Optimizing Benefits and Reducing Negative Effects of Mental Health Open Notes

对退伍军人医疗保健的预期影响：今年，退伍军人开始直接进入VA 通过MyHealtheVet，VA的在线界面的医疗记录进展说明。弗吉尼亚州在全国范围内的推广 OpenNotes支持VA 2013-2018年的第一个战略目标：为退伍军人提供个性化， 积极主动、以患者为导向的医疗保健。拟议项目将提供重要和及时的信息， 开放式笔记对退伍军人，临床医生和护理的影响;项目期间开发的培训模块是 旨在优化退伍军人与临床医生的互动，并最大限度地减少意外的负面后果。 项目背景：关于开放式笔记的好处和危害知之甚少。关切 有人提出，开放的笔记可能会导致患者感到焦虑，冒犯或困惑。临床医生 表示担心开放式笔记可能会导致与患者的冲突或导致更长的预约。一个 特别有争议的领域涉及精神健康;精神健康笔记通常包含敏感信息， 有人认为，接受精神健康治疗的患者使用的开放式笔记可能具有独特的 负面后果，包括对自己或他人造成伤害的风险。另一方面，开放式笔记的使用 帮助患者更了解自己的健康状况，并更多地参与护理的潜力。 项目目标：主要目标是1）检查开放的好处和意想不到的负面后果 记录接受VA心理健康护理的退伍军人和VA心理健康临床医生所感知的使用情况，以及2） 开发和评估旨在帮助退伍军人和临床医生使用的简短原型基于网络的培训模块 以优化退伍军人-临床医生协作并最大限度地减少意外后果的方式打开笔记。 项目方法：该混合方法项目将在波特兰弗吉尼亚州进行42个月 医疗中心（VAMC）。第1阶段有几个组成部分：1）我们将进行个人定性研究， 采访了大约30名接受精神健康临床医生治疗并使用MyHealthVet的退伍军人 在前一年，并进行焦点小组和个人访谈20 - 30波特兰VAMC心理健康 临床医生访谈和焦点小组将探讨利益相关者的观点、经验和偏好 关于开放式笔记我们将要求利益相关者确定对开放式笔记教育的偏好， 和有用的关键信息，以传达给他人; 2）两名退伍军人和两名临床医生谁参加 在进行定性分析、培训时，将邀请定性访谈向研究团队提供咨询 3）将开发原型网络培训模块 使用ADDIE模型（分析、设计、开发、实施和评估）; 4）我们将 管理关于MyHealthVet使用情况的简短调查，并向多达3，000名退伍军人公开说明，以确定 队列的360名退伍军人接受心理健康护理目前使用或愿意使用开放式笔记;和5）使用 我们的定性研究结果和认知访谈，我们将改编调查从罗伯特伍德约翰逊 基础（非VA）OpenNotes项目，并添加经验证的患者-临床医生自我报告指标 沟通，满意度，自我效能和患者激活。 在第2阶段，我们的退伍军人队列（n=360）和所有波特兰VAMC精神卫生临床医生（n=184）将 在基线、4个月和8个月时完成主要研究调查。退伍军人和临床医生培训干预措施将是 分两波交付，在第1个月向一半的退伍军人和临床医生提供，在第5个月向另一半提供。 培训计划的评估将遵循RE-AIM（覆盖范围、有效性、采用率， 执行和维护）模型。在两轮培训后，将进行焦点小组讨论， 培训参与者的样本，以获取有关培训计划的定性反馈。定量 有效性评价，切换复制时间序列分析将用于比较退伍军人和 在每个阶段，临床医生调查训练组和对照组之间的反应。

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.