Is Trust in Mental Health Clinicians Affected Among Patients Who Access Clinical Notes Online? Interview with:

Steven K. Dobscha, M.D. Professor, Department of Psychiatry, OHSU Director, VAPORHCS Center to Improve Veteran Involvement in Care Oregon Health & Science University

Dr. Dobscha

Steven K. Dobscha, M.D.
Professor, Department of Psychiatry, OHSU
Director, VAPORHCS Center to Improve Veteran Involvement in Care
Oregon Health & Science University What is the background for this study? 

Response: Several health care systems across the United States now offer patients online access to all of their clinical notes (sometimes referred to as progress notes) through electronic health record portals; this type of access has been referred to as OpenNotes (see for more information on the national OpenNotes initiative). Veterans have been able to use OpenNotes in the Veterans Health Care (VHA) system since 2013. However, some individuals have expressed concern that online access to clinical notes related to mental health could cause some patient harms.

We are conducting a VA-funded research project with several objectives:
1) to examine benefits and unintended negative consequences of OpenNotes use as perceived by veterans receiving VHA mental health care and by VHA mental health clinicians, and
2) to develop and evaluate brief web-based courses designed to help veterans and clinicians use OpenNotes in ways that optimize Veteran-clinician collaboration and minimize unintended consequences.  What are the main findings?

Response: In a study of 28 Veterans receiving VHA mental health care who were interviewed about their experiences with OpenNotes, we found that trust is a critical aspect of the therapeutic relationship patients have with their clinicians. OpenNotes can have substantial positive or negative impacts on that trust. In particular, transparency and respect as conveyed in clinical notes is critical for maintaining or promoting trust. What should readers take away from your report?

Response: Mental health clinicians need to be aware that patients are increasingly reading their notes and as such, pay special attention to making sure that the information conveyed in notes matches what occurs during appointments; it is important to avoid surprises, that is, new information such as new diagnoses that were not discussed with the patient. Notes should also reflect the individuality of the patient and the patient experience.

For example, many electronic health record systems allow clinicians to create templates that can be carried forward from note to note. While this might enhance efficiency, if the note looks the same every time, without including new information obtained from the patient, patients may (understandably) interpret this as reflecting a lack of interest on the part of the clinician. It can also be helpful for mental health clinicians to highlight strengths and progress made by patients, in addition to discussing problems or symptoms. What recommendations do you have for future research as a result of this study?

Response: Our team is currently in the process of conducting a preliminary evaluation of the clinician and veteran web-based courses. It would be helpful to learn how these courses may influence communications between clinicians and patients and clinical outcomes. Is there anything else you would like to add?

Response: The content of the web-based courses, including approaches and suggestions, was primarily derived from the qualitative interviews of the clinicians and the veterans who participated in qualitative interviews.

Aside from this being a VA Health Services Research and Development-funded study, I have nothing to disclose. Thank you for your contribution to the community.


Risa Cromer, Lauren M. Denneson, Maura Pisciotta, Holly Williams, Susan Woods, Steven K. Dobscha. Trust in Mental Health Clinicians Among Patients Who Access Clinical Notes Online. Psychiatric Services, 2017; DOI: 10.1176/

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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