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Kharko A, Buergler S, Bärkås A, Hägglund M, Gaab J, Fagerlund AJ, Locher C, Blease C. Open notes in psychotherapy: An exploratory mixed methods survey of psychotherapy students in Switzerland. Digit Health 2024; 10:20552076241242772. [PMID: 38559581 PMCID: PMC10981219 DOI: 10.1177/20552076241242772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
Background In a growing number of countries, patients are offered access to their full online clinical records, including the narrative reports written by clinicians (the latter, referred to as "open notes"). Even in countries with mature patient online record access, access to psychotherapy notes is not mandatory. To date, no research has explored the views of psychotherapy trainees about open notes. Objective This study aimed to explore the opinions of psychotherapy trainees in Switzerland about patients' access to psychotherapists' free-text summaries. Methods We administered a web-based mixed methods survey to 201 psychotherapy trainees to explore their familiarity with and opinions about the impact on patients and psychotherapy practice of offering patients online access to their psychotherapy notes. Descriptive statistics were used to analyze the 42-item survey, and qualitative descriptive analysis was employed to examine written responses to four open-ended questions. Results Seventy-two (35.8%) trainees completed the survey. Quantitative results revealed mixed views about open notes. 75% agreed that, in general open notes were a good idea, and 94.1% agreed that education about open notes should be part of psychotherapy training. When considering impact on patients and psychotherapy, four themes emerged: (a) negative impact on therapy; (b) positive impact on therapy; (c) impact on patients; and (d) documentation. Students identified concerns related to increase in workload, harm to the psychotherapeutic relationship, and compromised quality of records. They also identified many potential benefits including better patient communication and informed consent processes. In describing impact on different therapy types, students believed that open notes might have differential impact depending on the psychotherapy approaches. Conclusions Sharing psychotherapy notes is not routine but is likely to expand. This mixed methods study provides timely insights into the views of psychotherapy trainees regarding the impact of open notes on patient care and psychotherapy practice.
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Affiliation(s)
- Anna Kharko
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Sarah Buergler
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Annika Bärkås
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | | | - Cosima Locher
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, Basel, Switzerland
| | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Uppsala, Sweden
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Schwarz J, Neumann K, Meier-Diedrich E, Mühlensiepen F, Hochwarter S, Blease C. Psychotherapists' views on open notes: An online survey from Germany. Digit Health 2024; 10:20552076241271813. [PMID: 39291155 PMCID: PMC11406606 DOI: 10.1177/20552076241271813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/04/2024] [Indexed: 09/19/2024] Open
Abstract
Background In an increasing number of countries, patients are given online record access (ORA) to their clinical notes ("open notes"). In many places, psychotherapy notes are exempt, even if patients explicitly wish to read them. Previous research suggests that psychotherapists (PTs) have reservations that are not yet fully understood. Objective To investigate the attitudes and perceived effects of open notes on psychotherapeutic care, patients, and individual psychotherapeutic practice in Germany. Methods Psychological and medical therapists were invited to participate in a national online survey. Sociodemographic characteristics such as gender, age, professional group, and psychotherapeutic school were gathered. Descriptive statistics were used to analyze the 51-item survey. Results 129 PTs completed the survey. Only a small proportion of respondents (30 out of 129, 23.3%) suspected that open notes would improve the efficiency of psychotherapeutic care. On the one hand, participants assumed that patients gain more control over their treatment (59 out of 129, 45.7%) and are better able to remember therapy goals (55 out of 129, 42.6%), although this was considered unlikely to lead to greater engagement in the therapy process (94 out of 129, 72.9%). On the other hand, PTs expected patients to misunderstand their notes, feel offended (98 out of 129, 76.0%), and approach them with questions (107 out of 129, 82.9%) or requests for changes (94 out of 129, 72.9%). The respondents also anticipated being less honest when writing (95 out of 129, 73.6%) and reported they needed more time for documentation (99 out of 129, 76.7%). A meaningful use of open notes for working with relatives was envisaged (101 out of 129, 78.3%). Conclusion PTs in Germany tend to have a negative attitude towards patients' ORA on open notes. Further research on clinical efficacy and feasibility is necessary to demonstrate whether open notes add value in the context of psychotherapy.
