. Trust in mental health clinicians among patients who access clinical notes online. Psychiatric Services. May 1, 2017;68(5):520-523.

Optimizing Benefits for Mental Health OpenNotes project abstract