- OpenNotes and patient data access have caused a shift toward patient-centered mental health treatment that providers are acutely aware of, according to recent research published in the Journal of Medical Internet Research.
OpenNotes – the idea that patients can openly access clinician notes – has become a widespread philosophy adopted by providers across the country.
Alongside its popularity have come apprehensions about OpenNotes’ effect on the patient-provider relationship. These concerns are exacerbated in the mental health field, an Oregon-based research team said.
“Despite promising findings from studies of primary care patients, some are concerned that this increased ease of access to mental health notes may cause unnecessary worry, confusion, or distress among patients who read their mental health progress notes without guidance or permission from their clinicians,” the researchers explained.
Through qualitative interviews with 28 mental health professionals employed by the VA, the investigators observed the effects of OpenNotes on the patient-provider relationship. Ultimately, these interviews showed that OpenNotes has noticeably made an impact on patient communications, tipping toward patient-centered care – whether or not that makes the provider comfortable.
“Primarily, [providers] perceived reduced control over the flow of information pertinent to the therapeutic process; the notes they write are now accessible to patients at any time without clinician approval or other barriers,” the researchers reported. “This change necessarily shifts the patient-clinician power dynamic toward a more equitable distribution.”
Clinicians reported that OpenNotes helped them build better partnerships with patients, shifting away from the traditional paternalistic relationships that have defined healthcare for decades. Open access to health information has empowered patients, clinician respondents pointed out.
Some clinicians said OpenNotes made them feel somewhat uneasy about their care encounters, but acknowledged that this discomfort may have its place in mental healthcare.
“Although most clinicians felt some discomfort with OpenNotes, it is also important to note that some clinicians thought this discomfort might improve care by motivating clinicians to be at their best and providing an impetus to generate ‘difficult’ but important conversations between patients and clinicians,” the researchers reported.
Other clinicians said OpenNotes has changed the way they take appointment notes. Aware that patients could access any and all notes, many clinicians compensated by altering the nature of their notes.
“Many clinicians felt that OpenNotes provided benefits such as enhanced opportunity for collaboration, mutual trust, and addressing patients’ concerns. However, many were also concerned that OpenNotes could cause unintentional harm for their patients—for whom the clinicians would feel responsible,” the researchers said. “Indeed, mental health clinicians’ changes in note writing reflected a desire to write notes that would mitigate potential harm.”
However, altering one’s notes may have unintended consequences for quality of care and information, the researchers pointed out.
“While OpenNotes may help to facilitate care that is more aligned with patient-centered care ideals, mental health clinicians are also often limiting what they write in response to a desire to protect themselves and their patients, which could have unintended negative consequences such as forcing clinicians to rely on their memory more often or reducing clinician-clinician collaboration,” the research team explained.
These findings suggest a number of future research opportunities, the team concluded. Future investigations should look at how OpenNotes facilitates stronger relationships, enhances patient-centered clinical care, or diminishes mental healthcare through damaged relationships and reduced therapeutic relationships.
Mental health providers are not the only clinicians to have reservations about OpenNotes.
At Colorado-based UCHealth, providers were apprehensive about OpenNotes’ workload effects and impact on patient relationships. The health system adopted a similar, home-grown version of OpenNotes in 2001 and did not successfully implement full OpenNotes until 2014 due to provider pushback.
“We had seven doctors in this cardiology practice, four of whom said ‘I don’t know if this is a good idea,’” recalled UCHealth Chief Medical Information Officer CT Lin, MD, FACP.
“’Progress notes are for doctors. Terminology is hard to understand,” Lin continued. “Do you not think we’re working hard enough already? Do you want patients to call us with terminology questions? Will they be offended when we call them obese? Or if we say they’re smoking or they smelled like smoke? This is going to be terrible,’ they said.”
To overcome this hurdle, Lin, who spearheaded the OpenNotes campaign at UCHealth, was persistent in proving to his peers the benefits of the philosophy.
“I met in private with a number of physician leaders, whom I anticipated would object to this,” Lin said. “I did my best to hear them out, address concerns, promise additional support for their clinical area if needed, and promise that we could revisit this decision if indeed patient response was overwhelming or negative.”
Lin successfully lobbied for OpenNotes implementation by 2014 by meeting individually with program naysayers and providing ample evidence about OpenNotes success.
Although OpenNotes has reached millions of patients across the country, many healthcare professionals still feel more must be done. Patient access to clinician notes will improve patient engagement and clinical care, proponents contend.
“It’s an uphill climb, culturally,” Lin said. “Physicians have lots of fears. Today we still get physicians asking if we should hide the notes or if this is a good idea. That conversation is not completely over, even in my own organization.”