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Affiliation(s)
- Julian Schwarz
- Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
- Faculty of Health Sciences Brandenburg, Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Katharina Neumann
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
- Department for Addictive Disorders, Salus Hospital Lindow, Lindow, Germany
| | - Eva Meier-Diedrich
- Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Felix Mühlensiepen
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
- Faculty of Health Sciences Brandenburg, Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Stefan Hochwarter
- HEALTH - Institute for Biomedical Research and Technologies, Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Division of General Medicine Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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Bärkås A, Kharko A, Blease C, Cajander Å, Johansen Fagerlund A, Huvila I, Johansen MA, Kane B, Kujala S, Moll J, Rexhepi H, Scandurra I, Wang B, Hägglund M. Errors, Omissions, and Offenses in the Health Record of Mental Health Care Patients: Results from a Nationwide Survey in Sweden. J Med Internet Res 2023; 25:e47841. [PMID: 37921861 PMCID: PMC10656659 DOI: 10.2196/47841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 09/06/2023] [Accepted: 09/28/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Previous research reports that patients with mental health conditions experience benefits, for example, increased empowerment and validation, from reading their patient-accessible electronic health records (PAEHRs). In mental health care (MHC), PAEHRs remain controversial, as health care professionals are concerned that patients may feel worried or offended by the content of the notes. Moreover, existing research has focused on specific mental health diagnoses, excluding the larger PAEHR userbase with experience in MHC. OBJECTIVE The objective of this study is to establish if and how the experiences of patients with and those without MHC differ in using their PAEHRs by (1) comparing patient characteristics and differences in using the national patient portal between the 2 groups and (2) establishing group differences in the prevalence of negative experiences, for example, rates of errors, omissions, and offenses between the 2 groups. METHODS Our analysis was performed on data from an online patient survey distributed through the Swedish national patient portal as part of our international research project, NORDeHEALTH. The respondents were patient users of the national patient portal 1177, aged 15 years or older, and categorized either as those with MHC experience or with any other health care experience (nonmental health care [non-MHC]). Patient characteristics such as gender, age, education, employment, and health status were gathered. Portal use characteristics included frequency of access, encouragement to read the record, and instances of positive and negative experiences. Negative experiences were further explored through rates of error, omission, and offense. The data were summarized through descriptive statistics. Group differences were analyzed through Pearson chi-square. RESULTS Of the total sample (N=12,334), MHC respondents (n=3131) experienced errors (1586/3131, 50.65%, and non-MHC 3311/9203, 35.98%), omissions (1089/3131, 34.78%, and non-MHC 2427/9203, 26.37%) and offenses (1183/3131, 37.78%, and non-MHC 1616/9203, 17.56%) in the electronic health record at a higher rate than non-MHC respondents (n=9203). Respondents reported that the identified error (MHC 795/3131, 50.13%, and non-MHC 1366/9203, 41.26%) and omission (MHC 622/3131, 57.12%, and non-MHC 1329/9203, 54.76%) were "very important," but most did nothing to correct them (MHC 792/3131, 41.29%, and non-MHC 1838/9203, 42.17%). Most of the respondents identified as women in both groups. CONCLUSIONS About 1 in 2 MHC patients identified an error in the record, and about 1 in 3 identified an omission, both at a much higher rate than in the non-MHC group. Patients with MHC also felt offended by the content of the notes more commonly (1 in 3 vs 1 in 6). These findings validate some of the worries expressed by health care professionals about providing patients with MHC with PAEHRs and highlight challenges with the documentation quality in the records.
