- Email: [email protected]
VA mental health clinician experiences and attitudes toward OpenNotes
General Hospital Psychiatry 38 (2016) 89–93
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
VA mental health clinician experiences and attitudes toward OpenNotes Steven K. Dobscha, M.D. a,b,c,⁎, Lauren M. Denneson, Ph.D. a,b,c, Laura E. Jacobson, M.P.H. a, Holly B. Williams, B.A. a, Risa Cromer, M.Phil. a, Susan Woods, M.D., M.P.H. a,1 a b c
Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System; PO Box 1034 (R&D66), Portland, OR 97207, USA Mental Health and Clinical Neurosciences Division, VA Portland Health Care System; PO Box 1034 (R&D66), Portland, OR 97207, USA Department of Psychiatry, Oregon Health & Science University; 3181 Sam Jackson Park Rd, Portland, OR 97239, USA
a r t i c l e
i n f o
Article history: Received 4 May 2015 Revised 31 July 2015 Accepted 4 August 2015 Keywords: Electronic health records Veterans Mental health Attitude of health personnel Health services research
a b s t r a c t Objective: To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button), which provides patients direct access to clinical notes online. Method: A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center. Results: Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes. Conclusion: As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes. Published by Elsevier Inc.
1. Introduction Over the past decade, a number of health systems have taken steps toward offering patients online access to portions of their electronic health record. More recently, some larger health systems have begun to offer patients online access to clinical notes (referred to here as OpenNotes) [1]. Early evidence suggests that patients with access to OpenNotes feel more informed about their health; are more engaged, adherent and satisfied with care; and may have improved health outcomes [1–5]. In January 2013, all veterans treated in the Department of Veterans Affairs Healthcare System (VA) nationally who were enrolled as premium authenticated users of MyHealtheVet, VA's online patient health record, gained access to their clinical notes through the Blue Button feature in MyHealtheVet. Some members of the medical community have raised concerns that online access to notes may cause patients to experience anxiety, confusion or offense in reaction to what is documented or become vulnerable to breaches of confidentiality [1,5–9]. An area of special controversy pertains to mental health: Mental health notes typically contain ⁎ Corresponding author at: Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, P.O. Box 1034 (R&D 66), Portland, OR 97207. Tel.: +1-503220-8262x52207. E-mail addresses: [email protected] (S.K. Dobscha), [email protected] (L.M. Denneson), [email protected] (L.E. Jacobson), [email protected] (H.B. Williams), [email protected] (R. Cromer), [email protected] (S. Woods). 1 Present address: Connected Health Office VACO, VA Maine Healthcare System; 1 VA Center, Augusta, ME 04330, USA. http://dx.doi.org/10.1016/j.genhosppsych.2015.08.001 0163-8343/Published by Elsevier Inc.
sensitive information, and some have suggested that giving patients access to mental health notes could result in special unintended negative consequences and create risks for patients and clinicians. However, limiting access to mental health notes could deny those individuals the potential benefits that OpenNotes may provide. To date, no published studies have systematically examined the potential benefits or harms of mental health OpenNotes or obtained information on mental health clinician attitudes toward mental health OpenNotes. The main objective of this study is to describe VA mental health clinician experiences with and attitudes toward OpenNotes use. A secondary objective is to examine relationships among clinician characteristics and clinician attitudes toward OpenNotes. 2. Material and methods This study was reviewed and approved by the Institutional Review Board of the VA Medical Center (VAMC) where the study was conducted. 2.1. Setting and subjects The study was conducted at a single VAMC. The VAMC is closely affiliated with a university, provides comprehensive care to approximately 85,000 veterans each year and serves as a tertiary referral site for other VA facilities in the region. Ambulatory care is provided at a main campus and 10 clinics located in metropolitan and rural locations throughout the region. Over 250 mental health clinicians (physicians, psychologists, social workers, nurse practitioners) and nurses (registered
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nurses and licensed practical nurses [LPNs]) provide mental health care to approximately 16,000 unique patients each year across a variety of services spanning inpatient care to homelessness programs. The VAMC served as one of nine VA facilities that participated in VA's MyHealtheVet pilot between 2000 and 2010; this pilot preceded VA's national rollout of OpenNotes in 2013 [5]. 2.2. Data sources Data were obtained from a 35-item online survey administered in late 2014 to psychiatrists, nurse practitioners, psychologists, licensed independent social workers and nurses who provided mental health care (together referred to here as mental health clinicians) at the VAMC. Survey data were collected and managed using Research Electronic Data Capture (REDCap), an electronic data capture tool hosted within the Veterans Affairs Informatics and Computer Infrastructure. REDCap is a secure, Web-based application designed to support data capture for research studies, providing an intuitive interface for validated data entry, audit trails for tracking data manipulation and export and automated export procedures for data downloads to statistical packages [10]. REDCap allows for de-identified data capture by tracking individual participant response via an internal subject ID. An initial introductory email was sent to all potential survey participants, followed 2 days later by an official invitation email with an individualized link to the survey. Follow-up reminders were emailed to nonresponders 1 and 2 weeks following survey initiation. At 3 weeks, an invitation to complete a paper survey (in lieu of online) was mailed to nonresponders. This group also received two final email invitations at Weeks 3 and 4. 2.3. Survey content Most survey items were adapted with permission for a mental health clinician population from a survey used by Delbanco et al. in a prior study on OpenNotes conducted in three large non-VA care settings [1]. These items had been informed by initial semistructured interviews with clinicians and pretesting conducted prior to the study's survey [1]. Our survey questions were designed to gather clinician perceptions and opinions on use of OpenNotes in general as well as in mental health care. The survey also included four clinician demographic questions. 