Open Notes: Big Benefits, Few Harms in Psychiatry, Experts Say

Megan Brooks

October 29, 2021

There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.

As of April 5, 2021, new federal rules in the US mandate that all patients are offered online access to their electronic health record (EHR). 

"Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial," Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, Massachusetts, told Medscape Medical News.

"However, the results of our poll suggest clinicians' anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks," Blease said in a news release.

The study was published online October 13 in PLOS ONE.

Empowering Patients

Investigators used an online Delphi poll, an established methodology used to investigate emerging healthcare policy — including in psychiatry — to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.

The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.

There was consensus among the panel that offering online access to mental health notes could enhance patients' understanding about their diagnosis, care plan, and rationale for treatments.

There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients' sense of control over their healthcare.

The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.

Confirmatory Findings

The poll results support an earlier study by Blease and colleagues evaluating the experiences of patients in accessing their online clinical notes. 

Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, "access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed," said Blease.

However, the expert panel in the Delphi poll predicted that with "open notes" some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients' personalities, or symptoms of paranoia in patients.

"If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. We also need more research into the experiences of patients hospitalized for their care," she added.

"In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes," senior author John Torous, MD, with Beth Israel Deaconess Harvard Medical School, told Medscape Medical News.

"One thing is clear," Blease said. "Patient access to their online medical records is now mainstream and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes."

Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life and Welfare (FORTE) grant ('Beyond Implementation of eHealth'). The authors have disclosed no relevant financial relationships.

PLOS ONE. Published online October 13, 2021. Full text

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