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Affiliation(s)
- Annika Bärkås
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- MedTech Science & Innovation Centre, Uppsala University Hospital, Uppsala, Sweden
| | - Anna Kharko
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- MedTech Science & Innovation Centre, Uppsala University Hospital, Uppsala, Sweden
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Charlotte Blease
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- MedTech Science & Innovation Centre, Uppsala University Hospital, Uppsala, Sweden
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Åsa Cajander
- Department of Information Technology, Uppsala University, Uppsala, Sweden
| | | | - Isto Huvila
- Department of ALM, Uppsala University, Uppsala, Sweden
| | - Monika Alise Johansen
- Norwegian Centre for E-Health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Telemedicine and E-health Research Group, Arctic University of Norway, Tromsø, Norway
| | - Bridget Kane
- Business School, Karlstad University, Karlstad, Sweden
| | - Sari Kujala
- Department of Computer Science, Aalto University, Espoo, Finland
| | - Jonas Moll
- Centre for Empirical Research on Information Systems, School of Business, Örebro University, Örebro, Sweden
| | - Hanife Rexhepi
- School of Informatics, University of Skövde, Skövde, Sweden
| | - Isabella Scandurra
- Centre for Empirical Research on Information Systems, School of Business, Örebro University, Örebro, Sweden
| | - Bo Wang
- Norwegian Centre for E-Health Research, University Hospital of North Norway, Tromsø, Norway
| | - Maria Hägglund
- Participatory eHealth and Health Data Research Group, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- MedTech Science & Innovation Centre, Uppsala University Hospital, Uppsala, Sweden
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Kassam I, Shin HD, Durocher K, Lo B, Shen N, Mehta R, Sockalingam S, Wiljer D, Gratzer D, Sequeira L, Strudwick G. "I think it's something that we should lean in to": The use of OpenNotes in Canadian psychiatric care contexts by clinicians. Digit Health 2022; 8:20552076221144106. [PMID: 36532111 PMCID: PMC9751166 DOI: 10.1177/20552076221144106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 11/18/2022] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND OpenNotes is the concept of patients having access to their health records and clinical notes in a digital form. In psychiatric settings, clinicians often feel uncomfortable with this concept, and require support during implementation. OBJECTIVE This study utilizes an implementation science lens to explore clinicians' perceptions about using OpenNotes in Canadian psychiatric care contexts. The findings are intended to inform the co-design of implementation strategies to support the implementation of OpenNotes in Canadian contexts. METHOD This qualitative descriptive study employed semi-structured interviews which were completed among health professionals of varying disciplines working in direct care psychiatric roles. Data analysis consisted of a qualitative directed content analysis using themes outlined from an international Delphi study of mental health clinicians and experts. Ethical approval was obtained from the Centre for Addiction and Mental Health and the University of Toronto. RESULTS In total, 23 clinicians from psychiatric settings participated in the interviews. Many of the themes outlined within the Delphi study were voiced. Benefits included enhancements to patient recall, and empowerment, improvements to care quality, strengthened relational effects and effects on professional autonomy and efficiencies. Despite the anticipated benefits of OpenNotes, identified challenges pertained to clarity surrounding exemption policies, training on patient facing notes, managing disagreements, and educating patients on reading clinical notes. CONCLUSION Many benefits and challenges were identified for adopting OpenNotes in Canadian psychiatric settings. Future work should focus on applying implementation frameworks to develop interventions that address the identified challenges.
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Affiliation(s)
- Iman Kassam
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Hwayeon Danielle Shin
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Keri Durocher
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Brian Lo
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- UHN Digital, University Health Network, Toronto, Ontario, Canada
| | - Nelson Shen
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rohan Mehta
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sanjeev Sockalingam
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Wiljer
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- UHN Digital, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Gratzer
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lydia Sequeira
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gillian Strudwick