2.4. Data analysis We present descriptive information for each survey item. Because we also sought to examine relationships between clinician characteristics and key survey responses based on content and scope, we a priori identified seven key items reflecting overall impressions of mental health OpenNotes and impacts on practice and documentation. Due to the small number of nurse practitioner participants, their responses were grouped with psychiatrists for these analyses. Chi-square tests were used to compare responses across clinician demographic categories. We collapsed several variables based on distributions to facilitate these analyses: years since clinician completed training and direct patient care hours per week. All analyses were conducted with International Business Machines (IBM) SPSS Statistics 22.0 (Chicago, IL, USA). 3. Results Two hundred eight of 263 (79%) potentially eligible participants completed the survey. Table 1 shows characteristics of survey respondents. The proportions of psychiatrists, psychologists and social workers responding were similar to the overall group eligible for participation. Table 2 shows the percentage of respondents who endorsed agree or strongly agree to items asking about their opinions and anticipated impacts of OpenNotes, and Table 3 focuses on clinician documentation practices and prior experiences with OpenNotes. The Fig. 1 shows distributions of responses for selected items. With regard to the use of
Table 1 Demographics of clinician/nurse population eligible and respondents. Clinician type
Survey respondents
Psychiatrist 14.7% Psychologist 18.8% Social worker 41.7% Nurse practitioner 4.6% Nurse 18.8% Gender Male 31.3% Female 56.3% Other 1.0% Decline to answer 11.5% Hours per week direct patient care Up to 20 h 42.0% 21–55 h 57.7% Years of practice since last formal training ≤10 years 54.6% N10 years 45.4%
Proportion of discipline in mental health service 14% 19% 39% 5% 23%
OpenNotes in general, most respondents agreed or somewhat agreed that making medical record notes available to patients is a good idea. Most believed that patients will better remember the plan of care, that OpenNotes will be a useful tool to facilitate communication and that OpenNotes will improve satisfaction with care. With respect to OpenNotes use in mental health care, about half agreed that making mental health notes available to patients is a good idea, two thirds believed patients will better remember their care plans and three quarters believed that patients will be better prepared for visits. In an openended question asking for additional comments about the impacts of OpenNotes, respondents said that OpenNotes could result in better documentation (n= 5), could improve patient participation in care Table 2 Views on OpenNotes and anticipated impacts of mental health OpenNotes: proportion of respondents who somewhat agree to agreea. Survey item
n
Opinions about OpenNotes in general: 1. In general, making medical record notes available to patients is 174 a good idea. 2. OpenNotes will increase medical care efficiency. 122 3. OpenNotes will improve patient satisfaction with healthcare. 145 4. OpenNotes will increase medical care quality. 126 5. OpenNotes will adversely impact patient safety. 71 6. OpenNotes will be useful vehicles for patient communication 165 and education. Among my patients who read their mental health progress notes: 7. A majority of patients will have a better understanding of their 127 health and medical conditions. 8. A majority of patients will worry more. 156 9. A majority of patients will find mental health notes to be more 135 confusing than helpful. 10. A majority of patients will better remember the plan for their care. 136 11. A majority of patients will disagree or find errors with what I or 169 other clinicians write in their notes. 12. A majority of patients will request changes to the content of visit notes. 155 13. A majority of patients will be more likely to adhere to treatment 82 recommendations. 14. A majority of patients will be better prepared for visits. 99 15. A majority of patients will take better care of themselves in general. 76 How you feel mental health OpenNotes may affect your practice over time: 16. My visits will take significantly longer. 54 17. I will spend significantly more time addressing patient questions 92 outside of visits. 18. Making visit notes available to patients online will increase my 82 risk for lawsuits or tort claims. 19. Patients will be less inclined to continue therapy/treatment. 67 20. I don't anticipate any discernible impact on my practice. 87
% 85 60 71 62 35 81
63 77 67 67 83 76 40 49 38 27 46 41 34 43
Note: The number of total responses for each item ranged from 188 to 208. Bolded items were examined further for differential responses according to clinician demographics. a Represents the number and percent of respondents who indicated somewhat agree to agree on a 4-point scale with response options disagree, somewhat disagree, somewhat agree and agree.
S.K. Dobscha et al. / General Hospital Psychiatry 38 (2016) 89–93 Table 3 Documentation practices and experiences with mental health OpenNotes. Survey item 21. I will be/already am less detailed in my documentation. Somewhat agree/agree Somewhat disagree/disagree 22. I will/already spend significantly more time writing or editing my notes. Somewhat agree/agree Somewhat disagree/disagree 23. In addition to notes that could be viewed by your patients, do you currently, or plan to, write separate notes that patients cannot view? Yes No 24. If you have made or will make changes in the way you document, please describe the changes (mark all that apply). Write fewer details Change the tone of the note Write less about the diagnosis Use fewer medical terms Write more details Other 25. I would estimate that the following proportion of veterans in my practice have read their mental health OpenNotes online: Less than 10% 11% to 25% 25% to 50% More than 50% 26. In conversations with your patients in the past year, how often did a patient bring up something about a note that you had written? None Less than once a month 1–3 times a month 1–6 times a week Daily 27. Approximately how many of your patients have requested changes to the content of visit notes they had seen online? None 1 2 3 4–10 28. Have you or your patients experienced any specific negative consequences that you are aware of as a result of patients reading their mental health notes online? Yes No 29. Making mental health OpenNotes available to patients online is a good idea. Somewhat agree/agree Somewhat disagree/disagree 30. How would you feel personally if mental health notes were discontinued? Somewhat pleased/very pleased Would not care either way Somewhat disappointed/very disappointed
n
%
127 63 71 35 120 60 81 40
20 10 180 90
108 68 45 35 17 25
69 44 29 22 11 16
112 64 20 4
56 32 10 2
80 95 19 6 0
40 48 10 3 0
105 40 23 8 12
56 21 12 4 6
53 27 146 73
107 54 92 46
98 62 40
49 31 20
Note: The number of total responses for each item ranged from 188 to 208. Bolded items were examined further for differential responses according to clinician demographics.
