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IIR 13-347 – HSR Study

IIR 13-347
Optimizing Benefits and Reducing Negative Effects of Mental Health Open Notes
Steven K. Dobscha, MD
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: April 2014 - March 2018
Since January 1, 2013, Veterans have had direct access to VA medical record progress notes (OpenNotes) through My HealtheVet, VA's online interface. Although previous research has found that OpenNotes can be beneficial for patients, concerns have been raised regarding OpenNotes use by patients receiving mental health care. On the other hand, early evidence suggests that patients with access to OpenNotes feel more informed about their health, are more engaged with and adherent to care, and may have improved health outcomes.

1) Examine benefits and unintended negative consequences of OpenNotes use as perceived by Veterans receiving VA mental health care and by mental health clinicians; and 2) develop and evaluate web-based training modules designed to help Veterans and clinicians use OpenNotes in ways that optimize Veteran-clinician collaboration and minimize unintended consequences.

This was a mixed-methods longitudinal study. Six Veterans and three clinicians were invited to consult to the research team during qualitative analysis, course development, and survey refinement phases. In Phase 1, we conducted individual qualitative interviews of 28 Veterans treated by mental health clinicians and 28 mental health clinicians. Interviews explored stakeholder perspectives, experiences, and preferences regarding OpenNotes.

Web-based courses were developed in collaboration with VA's Mental Health Web Services Office and built by a contractor. Clinicians and Veterans completed surveys with items adapted from the Robert Wood Johnson Foundation OpenNotes project as well as measures of the patient-clinician therapeutic relationship, satisfaction, self-efficacy, and patient participation in care.

In Phase 2, 407 Veterans receiving mental health care who were registered users of My HealtheVet, and all VA Portland Health Care System mental health clinicians and nurses (n=251) were recruited to complete study surveys before and after participating in the courses. Focus groups were conducted with a sample of participants to capture additional feedback about the courses. In the quantitative evaluation of training course effectiveness, we compared Veteran and clinician survey responses between training and control groups across two waves of course implementation.

Results from an initial survey of mental health clinicians showed that clinicians are positive about OpenNotes in general, but are more ambivalent about their use in mental health care. While clinicians believe their patients will somewhat benefit from OpenNotes, the majority believe that patients are moderately to very likely to worry more and be confused by their notes.

Qualitative interviews with 28 clinicians revealed that OpenNotes has had impacts on how clinicians perceive, document, and provide care for patients. Most changes can be attributed to clinician perceptions of reduced control over flow of information, which is shifting the patient-clinician power dynamic.

In qualitative interviews with 28 Veterans, trust emerged as a key theme. Perceptions of transparency and respect in notes help to strengthen and maintain trust.

Quantitative analyses with the full sample of 407 Veterans revealed that Veterans who are active in mental health treatment were more likely to use OpenNotes if they have post-traumatic stress disorder (PTSD) diagnoses, if their clinicians spoke with them previously about availability of OpenNotes, or were more confident in understanding the use and purposes of OpenNotes. Notably, these knowledge-related factors were stronger predictors of OpenNotes use than demographic factors, such as age or eHealth literacy. Veterans frequently reported benefiting from reading their notes - such as making them feel more in control of their care - and rarely experienced negative emotional responses (e.g., worry, stress) to reading notes. The results also showed that Veterans with PTSD may experience negative emotional responses more frequently than other Veterans, but they may also experience stronger increases in patient-clinician alliance compared to other Veterans.

Our final quantitative analyses of longitudinal survey data showed that after completing the clinician course, clinicians were significantly more likely to report improvements in their ability to communicate with patients about OpenNotes and to experience reductions in concerns about negative consequences. Clinicians were also more likely to report educating patients about OpenNotes and advising them to read their notes online. After taking the Veteran course, Veterans felt significantly more empowered, more involved in their healthcare, and reported having stronger therapeutic relationships with their mental health clinicians.

In the qualitative assessment of the two courses, most clinicians felt the course gave helpful recommendations on how to reframe the content of notes to be more supportive of Veterans, and how to communicate with patients about OpenNotes. Others felt that difficult situations arising from patient access to mental health notes were under-addressed, that the offered suggestions would increase time spent writing notes, and that the course felt repetitious. While some Veterans thought that course content was too basic and the training was too long, most Veterans found the course easy to use, that it helped them better understand how to use OpenNotes and their mental health notes, and that the provided information offered tools to become more involved in their treatment.