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Schwarz J, Bärkås A, Blease C, Collins L, Hägglund M, Markham S, Hochwarter S. Sharing Clinical Notes and Electronic Health Records With People Affected by Mental Health Conditions: Scoping Review. JMIR Ment Health 2021; 8:e34170. [PMID: 34904956 PMCID: PMC8715358 DOI: 10.2196/34170] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Electronic health records (EHRs) are increasingly implemented internationally, whereas digital sharing of EHRs with service users (SUs) is a relatively new practice. Studies of patient-accessible EHRs (PAEHRs)-often referred to as open notes-have revealed promising results within general medicine settings. However, studies carried out in mental health care (MHC) settings highlight several ethical and practical challenges that require further exploration. OBJECTIVE This scoping review aims to map available evidence on PAEHRs in MHC. We seek to relate findings with research from other health contexts, to compare different stakeholders' perspectives, expectations, actual experiences with PAEHRs, and identify potential research gaps. METHODS A systematic scoping review was performed using 6 electronic databases. Studies that focused on the digital sharing of clinical notes or EHRs with people affected by mental health conditions up to September 2021 were included. The Mixed Methods Appraisal Tool was used to assess the quality of the studies. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Extension for Scoping Reviews guided narrative synthesis and reporting of findings. RESULTS Of the 1034 papers screened, 31 were included in this review. The studies used mostly qualitative methods or surveys and were predominantly published after 2018 in the United States. PAEHRs were examined in outpatient (n=29) and inpatient settings (n=11), and a third of all research was conducted in Veterans Affairs Mental Health. Narrative synthesis allowed the integration of findings according to the different stakeholders. First, SUs reported mainly positive experiences with PAEHRs, such as increased trust in their clinician, health literacy, and empowerment. Negative experiences were related to inaccurate notes, disrespectful language use, or uncovering of undiscussed diagnoses. Second, for health care professionals, concerns outweigh the benefits of sharing EHRs, including an increased clinical burden owing to more documentation efforts and possible harm triggered by reading the notes. Third, care partners gained a better understanding of their family members' mental problems and were able to better support them when they had access to their EHR. Finally, policy stakeholders and experts addressed ethical challenges and recommended the development of guidelines and trainings to better prepare both clinicians and SUs on how to write and read notes. CONCLUSIONS PAEHRs in MHC may strengthen user involvement, patients' autonomy, and shift medical treatment to a coproduced process. Acceptance issues among health care professionals align with the findings from general health settings. However, the corpus of evidence on digital sharing of EHRs with people affected by mental health conditions is limited. Above all, further research is needed to examine the clinical effectiveness, efficiency, and implementation of this sociotechnical intervention.
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Affiliation(s)
- Julian Schwarz
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany.,Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Annika Bärkås
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Lorna Collins
- Social Science Research Unit, University College London, London, United Kingdom
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sarah Markham
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Stefan Hochwarter
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany.,Department of Computer Science, Norwegian University of Science and Technology, Trondheim, Norway
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Patients' Access to Their Psychiatric Notes: Current Policies and Practices in Sweden. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179140. [PMID: 34501730 PMCID: PMC8431356 DOI: 10.3390/ijerph18179140] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
Patients’ access to electronic health records (EHRs) is debated worldwide, and access to psychiatry records is even more criticized. There is a nationwide service in Sweden which offers all citizens the opportunity to read their EHR, including clinical notes. This study aims to explore Swedish national and local policy regulations regarding patients’ access to their psychiatric notes and describe to what extent patients currently are offered access to them. The rationale behind the study is that current policies and current practices may differ between the 21 self-governing regions, although there is a national regulation. We gathered web-based information from policy documents and regulations from each region’s website. We also conducted key stakeholder interviews with respondents from the regions and cross-regional private care providers, using a qualitative approach. The results show that 17 of 21 regions share psychiatric notes with patients, where forensic psychiatric care was the most excluded psychiatric care setting. All private care providers reported that they mainly follow the regions’ guidelines. Our findings show that regional differences concerning sharing psychiatric notes persist, despite Swedish regulations and a national policy that stipulates equal care for everyone. The differences, however, appear to have decreased over time, and we report evidence that the regions are moving toward increased transparency for psychiatry patients.
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Blease C, Salmi L, Rexhepi H, Hägglund M, DesRoches CM. Patients, clinicians and open notes: information blocking as a case of epistemic injustice. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107275. [PMID: 33990427 PMCID: PMC9554023 DOI: 10.1136/medethics-2021-107275] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/24/2021] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians ('open notes'). However, even in countries that have implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to (oftentimes, non-intentional) epistemic injustice. Nonetheless, we conclude that the marginalisation of patients' access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety.