(n= 3), could increase collaboration (n= 2) or were generally positive (n= 2). Approximately half of respondents believed that OpenNotes will have discernable impacts on their practices, with many reporting being less detailed and changing the tone of their notes. Most respondents felt that patients will find errors in their notes and request changes. Forty percent of respondents reported that they had not yet discussed reading notes online with a patient, and a small proportion of respondents reported having conversations with patients about their notes one or more times per month. Most did not feel that OpenNotes will result in longer visits with patients or result in more time spent addressing patient questions outside of visits. A minority reported using or considering using separate psychotherapy or process notes (which would not be available to patients online).
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Many respondents felt that patients will worry more; and a third felt that there will be impacts on safety. About half of respondents reported that they would be somewhat to very pleased if mental health OpenNotes was discontinued. Fifty-three (27%) participants reported that they or their patients had experienced specific negative consequences as a result of patients reading mental health open notes. Fifty-two of these respondents added more detailed comments about these negative consequences: These included patient disengagement from care (n=14), disagreements about noted content (n=12), disruptions in the therapeutic relationship or trust (n= 7), patients being upset or disagreeing with a diagnosis (n=6), increased clinician burden (n= 3), patient expressed suicidal or homicidal ideation (n= 3) and other (n=7). The seven items we chose to examine for differential responses according to clinician demographics are bolded in Tables 2 and 3. For these items, there were no significant differences when comparing responses across clinician characteristics. However clinicians who spend more than 20 h in direct patient care each week disagreed more often with Item 29: “Making mental health OpenNotes available to patients online is a good idea” (32% vs. 12%; n=186; χ2= 16.47, Pb.01); and reported being very pleased more often in response to Item 30: “How would you feel personally if mental health OpenNotes were discontinued?” as compared to those spending fewer than 20 h in direct patient care each week (28% vs. 13%; n=187; χ2= 10.92, P=.03). Psychiatrists and nurse practitioners (35%) were also more likely to report being very pleased if mental health OpenNotes were discontinued as compared to psychologists (27%), social workers (15%) and nurses (11%) (n= 191; χ 2=22.26, P= .04). However, we detected no significant differences in responses to Item 16: “My visits will take significantly longer” (P=.24), and Item 17: “I will spend significantly more time addressing patient questions outside of visits” (P= .21), according to hours per week spent in clinic. 4. Discussion To our knowledge, this is the first study to systematically examine mental health clinician experiences and attitudes related to the use of OpenNotes in mental health care. We found that although mental health clinicians are positive about OpenNotes in general, they are more ambivalent about their use in mental health care; recognizing some potential benefits, but also expressing concerns about potential negative impacts on patients and their practices. Although many clinicians did not report personal experiences with their patients using OpenNotes, some did report experiences with disruptions in the therapeutic relationship or trust. In addition, some clinicians reported experiences in which patients disagreed or felt upset about note content, and a small number of clinicians reported that they had observed increases in violent ideation among their patients that were associated with OpenNotes; unfortunately, we do not know specific details about these events. We also found that the clinicians who spend most of their time doing clinical work and those who prescribe are overall less favorable toward OpenNotes. It is possible that those who see more patients or those who see more patients in a fixed amount of time may be especially concerned about time demands related to OpenNotes. Interestingly, we did not see significant differences in responses to particular items related to concerns about time being spent in or out of session according to discipline or to time spent working in clinic. Another possibility here is that clinicians who see more patients have either had more negative experiences or heard of more negative experiences related to OpenNotes that influence their attitudes. This is clearly worthy of additional exploration. Worth emphasizing is that half of the respondents agreed that making mental health notes available to patients online is a good idea. As such, our results may be viewed as highlighting an opportunity to build on this perception by addressing mental health clinicians' specific concerns, which may make them feel more comfortable with OpenNotes.
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Response options:
Disagree
.
Somewhat Disagree
Somewhat Agree
Agree
Please respond to the following statements based on your opinions regarding healthcare and OpenNotes in general. 0% 20% 40% 60% 80% 100% 1)
In general, making medical record notes available to patients is a good idea.
2)
OpenNoteswill increase medical care efficiency.
3)
OpenNotes will improve patient satisfaction
47
38
5 10
20
51
19
10
14
47
26
13
with healthcare. 4)
OpenNotes will increase medical care quality.
5)
OpenNotes will adversely affect patient safety.
6)
OpenNoteswill be useful vehicles for patient
25
13 28
7
28
38
32
49
13
5
communication and education.
20
42
Please respond to the following statements based on how you think reading mental health Open Notes may affect your patients over time. Among my patients who read their mental health progress notes, a majority will: 0% 20% 40% 60% 80% 100% 7)
Have a better understanding of their health and medical conditions.
8)
Worry more.
6
9)
Find mental health notes to be more confusing than helpful.
6
10)
Better remember the plan for their care.
11)
Disagree or find errors with what I or other clinicians write in their notes.
3
12)
Request changes to the content of visit notes.
5
13)
Be more likely to adhere to treatment recommendations
14
14)
Be better prepared for visits.
15
15)
Take better care of themselves in general.
13
24
46
16
52 27
9
17 25
43
23
24
48
13
19
42
41
19
43
34
45
32
37
18
8
40
8
44
33
5
Please respond to the following statements based on how you feel Veterans reading mental health Open Notes online may affect your practice over time. 0%
20%
16)
My visits will take significantly longer.
17)
I will spend significantly more time addressing patient questions outside of visits.
18)
Making visit notes available to patients online will increase my risk for lawsuits or tort claims.
22
19)
Patients will be less inclined to continue therapy/treatment.