As VA continues to shift toward providing Veteran-centric care and OpenNotes gains more acceptance nationally across multiple systems, it will be important to educate patients and clinicians about how to use OpenNotes in ways that facilitate the patient-clinician relationship and minimize unintended consequences. Results of this project, including detailed course outlines, have been shared with multiple healthcare systems which are developing their own training materials around OpenNotes in mental health care. Next steps in this line of work include gaining a deeper understanding of the current use and needs of Veterans and clinicians for other types of eHealth tools to support mental health care.

External Links for this Project

NIH Reporter

Grant Number: I01HX001470-01

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Journal Articles

  1. Denneson LM, Cromer R, Williams HB, Pisciotta M, Dobscha SK. 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. 2017 Jun 14; 19(6):e208. [view]
  2. Dobscha SK, Kenyon EA, Pisciotta MK, Niederhausen M, Woods S, Denneson LM. Impacts of a Web-Based Course on Mental Health Clinicians' Attitudes and Communication Behaviors Related to Use of OpenNotes. Psychiatric services (Washington, D.C.). 2019 Jun 1; 70(6):474-479. [view]
  3. Denneson LM, Pisciotta M, Hooker ER, Trevino A, Dobscha SK. Impacts of a web-based educational program for veterans who read their mental health notes online. Journal of the American Medical Informatics Association : JAMIA. 2019 Jan 1; 26(1):3-8. [view]
  4. Denneson LM, Chen JI, Pisciotta M, Tuepker A, Dobscha SK. Patients' Positive and Negative Responses to Reading Mental Health Clinical Notes Online. Psychiatric services (Washington, D.C.). 2018 May 1; 69(5):593-596. [view]
  5. Dobscha SK, Denneson LM, Pisciotta MK, Bourne DS, Chen JI, Philipps-Moses D, Woods SS. Predictors of viewing progress notes among users of VA's electronic health portal who receive mental health care. Journal of the Medical Informatics Association Open. 2018 Jul 1; 1(1):122-27. [view]
  6. Pisciotta M, Denneson LM, Williams HB, Woods S, Tuepker A, Dobscha SK. Providing mental health care in the context of online mental health notes: advice from patients and mental health clinicians. Journal of mental health (Abingdon, England). 2019 Feb 1; 28(1):64-70. [view]
  7. Dobscha SK, Cromer R, Crain A, Denneson LM. Qualitative analysis of US Department of veterans affairs mental health clinician perspectives on patient-centered care. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2016 Jun 1; 28(3):355-62. [view]
  8. Cromer R, Denneson LM, Pisciotta M, Williams H, Woods S, Dobscha SK. Trust in Mental Health Clinicians Among Patients Who Access Clinical Notes Online. Psychiatric services (Washington, D.C.). 2017 May 1; 68(5):520-523. [view]
  9. Dobscha SK, Denneson LM, Jacobson LE, Williams HB, Cromer R, Woods S. VA mental health clinician experiences and attitudes toward OpenNotes. General hospital psychiatry. 2016 Jan 1; 38:89-93. [view]

  1. Dobscha SK, Denneson LM, Jacobson LE, Williams HB, Cromer RD, Woods SS. Survey of VA mental health clinician experiences and attitudes towards OpenNotes. Report submitted to VA Operations Partners. Portland, OR: VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC); 2015 Feb 1. 25 p. [view]
HSR&D or QUERI Articles

  1. Dobscha SK, Denneson LM. The Virtual Hope Box Smartphone Application. HSR&D FORUM: Innovation Update. 2018 May 1; 1. [view]
VA Cyberseminars

  1. Denneson LM, Gleason T, Teo AR. Systematic Review of Suicide Prevention in Veterans. Spotlight on Evidence-based Synthesis Program [Cyberseminar]. US Department of Veterans Affairs, HSR&D. 2016 Jun 9. [view]
Conference Presentations

  1. Pisciotta MK, Denneson LM, Jacobson LE, Cromer RD, Williams HB, Woods SS, Dobscha SK. Incorporating end-user input to develop learning objectives and content for web-based courses on OpenNotes for VA Mental Health Clinicians and Veterans. Paper presented at: International Society for Research on Internet Interventions Scientific Meeting; 2016 Apr 8; Seattle, WA. [view]
  2. Dobscha SK, Denneson LM, Jacobson LE, Williams HB, Woods SS. Survey of Mental Health Clinician Experiences and Attitudes toward OpenNotes. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 14; Minneapolis, MN. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none

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