Optimizing Benefits and Reducing Negative Effects of Mental Health Open Notes

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Anticipated Impacts on Veterans' Healthcare: This year, Veterans began to gain direct access to VA medical record progress notes through MyHealtheVet, VA's online interface. This national rollout of VA OpenNotes supports the first of VA's Strategic Goals for 2013-2018: to provide Veterans personalized, proactive, patient-driven healthcare. The proposed project will provide important and timely information about impacts of open notes on Veterans, clinicians, and care; the training modules developed during the project are designed to optimize Veteran-clinician interactions and to minimize unintended negative consequences. Project Background: Little is known about the benefits and harms of open notes. Concerns have been raised that open notes may cause patients to experience anxiety, offense or confusion. Clinicians have expressed concerns that open notes may lead to conflicts with patients or result in lengthier appointments. An area of special controversy pertains to mental health; mental health notes typically contain sensitive information, and it has been suggested that open notes use by patients receiving mental health treatment may have unique negative consequences including risk of harm to self or others. On the other hand, open notes use has the potential to help patients feel more informed about their health, and more engaged in care. Project Objectives: Main goals are to 1) examine benefits and unintended negative consequences of open note use as perceived by Veterans receiving VA mental health care and by VA mental health clinicians, and 2) develop and evaluate brief prototype web-based training modules designed to help Veterans and clinicians use open notes in ways that optimize Veteran-clinician collaboration and minimize unintended consequences. Project Methods: This mixed-methods project will be conducted over 42 months at the Portland VA Medical Center (VAMC). There are several components of Phase 1: 1) We will conduct individual qualitative interviews of approximately 30 Veterans treated by mental health clinicians and who have used MyHealtheVet in the prior year, and conduct focus groups and individual interviews with 20 - 30 Portland VAMC mental health clinicians. Interviews and focus groups will explore stakeholder perspectives, experiences, and preferences with regard to open notes. We will ask stakeholders to identify preferences for education about open notes, and helpful key messages to communicate to others; 2) Two Veterans and two clinicians who participate in qualitative interviews will be invited to consult to the research team during the qualitative analysis, training module development, and survey refinement phases; 3) Prototype web-training modules will be developed using the ADDIE model (Analysis, Design, Development, Implementation, and Evaluation); 4) We will administer brief surveys on the use of MyHealtheVet and open notes to up to 3,000 Veterans to identify a cohort of 360 Veterans receiving mental health care currently using or willing to use open notes; and 5) Using our qualitative findings and cognitive interviewing, we will adapt surveys from the Robert Wood Johnson Foundation (non-VA) OpenNotes project, and add validated self-report measures of patient-clinician communication, satisfaction, self-efficacy, and patient activation. In Phase 2, our Veteran cohort (n=360) and all Portland VAMC mental health clinicians (n=184) will complete main study surveys at baseline, 4 and 8 months. Veteran and clinician training interventions will be delivered in two waves, to half of the Veterans and clinicians in month 1 and to the other half in month 5. Evaluation of the training programs will be guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) Model. After both training waves, focus groups will be conducted with a sample of training participants to capture qualitative feedback about the training programs. In the quantitative evaluation of effectiveness, switching replication time series analyses will be used to compare Veteran and clinician survey responses between training and control groups during each phase.