22
20)
I don’t anticipate any discernable impact on my practice.
40%
31 18
80%
42 36
27
60%
23 35
37
4 10
29
45 29
100%
22 31
13 12 12
Fig. 1. Mental health clinician perceptions of OpenNotes' impact on healthcare, patients and practice.
An important consideration to keep in mind is that many respondents did not yet have direct experiences with their patients reading their notes online; this is consistent with a recent study indicating that many MyHealtheVet users are not yet aware that they can access their notes [11].
Our findings are consistent with those of Walker [12] who surveyed 110 primary care physicians from three non-VA sites about their experiences with OpenNotes. In this study, most primary care physicians who were surveyed had anticipated that OpenNotes would improve physician–patient communication and patient education. However,
S.K. Dobscha et al. / General Hospital Psychiatry 38 (2016) 89–93
more than half expected that OpenNotes would result in greater worry among patients, and 36% to 50% anticipated more patient questions between visits. In the follow-up study that surveyed the same physicians after their patients had had access to OpenNotes [1], few physicians reported potentially negative impacts on their practices including longer visits, spending more time addressing patients' questions outside of visits, changing documentation content or taking more time to write notes. Unfortunately, few prior studies exist that describe clinicians' views of patients viewing their mental health records. In a study of nonelectronic medical records conducted in 1979 on an inpatient psychiatry unit [13], 90% of staff were favorably disposed to open medical records after their patients used them, and 79% wanted to continue to give patients access to notes after the research project ended. Over two thirds felt that the approach was helpful to patients. On the other hand, one quarter of the staff reported that they were more likely to omit certain types of information from their notes, and one quarter believed that at least one patient had been harmed (defined broadly) by the approach. There are a number of limitations to our project. First, this crosssectional survey was administered to mental health clinicians at a single VAMC; we do not know to what extent the results may be generalizable to other VA medical centers or to non-VA care systems or to what extent clinician attitudes may change over time. In addition, although our response rate was high (79%), we do not know the extent to which nonrespondents might be dissimilar from respondents.
5. Conclusions In this study, we found that while most mental health clinicians believe that OpenNotes is a good idea in general, fewer believe that making mental health notes available online is a good idea. Clinicians reported having only limited direct experiences with their patients around OpenNotes thus far, but based on these direct expressions and other impressions, they identified a number of potential benefits as well as potential negative consequences for patients and practice. Our results call for several next steps. First, it would be helpful to monitor mental health clinician attitudes longitudinally, as VA's OpenNotes initiative is relatively new, and we can expect that clinicians will gain more direct experience with OpenNotes over time. Second, it would be helpful to improve our understanding of outcomes related to the use of OpenNotes in mental health — such outcomes might include patient perceptions of care; measures of patient–clinician communication; measures of patient activation and engagement and mental health symptoms; or indicators of dissatisfaction including requests to change notes or complaints to patient advocates. Third, because many mental health clinicians have some level of concern about OpenNotes, it will be important to continue to develop and provide education and other
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supports to assist them in optimizing potential benefits associated with OpenNotes while minimizing unintended consequences. Acknowledgments This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration and Health Services Research and Development Service Project IIR 13-347. The funders did not give input on study design; the collection, analysis or interpretation of data; the writing of the article; or the decision to submit it for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or United States government. We gratefully acknowledge Dr. Delbanco and Dr. Walker for permission to adapt survey items from their previous studies of OpenNotes. We also thank Benjamin Laman-Maharg for assistance with data collection. References [1] Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012;157:461–70. [2] Winkelman WJ, Leonard KJ, Rossos PG. Patient-perceived usefulness of online electronic medical records: employing grounded theory in the development of information and communication technologies for use by patients living with chronic illness. J Am Med Inform Assoc 2005;12:306–14. [3] Nazi KM. The personal health record paradox: health care professionals’ perspectives and the information ecology of personal health record systems in organizational and clinical settings. J Med Internet Res 2013;15:e70. http://dx.doi.org/10.2196/jmir.2443. [4] Nazi KM, Hogan TP, McInnes DK, Woods SS, Graham G. Evaluating patient access to electronic health records: results from a survey of veterans. Med Care 2013;51:S52–6. [5] Woods SS, Schwartz E, Tuepker A, Press NA, Nazi KM, Nichol WP. Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet personal health record pilot: a qualitative study. J Med Internet Res 2013;15:E65. http:// dx.doi.org/10.2196/jmir.2356 [Published online 2013 Mar 27]. [6] Hassol A, Walker JM, Kidder D, Rokita K, Young D, Pierdon S, et al. Patient experiences and attitudes about access to a patient electronic health care record and linked web messaging. J Am Med Inform Assoc 2004;11:505–13. [7] Huba N, Zhang Y. Designing patient-centered personal health records (PHRs): health care professionals' perspective on patient-generated data. J Med Syst 2012;36: 3893–905. [8] Gill MW, Scott DL. Can patients benefit from reading copies of their doctors' letters about them? Br Med J (Clin Res Ed) 1986;293:1278–9. [9] Ross SE, Lin CT. The effects of promoting patient access to medical records: a review. J Am Med Inform Assoc 2003;10:129–38. [10] Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. [11] Nazi KM, Turvey CL, Klein DM, Hogan TP, Woods SS. VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. J Am Med Inform Assoc 2015;22:380–9. [12] Walker J, Leveille SG, Ngo L, Vodicka E, Darer JD, Dhanireddy S, et al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med 2011;155:811–9. [13] Stein EJ, Furedy RL, Simonton MJ, Neuffer CH. Patient access to medical records on a psychiatric inpatient unit. Am J Psychiatry 1979;136:327–9.
