A Qualitative Analysis of How Online Access to Mental Health Notes Is Changing Clinician Perceptions of Power and the Therapeutic Relationship

Background: As part of the national OpenNotes initiative, the Veterans Health Administration (VHA) provides veterans online access to their clinical progress notes, raising concern in mental health settings. Objective: The aim of this study was to examine the perspectives and experiences of mental health clinicians with OpenNotes to better understand how OpenNotes may be affecting mental health care. Methods: We conducted individual semi-structured interviews with 28 VHA mental health clinicians and nurses. Transcripts were analyzed using a thematic analysis approach, which allows for both inductive and deductive themes to be explored using an iterative, constant comparative coding process. Results: OpenNotes is changing VHA mental health care in ways that mental health clinicians perceive as both challenging and beneficial. At the heart of these changes is a shifting power distribution within the patient-clinician relationship. Some clinicians view OpenNotes as an opportunity to better partner with patients, whereas others feel that it has the potential to undo the therapeutic relationship. Many clinicians are uncomfortable with OpenNotes, but acknowledge that this discomfort could both improve and diminish care and documentation practices. Specifically, we found that ( 1) OpenNotes is empowering patients, ( 2) OpenNotes is affecting how clinicians build and maintain the therapeutic relationship, and ( 3) mental health clinicians are adjusting their practices to protect patients and themselves from adverse consequences of OpenNotes. Conclusions: Our findings suggest that future research should monitor whether OpenNotes notes facilitates stronger patient-clinician relationships, enhancing patient-centered mental health care, or diminishes the quality of mental health care through disruptions in the therapeutic relationship and reduced documentation.