Easy Access, Difficult Consequences? Providing Psychiatric Patients With Access to Their Health Records Electronically

Should psychiatric patients have access to their clinical notes (often referred to as OpenNotes)?For decades, mental health providers have debated this.Some have argued that open access to notes will undermine the therapeutic rapport, and possibly undermine care itself (1).Others have suggested that involving patients in their care decisions must include access to their records; in 2014, an editorial called on providers to "show patients their mental health records" (2).Following this publication, several psychiatrists opened up their clinical notes to patients electronically through patient portals and have been providing access ever since (3).Despite initial concerns from providers about what opening up their notes might to do therapy and care, these concerns have generally not been realized (4, 5).We believe that more effort needs to be made to support providers in feeling more comfortable opening up their notes.Although patient portals are increasingly found in other areas of medicine, they are not available to the same extent in psychiatry.Progress has been made both in terms of: 1) the number of organizations that have opened up their psychiatric notes (6); and, 2) our understanding of the impact of opening up notes to both patients and providers (7, 8).Yet, in our opinion, the uptake of "opening up" mental health clinical notes remains slow.In large part, we believe that this is due to the ongoing discomfort and concerns that providers have had (9).A recent study has shown that working in psychiatry is a predictor of discomfort in providing clinical notes to patients, with psychiatrists and those working in acute settings being particularly concerned (9).This does not come as a surprise as we are aware of the sensitive topics discussed during clinical encounters, and the stigma often associated with mental illness.In our experience talking to providers about this topic, we have received mixed feedback from those that have not yet opened up their notes.There are providers who see the merit in opening up clinical notes to support patient empowerment, and providers who are opposed to the idea (often adamantly) due to a number of clinical concerns.These concerns include possible documentation changes that influence the clinical utility of the notes (note "sanitization"); patients reading their notes in unsupported environments and becoming upset; providers answering more questions after hours; patients not understanding the content of their notes; clinical interactions taking more time as questions related to note content are discussed; concerns about providers being subjected to violence; and, the list goes on (5, 8-10).Since there have now been implementations of psychiatric patient portals with OpenNotes in numerous organizations, the question is now: what have the experiences been of providers?Generally speaking the literature has shown that the concerns of providers who are less