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
VA mental health clinician experiences and attitudes toward OpenNotes Steven K. Dobscha, M.D. a,b,c,⁎, Lauren M. Denneson, Ph.D. a,b,c, Laura E. Jacobson, M.P.H. a, Holly B. Williams, B.A. a, Risa Cromer, M.Phil. a, Susan Woods, M.D., M.P.H. a,1 a b c
Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System; PO Box 1034 (R&D66), Portland, OR 97207, USA Mental Health and Clinical Neurosciences Division, VA Portland Health Care System; PO Box 1034 (R&D66), Portland, OR 97207, USA Department of Psychiatry, Oregon Health & Science University; 3181 Sam Jackson Park Rd, Portland, OR 97239, USA
a r t i c l e
i n f o
Article history: Received 4 May 2015 Revised 31 July 2015 Accepted 4 August 2015 Keywords: Electronic health records Veterans Mental health Attitude of health personnel Health services research
a b s t r a c t Objective: To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button), which provides patients direct access to clinical notes online. Method: A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center. Results: Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes. Conclusion: As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes. Published by Elsevier Inc.
1. Introduction Over the past decade, a number of health systems have taken steps toward offering patients online access to portions of their electronic health record. More recently, some larger health systems have begun to offer patients online access to clinical notes (referred to here as OpenNotes) [1]. Early evidence suggests that patients with access to OpenNotes feel more informed about their health; are more engaged, adherent and satisfied with care; and may have improved health outcomes [1–5]. In January 2013, all veterans treated in the Department of Veterans Affairs Healthcare System (VA) nationally who were enrolled as premium authenticated users of MyHealtheVet, VA's online patient health record, gained access to their clinical notes through the Blue Button feature in MyHealtheVet. Some members of the medical community have raised concerns that online access to notes may cause patients to experience anxiety, confusion or offense in reaction to what is documented or become vulnerable to breaches of confidentiality [1,5–9]. An area of special controversy pertains to mental health: Mental health notes typically contain ⁎ Corresponding author at: Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, P.O. Box 1034 (R&D 66), Portland, OR 97207. Tel.: +1-503220-8262x52207. E-mail addresses: [email protected] (S.K. Dobscha), [email protected] (L.M. Denneson), [email protected] (L.E. Jacobson), [email protected] (H.B. Williams), [email protected] (R. Cromer), [email protected] (S. Woods). 1 Present address: Connected Health Office VACO, VA Maine Healthcare System; 1 VA Center, Augusta, ME 04330, USA. http://dx.doi.org/10.1016/j.genhosppsych.2015.08.001 0163-8343/Published by Elsevier Inc.
sensitive information, and some have suggested that giving patients access to mental health notes could result in special unintended negative consequences and create risks for patients and clinicians. However, limiting access to mental health notes could deny those individuals the potential benefits that OpenNotes may provide. To date, no published studies have systematically examined the potential benefits or harms of mental health OpenNotes or obtained information on mental health clinician attitudes toward mental health OpenNotes. The main objective of this study is to describe VA mental health clinician experiences with and attitudes toward OpenNotes use. A secondary objective is to examine relationships among clinician characteristics and clinician attitudes toward OpenNotes. 2. Material and methods This study was reviewed and approved by the Institutional Review Board of the VA Medical Center (VAMC) where the study was conducted. 2.1. Setting and subjects The study was conducted at a single VAMC. The VAMC is closely affiliated with a university, provides comprehensive care to approximately 85,000 veterans each year and serves as a tertiary referral site for other VA facilities in the region. Ambulatory care is provided at a main campus and 10 clinics located in metropolitan and rural locations throughout the region. Over 250 mental health clinicians (physicians, psychologists, social workers, nurse practitioners) and nurses (registered
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nurses and licensed practical nurses [LPNs]) provide mental health care to approximately 16,000 unique patients each year across a variety of services spanning inpatient care to homelessness programs. The VAMC served as one of nine VA facilities that participated in VA's MyHealtheVet pilot between 2000 and 2010; this pilot preceded VA's national rollout of OpenNotes in 2013 [5]. 2.2. Data sources Data were obtained from a 35-item online survey administered in late 2014 to psychiatrists, nurse practitioners, psychologists, licensed independent social workers and nurses who provided mental health care (together referred to here as mental health clinicians) at the VAMC. Survey data were collected and managed using Research Electronic Data Capture (REDCap), an electronic data capture tool hosted within the Veterans Affairs Informatics and Computer Infrastructure. REDCap is a secure, Web-based application designed to support data capture for research studies, providing an intuitive interface for validated data entry, audit trails for tracking data manipulation and export and automated export procedures for data downloads to statistical packages [10]. REDCap allows for de-identified data capture by tracking individual participant response via an internal subject ID. An initial introductory email was sent to all potential survey participants, followed 2 days later by an official invitation email with an individualized link to the survey. Follow-up reminders were emailed to nonresponders 1 and 2 weeks following survey initiation. At 3 weeks, an invitation to complete a paper survey (in lieu of online) was mailed to nonresponders. This group also received two final email invitations at Weeks 3 and 4. 2.3. Survey content Most survey items were adapted with permission for a mental health clinician population from a survey used by Delbanco et al. in a prior study on OpenNotes conducted in three large non-VA care settings [1]. These items had been informed by initial semistructured interviews with clinicians and pretesting conducted prior to the study's survey [1]. Our survey questions were designed to gather clinician perceptions and opinions on use of OpenNotes in general as well as in mental health care. The survey also included four clinician demographic questions. 