Absence of conflict of interest
Citation
Highlights
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The study’s objective was to examine the impact of participation in the VA OpenNotes for Mental Health Clinicians course on clinicians’ attitudes towards their work.
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The study used an interrupted time series design to compare clinician attitudes before and after participation in the course using survey data.
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The study suggested there was a positive relationship between participation in the course and improvement in a clinician’s belief of their ability to communicate with and educate their patients and a reduction of their fear of negative consequences resulting from using OpenNotes.
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The quality of causal evidence presented in this report is low because the authors did not observe outcomes for multiple periods before and after the intervention. This means we are not confident that the estimated effects are attributable to the VA OpenNotes for Mental Health Clinicians course; other factors are likely to have contributed.
Intervention Examined
VA OpenNotes for Mental Health Clinicians course
Features of the Intervention
To provide patients with online access to their clinical progress notes, the Veterans Health Administration (VHA) nationally implemented OpenNotes beginning in 2013 for users with online patient portal access. As of 2017, approximately half of all VHA patients had accessed their clinical notes.
The present study created a web-based program for mental health clinicians on the use of OpenNotes (VA OpenNotes for Mental Health Clinicians course). The 30-minute course aimed to familiarize clinicians with OpenNotes and help them learn about best practices. The course also covered how to write notes and how to talk to patients about their notes, with a focus on preventing unintended negative consequences.
The intervention served mental health clinicians employed at a U.S. Department of Veteran Affairs (VA) facility.
Features of the Study
The study used an interrupted time series design to compare clinician attitudes before and after participation in the VA OpenNotes for Mental Health Clinicians course.
All mental health clinicians employed at a VA medical center in Portland, Oregon were invited to participate in the course. Those who completed an initial survey were randomly assigned to participate in the course in the first or second wave. In total, 113 mental health clinicians (psychiatrists, psychologists, social workers, and nurse practitioners) employed at a VA medical center in Portland, Oregon participated in the study. The facility provides mental health services to about 16,000 veterans every year.
The study conducted pre-post comparisons of participant survey data using a statistical model. All clinicians took surveys at 3 time-points (between August 2016 and January 2017). However, only one baseline and one follow-up survey were used for each clinician, depending on when they participated in the course.
Findings
Attitudes
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The study reported a positive statistically significant relationship between the VA OpenNotes for Mental Health Clinicians course and clinicians' worry about negative consequences.
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The study found a positive statistically significant relationship between the VA OpenNotes for Mental Health Clinicians course and clinicians' belief in their ability to communicate with and educate their patients.
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The study found no statistically significant relationship between the VA OpenNotes for Mental Health Clinicians course and clinicians' belief that patients who read their notes online will trust them more, clinicians' belief that patients’ ability to read their notes online will negatively impact the treatment relationship, and clinicians' belief that patients will be less inclined to continue therapy/treatment.
Considerations for Interpreting the Findings
The authors compared the outcomes of participants measured once before and once after they participated in the VA OpenNotes for Mental Health Clinicians course. CLEAR’s guidelines require that the authors must observe outcomes for multiple periods before the intervention to rule out the possibility that participants had increasing or decreasing trends in the outcomes examined before enrollment in the program. That is, if program enrollment was higher among participants who had more favorable views of how OpenNotes impacts their work, we would anticipate a difference in view of OpenNotes, even without participation in the program. Without knowing the trends before program enrollment, we cannot rule this out. Therefore, the study is not eligible for a moderate causal evidence rating, the highest rating available for nonexperimental designs.
Baseline data was imputed for nine clinicians that participated in the second wave using their initial survey conducted in August 2016, and follow-up data was imputed for one clinician that participated in the first wave using their final survey conducted in July 2017.
In addition, because the study relied on data from a single VA Center, we cannot disentangle the effects of the intervention from the potential center-specific characteristics of the VA Center.
Causal Evidence Rating
The quality of causal evidence presented in this report is low because the authors did not observe outcomes for multiple periods before and after the intervention. This means we are not confident that the estimated effects are attributable to the VA OpenNotes for Mental Health Clinicians course; other factors are likely to have contributed.