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，退伍军人开始直接获得退伍军人管理局 通过退伍军人事务部的在线界面MyHealtheVet提供病历进度记录。退伍军人管理局在全国范围内的推广 OpenNotes支持退伍军人管理局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。拟议项目将提供有关以下方面的重要和及时信息 公开说明对退伍军人、临床医生和护理的影响；在该项目期间开发的培训模块包括 旨在优化老兵与临床医生的互动，并将意外的负面后果降至最低。 项目背景：人们对开放笔记的利与弊知之甚少。令人担忧的是 提出打开笔记可能会导致患者感到焦虑、冒犯或困惑。临床医生有 表示担心开放的笔记可能会导致与患者的冲突或导致更长的预约时间。一个 特别有争议的领域与精神健康有关；精神健康笔记通常包含敏感信息， 有研究表明，接受心理健康治疗的患者使用的开放笔记可能具有独特的 负面后果，包括伤害自己或他人的风险。另一方面，打开笔记的使用具有 潜在地帮助患者更了解自己的健康，并更多地参与护理。 项目目标：主要目标是：1)检查开放带来的好处和意外的负面后果 注意接受退伍军人精神卫生护理的退伍军人和退伍军人精神卫生临床医生所感知的使用情况，以及2) 开发和评估基于Web的简单原型培训模块，旨在帮助退伍军人和临床医生使用 以优化资深临床医生协作并将意外后果降至最低的方式打开病历。 项目方法：这个混合方法项目将在波特兰退伍军人管理局进行42个月 医疗中心(VAMC)。第一阶段有几个组成部分：1)我们将进行个别定性 约30名退伍军人接受心理健康临床医生治疗并使用MyHealtheVet的访谈 在前一年，并对20-30名波特兰VAMC心理健康进行焦点小组和个人访谈 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 关于未结票据。我们将要求利益相关者确定有关开放笔记的教育偏好， 和帮助他人交流的关键信息；2)两名退伍军人和两名临床医生参与 定性访谈将邀请研究团队在定性分析、培训期间进行咨询 模块开发和调查改进阶段；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 管理有关MyHealtheVet使用情况的简要调查，并向多达3,000名退伍军人开放笔记，以确定 360名正在接受心理健康护理的退伍军人目前正在使用或愿意使用开放笔记；以及5)使用 我们的定性发现和认知采访，我们将改编来自罗伯特·伍德·约翰逊的调查 基础(非VA)OpenNotes项目，并添加经过验证的患者-临床医生自我报告措施 沟通、满足感、自我效能感和患者激励性。 在第二阶段，我们的资深队列(n=360)和所有波特兰VAMC精神健康临床医生(n=184)将 在基线、4个月和8个月完成主要研究调查。退伍军人和临床医生培训干预将是 分两波交付，第一个月交付给一半的退伍军人和临床医生，第五个月交付给另一半。 培训计划的评估将由RE-AIM(REACH、有效性、采用、 实施和维护)模型。在两次培训之后，焦点小组将在 培训参与者样本，以获取有关培训计划的定性反馈。在数量上 有效性评估，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，临床医生在训练组和对照组之间的调查反应。

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.