2.4. Data analysis We present descriptive information for each survey item. Because we also sought to examine relationships between clinician characteristics and key survey responses based on content and scope, we a priori identified seven key items reflecting overall impressions of mental health OpenNotes and impacts on practice and documentation. Due to the small number of nurse practitioner participants, their responses were grouped with psychiatrists for these analyses. Chi-square tests were used to compare responses across clinician demographic categories. We collapsed several variables based on distributions to facilitate these analyses: years since clinician completed training and direct patient care hours per week. All analyses were conducted with International Business Machines (IBM) SPSS Statistics 22.0 (Chicago, IL, USA). 3. Results Two hundred eight of 263 (79%) potentially eligible participants completed the survey. Table 1 shows characteristics of survey respondents. The proportions of psychiatrists, psychologists and social workers responding were similar to the overall group eligible for participation. Table 2 shows the percentage of respondents who endorsed agree or strongly agree to items asking about their opinions and anticipated impacts of OpenNotes, and Table 3 focuses on clinician documentation practices and prior experiences with OpenNotes. The Fig. 1 shows distributions of responses for selected items. With regard to the use of
Table 1 Demographics of clinician/nurse population eligible and respondents. Clinician type
Survey respondents
Psychiatrist 14.7% Psychologist 18.8% Social worker 41.7% Nurse practitioner 4.6% Nurse 18.8% Gender Male 31.3% Female 56.3% Other 1.0% Decline to answer 11.5% Hours per week direct patient care Up to 20 h 42.0% 21–55 h 57.7% Years of practice since last formal training ≤10 years 54.6% N10 years 45.4%
Proportion of discipline in mental health service 14% 19% 39% 5% 23%
OpenNotes in general, most respondents agreed or somewhat agreed that making medical record notes available to patients is a good idea. Most believed that patients will better remember the plan of care, that OpenNotes will be a useful tool to facilitate communication and that OpenNotes will improve satisfaction with care. With respect to OpenNotes use in mental health care, about half agreed that making mental health notes available to patients is a good idea, two thirds believed patients will better remember their care plans and three quarters believed that patients will be better prepared for visits. In an openended question asking for additional comments about the impacts of OpenNotes, respondents said that OpenNotes could result in better documentation (n= 5), could improve patient participation in care Table 2 Views on OpenNotes and anticipated impacts of mental health OpenNotes: proportion of respondents who somewhat agree to agreea. Survey item
n
Opinions about OpenNotes in general: 1. In general, making medical record notes available to patients is 174 a good idea. 2. OpenNotes will increase medical care efficiency. 122 3. OpenNotes will improve patient satisfaction with healthcare. 145 4. OpenNotes will increase medical care quality. 126 5. OpenNotes will adversely impact patient safety. 71 6. OpenNotes will be useful vehicles for patient communication 165 and education. Among my patients who read their mental health progress notes: 7. A majority of patients will have a better understanding of their 127 health and medical conditions. 8. A majority of patients will worry more. 156 9. A majority of patients will find mental health notes to be more 135 confusing than helpful. 10. A majority of patients will better remember the plan for their care. 136 11. A majority of patients will disagree or find errors with what I or 169 other clinicians write in their notes. 12. A majority of patients will request changes to the content of visit notes. 155 13. A majority of patients will be more likely to adhere to treatment 82 recommendations. 14. A majority of patients will be better prepared for visits. 99 15. A majority of patients will take better care of themselves in general. 76 How you feel mental health OpenNotes may affect your practice over time: 16. My visits will take significantly longer. 54 17. I will spend significantly more time addressing patient questions 92 outside of visits. 18. Making visit notes available to patients online will increase my 82 risk for lawsuits or tort claims. 19. Patients will be less inclined to continue therapy/treatment. 67 20. I don't anticipate any discernible impact on my practice. 87
% 85 60 71 62 35 81
63 77 67 67 83 76 40 49 38 27 46 41 34 43
Note: The number of total responses for each item ranged from 188 to 208. Bolded items were examined further for differential responses according to clinician demographics. a Represents the number and percent of respondents who indicated somewhat agree to agree on a 4-point scale with response options disagree, somewhat disagree, somewhat agree and agree.
S.K. Dobscha et al. / General Hospital Psychiatry 38 (2016) 89–93 Table 3 Documentation practices and experiences with mental health OpenNotes. Survey item 21. I will be/already am less detailed in my documentation. Somewhat agree/agree Somewhat disagree/disagree 22. I will/already spend significantly more time writing or editing my notes. Somewhat agree/agree Somewhat disagree/disagree 23. In addition to notes that could be viewed by your patients, do you currently, or plan to, write separate notes that patients cannot view? Yes No 24. If you have made or will make changes in the way you document, please describe the changes (mark all that apply). Write fewer details Change the tone of the note Write less about the diagnosis Use fewer medical terms Write more details Other 25. I would estimate that the following proportion of veterans in my practice have read their mental health OpenNotes online: Less than 10% 11% to 25% 25% to 50% More than 50% 26. In conversations with your patients in the past year, how often did a patient bring up something about a note that you had written? None Less than once a month 1–3 times a month 1–6 times a week Daily 27. Approximately how many of your patients have requested changes to the content of visit notes they had seen online? None 1 2 3 4–10 28. Have you or your patients experienced any specific negative consequences that you are aware of as a result of patients reading their mental health notes online? Yes No 29. Making mental health OpenNotes available to patients online is a good idea. Somewhat agree/agree Somewhat disagree/disagree 30. How would you feel personally if mental health notes were discontinued? Somewhat pleased/very pleased Would not care either way Somewhat disappointed/very disappointed
n
%
127 63 71 35 120 60 81 40
20 10 180 90
108 68 45 35 17 25
69 44 29 22 11 16
112 64 20 4
56 32 10 2
80 95 19 6 0
40 48 10 3 0
105 40 23 8 12
56 21 12 4 6
53 27 146 73
107 54 92 46
98 62 40
49 31 20
Note: The number of total responses for each item ranged from 188 to 208. Bolded items were examined further for differential responses according to clinician demographics.