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Affiliation(s)
- Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Liz Salmi
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hanife Rexhepi
- School of Informatics, University of Skövde, Skovde, Västra Götaland, Sweden
| | - Maria Hägglund
- Department of Women's and Children's Studies, Uppsala Universitet, Uppsala, Sweden
| | - Catherine M DesRoches
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Blease C, Torous J, Kharko A, DesRoches CM, Harcourt K, O'Neill S, Salmi L, Wachenheim D, Hägglund M. Preparing Patients and Clinicians for Open Notes in Mental Health: Qualitative Inquiry of International Experts. JMIR Ment Health 2021; 8:e27397. [PMID: 33861202 PMCID: PMC8087962 DOI: 10.2196/27397] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND In a growing number of countries worldwide, clinicians are sharing mental health notes, including psychiatry and psychotherapy notes, with patients. OBJECTIVE The aim of this study is to solicit the views of experts on provider policies and patient and clinician training or guidance in relation to open notes in mental health care. METHODS In August 2020, we conducted a web-based survey of international experts on the practice of sharing mental health notes. Experts were identified as informaticians, clinicians, chief medical information officers, patients, and patient advocates who have extensive research knowledge about or experience of providing access to or having access to mental health notes. This study undertook a qualitative descriptive analysis of experts' written responses and opinions (comments) to open-ended questions on training clinicians, patient guidance, and suggested policy regulations. RESULTS A total of 70 of 92 (76%) experts from 6 countries responded. We identified four major themes related to opening mental health notes to patients: the need for clarity about provider policies on exemptions, providing patients with basic information about open notes, clinician training in writing mental health notes, and managing patient-clinician disagreement about mental health notes. CONCLUSIONS This study provides timely information on policy and training recommendations derived from a wide range of international experts on how to prepare clinicians and patients for open notes in mental health. The results of this study point to the need for further refinement of exemption policies in relation to sharing mental health notes, guidance for patients, and curricular changes for students and clinicians as well as improvements aimed at enhancing patient and clinician-friendly portal design.
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Affiliation(s)
- Charlotte Blease
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - John Torous
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Anna Kharko
- School of Psychology, University of Plymouth, Plymouth, United Kingdom
| | - Catherine M DesRoches
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Kendall Harcourt
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Stephen O'Neill
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Liz Salmi
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Deborah Wachenheim
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Maria Hägglund
- Department of Women's and Children's Health, University of Uppsala, Uppsala, Sweden
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9
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Blease CR, O'Neill SF, Torous J, DesRoches CM, Hagglund M. Patient Access to Mental Health Notes: Motivating Evidence-Informed Ethical Guidelines. J Nerv Ment Dis 2021; 209:265-269. [PMID: 33764954 DOI: 10.1097/nmd.0000000000001303] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In the last decade, many health organizations have embarked on a revolution in clinical communication. Using electronic devices, patients can now gain rapid access to their online clinical records. Legally, patients in many countries already have the right to obtain copies of their health records; however, the practice known as "open notes" is different. Via secure online health portals, patients are now able to access their test results, lists of medications, and the very words that clinicians write about them. Open notes are growing with most patients in the Nordic countries already offered access to their full electronic record. From April 2021, a new federal ruling in the United States mandates-with few exemptions-that providers offer patients access to their online notes (Office of the National Coordinator for Health Information Technology, Department of Health and Human Services, Available at: https://www.govinfo.gov/content/pkg/FR-2019-03-04/pdf/2019-02224.pdf#page=99). Against these policy changes, only limited attention has been paid to the ethical question about whether patients with mental health conditions should access their notes, as mentioned in the articles by Strudwick, Yeung, and Gratzer (Front Psychiatry 10:917, 2019) and Blease, O'Neill, Walker, Hägglund, and Torous (Lancet Psychiatry 7:924-925, 2020). In this article, our goal is to motivate further inquiry into opening mental health notes to patients, particularly among persons with serious mental illness and those accessing psychological treatments. Using biomedical ethical principles to frame our discussion, we identify key empirical questions that must be pursued to inform ethical practice guidelines.
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Affiliation(s)
| | | | | | | | - Maria Hagglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Smith CM, Stavig A, McCann P, Moskovich AA, Merwin RM. "Let's Talk About Your Note": Using Open Notes as an Acceptance and Commitment Therapy Based Intervention in Mental Health Care. Front Psychiatry 2021; 12:704415. [PMID: 34349686 PMCID: PMC8328223 DOI: 10.3389/fpsyt.2021.704415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Colin M Smith
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Alissa Stavig
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Peter McCann
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States.,Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ashley A Moskovich
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Rhonda M Merwin
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
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