(n= 3), could increase collaboration (n= 2) or were generally positive (n= 2). Approximately half of respondents believed that OpenNotes will have discernable impacts on their practices, with many reporting being less detailed and changing the tone of their notes. Most respondents felt that patients will find errors in their notes and request changes. Forty percent of respondents reported that they had not yet discussed reading notes online with a patient, and a small proportion of respondents reported having conversations with patients about their notes one or more times per month. Most did not feel that OpenNotes will result in longer visits with patients or result in more time spent addressing patient questions outside of visits. A minority reported using or considering using separate psychotherapy or process notes (which would not be available to patients online).
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Many respondents felt that patients will worry more; and a third felt that there will be impacts on safety. About half of respondents reported that they would be somewhat to very pleased if mental health OpenNotes was discontinued. Fifty-three (27%) participants reported that they or their patients had experienced specific negative consequences as a result of patients reading mental health open notes. Fifty-two of these respondents added more detailed comments about these negative consequences: These included patient disengagement from care (n=14), disagreements about noted content (n=12), disruptions in the therapeutic relationship or trust (n= 7), patients being upset or disagreeing with a diagnosis (n=6), increased clinician burden (n= 3), patient expressed suicidal or homicidal ideation (n= 3) and other (n=7). The seven items we chose to examine for differential responses according to clinician demographics are bolded in Tables 2 and 3. For these items, there were no significant differences when comparing responses across clinician characteristics. However clinicians who spend more than 20 h in direct patient care each week disagreed more often with Item 29: “Making mental health OpenNotes available to patients online is a good idea” (32% vs. 12%; n=186; χ2= 16.47, Pb.01); and reported being very pleased more often in response to Item 30: “How would you feel personally if mental health OpenNotes were discontinued?” as compared to those spending fewer than 20 h in direct patient care each week (28% vs. 13%; n=187; χ2= 10.92, P=.03). Psychiatrists and nurse practitioners (35%) were also more likely to report being very pleased if mental health OpenNotes were discontinued as compared to psychologists (27%), social workers (15%) and nurses (11%) (n= 191; χ 2=22.26, P= .04). However, we detected no significant differences in responses to Item 16: “My visits will take significantly longer” (P=.24), and Item 17: “I will spend significantly more time addressing patient questions outside of visits” (P= .21), according to hours per week spent in clinic. 4. Discussion To our knowledge, this is the first study to systematically examine mental health clinician experiences and attitudes related to the use of OpenNotes in mental health care. We found that although mental health clinicians are positive about OpenNotes in general, they are more ambivalent about their use in mental health care; recognizing some potential benefits, but also expressing concerns about potential negative impacts on patients and their practices. Although many clinicians did not report personal experiences with their patients using OpenNotes, some did report experiences with disruptions in the therapeutic relationship or trust. In addition, some clinicians reported experiences in which patients disagreed or felt upset about note content, and a small number of clinicians reported that they had observed increases in violent ideation among their patients that were associated with OpenNotes; unfortunately, we do not know specific details about these events. We also found that the clinicians who spend most of their time doing clinical work and those who prescribe are overall less favorable toward OpenNotes. It is possible that those who see more patients or those who see more patients in a fixed amount of time may be especially concerned about time demands related to OpenNotes. Interestingly, we did not see significant differences in responses to particular items related to concerns about time being spent in or out of session according to discipline or to time spent working in clinic. Another possibility here is that clinicians who see more patients have either had more negative experiences or heard of more negative experiences related to OpenNotes that influence their attitudes. This is clearly worthy of additional exploration. Worth emphasizing is that half of the respondents agreed that making mental health notes available to patients online is a good idea. As such, our results may be viewed as highlighting an opportunity to build on this perception by addressing mental health clinicians' specific concerns, which may make them feel more comfortable with OpenNotes.
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Response options:
Disagree
.
Somewhat Disagree
Somewhat Agree
Agree
Please respond to the following statements based on your opinions regarding healthcare and OpenNotes in general. 0% 20% 40% 60% 80% 100% 1)
In general, making medical record notes available to patients is a good idea.
2)
OpenNoteswill increase medical care efficiency.
3)
OpenNotes will improve patient satisfaction
47
38
5 10
20
51
19
10
14
47
26
13
with healthcare. 4)
OpenNotes will increase medical care quality.
5)
OpenNotes will adversely affect patient safety.
6)
OpenNoteswill be useful vehicles for patient
25
13 28
7
28
38
32
49
13
5
communication and education.
20
42
Please respond to the following statements based on how you think reading mental health Open Notes may affect your patients over time. Among my patients who read their mental health progress notes, a majority will: 0% 20% 40% 60% 80% 100% 7)
Have a better understanding of their health and medical conditions.
8)
Worry more.
6
9)
Find mental health notes to be more confusing than helpful.
6
10)
Better remember the plan for their care.
11)
Disagree or find errors with what I or other clinicians write in their notes.
3
12)
Request changes to the content of visit notes.
5
13)
Be more likely to adhere to treatment recommendations
14
14)
Be better prepared for visits.
15
15)
Take better care of themselves in general.
13
24
46
16
52 27
9
17 25
43
23
24
48
13
19
42
41
19
43
34
45
32
37
18
8
40
8
44
33
5
Please respond to the following statements based on how you feel Veterans reading mental health Open Notes online may affect your practice over time. 0%
20%
16)
My visits will take significantly longer.
17)
I will spend significantly more time addressing patient questions outside of visits.
18)
Making visit notes available to patients online will increase my risk for lawsuits or tort claims.
22
19)
Patients will be less inclined to continue therapy/treatment.
22
20)
I don’t anticipate any discernable impact on my practice.
40%
31 18
80%
42 36
27
60%
23 35
37
4 10
29
45 29
100%
22 31
13 12 12
Fig. 1. Mental health clinician perceptions of OpenNotes' impact on healthcare, patients and practice.
An important consideration to keep in mind is that many respondents did not yet have direct experiences with their patients reading their notes online; this is consistent with a recent study indicating that many MyHealtheVet users are not yet aware that they can access their notes [11].
Our findings are consistent with those of Walker [12] who surveyed 110 primary care physicians from three non-VA sites about their experiences with OpenNotes. In this study, most primary care physicians who were surveyed had anticipated that OpenNotes would improve physician–patient communication and patient education. However,
S.K. Dobscha et al. / General Hospital Psychiatry 38 (2016) 89–93
more than half expected that OpenNotes would result in greater worry among patients, and 36% to 50% anticipated more patient questions between visits. In the follow-up study that surveyed the same physicians after their patients had had access to OpenNotes [1], few physicians reported potentially negative impacts on their practices including longer visits, spending more time addressing patients' questions outside of visits, changing documentation content or taking more time to write notes. Unfortunately, few prior studies exist that describe clinicians' views of patients viewing their mental health records. In a study of nonelectronic medical records conducted in 1979 on an inpatient psychiatry unit [13], 90% of staff were favorably disposed to open medical records after their patients used them, and 79% wanted to continue to give patients access to notes after the research project ended. Over two thirds felt that the approach was helpful to patients. On the other hand, one quarter of the staff reported that they were more likely to omit certain types of information from their notes, and one quarter believed that at least one patient had been harmed (defined broadly) by the approach. There are a number of limitations to our project. First, this crosssectional survey was administered to mental health clinicians at a single VAMC; we do not know to what extent the results may be generalizable to other VA medical centers or to non-VA care systems or to what extent clinician attitudes may change over time. In addition, although our response rate was high (79%), we do not know the extent to which nonrespondents might be dissimilar from respondents.
5. Conclusions In this study, we found that while most mental health clinicians believe that OpenNotes is a good idea in general, fewer believe that making mental health notes available online is a good idea. Clinicians reported having only limited direct experiences with their patients around OpenNotes thus far, but based on these direct expressions and other impressions, they identified a number of potential benefits as well as potential negative consequences for patients and practice. Our results call for several next steps. First, it would be helpful to monitor mental health clinician attitudes longitudinally, as VA's OpenNotes initiative is relatively new, and we can expect that clinicians will gain more direct experience with OpenNotes over time. Second, it would be helpful to improve our understanding of outcomes related to the use of OpenNotes in mental health — such outcomes might include patient perceptions of care; measures of patient–clinician communication; measures of patient activation and engagement and mental health symptoms; or indicators of dissatisfaction including requests to change notes or complaints to patient advocates. Third, because many mental health clinicians have some level of concern about OpenNotes, it will be important to continue to develop and provide education and other
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supports to assist them in optimizing potential benefits associated with OpenNotes while minimizing unintended consequences. Acknowledgments This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration and Health Services Research and Development Service Project IIR 13-347. The funders did not give input on study design; the collection, analysis or interpretation of data; the writing of the article; or the decision to submit it for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or United States government. We gratefully acknowledge Dr. Delbanco and Dr. Walker for permission to adapt survey items from their previous studies of OpenNotes. We also thank Benjamin Laman-Maharg for assistance with data collection. References [1] Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting patients to read their doctors' notes: a quasi-experimental study and a look ahead. Ann Intern Med 2012;157:461–70. [2] Winkelman WJ, Leonard KJ, Rossos PG. Patient-perceived usefulness of online electronic medical records: employing grounded theory in the development of information and communication technologies for use by patients living with chronic illness. J Am Med Inform Assoc 2005;12:306–14. [3] Nazi KM. The personal health record paradox: health care professionals’ perspectives and the information ecology of personal health record systems in organizational and clinical settings. J Med Internet Res 2013;15:e70. http://dx.doi.org/10.2196/jmir.2443. [4] Nazi KM, Hogan TP, McInnes DK, Woods SS, Graham G. Evaluating patient access to electronic health records: results from a survey of veterans. Med Care 2013;51:S52–6. [5] Woods SS, Schwartz E, Tuepker A, Press NA, Nazi KM, Nichol WP. Patient experiences with full electronic access to health records and clinical notes through the My HealtheVet personal health record pilot: a qualitative study. J Med Internet Res 2013;15:E65. http:// dx.doi.org/10.2196/jmir.2356 [Published online 2013 Mar 27]. [6] Hassol A, Walker JM, Kidder D, Rokita K, Young D, Pierdon S, et al. Patient experiences and attitudes about access to a patient electronic health care record and linked web messaging. J Am Med Inform Assoc 2004;11:505–13. [7] Huba N, Zhang Y. Designing patient-centered personal health records (PHRs): health care professionals' perspective on patient-generated data. J Med Syst 2012;36: 3893–905. [8] Gill MW, Scott DL. Can patients benefit from reading copies of their doctors' letters about them? Br Med J (Clin Res Ed) 1986;293:1278–9. [9] Ross SE, Lin CT. The effects of promoting patient access to medical records: a review. J Am Med Inform Assoc 2003;10:129–38. [10] Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. [11] Nazi KM, Turvey CL, Klein DM, Hogan TP, Woods SS. VA OpenNotes: exploring the experiences of early patient adopters with access to clinical notes. J Am Med Inform Assoc 2015;22:380–9. [12] Walker J, Leveille SG, Ngo L, Vodicka E, Darer JD, Dhanireddy S, et al. Inviting patients to read their doctors' notes: patients and doctors look ahead: patient and physician surveys. Ann Intern Med 2011;155:811–9. [13] Stein EJ, Furedy RL, Simonton MJ, Neuffer CH. Patient access to medical records on a psychiatric inpatient unit. Am J Psychiatry 1979;136:327–9.