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Some say sharing session notes with patients improves the treatment of substance use disorders

Transparency is a buzzword these days. From political activists protesting NSA activities to parents criticizing the lack of transparency behind the Common Core in schools, people are clamoring for it.

We want more transparency from the big corporations who supply our food, medications, and technology; from government, religious leaders, universities and schools, from each other. We don’t want Oz behind the curtain, pulling levers and buzzing buzzers. We want to know what’s going on “behind the scenes” so that we can communicate better with those who provide us services and hold them accountable for their work.

Transparency is also expected from our health care providers. It’s what’s behind patient listservs and organizations like PatientsLikeMe that work to connect patients with each other and make health information accessible. It’s the philosophy behind  the creation of, as well as the Health Insurance Portability and Accountability Act (HIPAA), which sets standards for individuals’ rights to understand and control how their health information is used.

It’s not uncommon for patients to register for an online portal to gain access to information about diagnoses, inoculations and prescriptions. But until just a few years ago, clients weren’t able to access their mental health provider’s notes about their sessions and treatment.

The sharing of session notes, also known as collaborative documentation, has not yet been widely adopted in behavioral health settings, but there is a growing movement in that direction.

Where it’s happening

At Beth Israel Deaconess Medical Center (BIDMC) in Boston, clinicians are making their mental health notes available to patients through an electronic system called OpenNotes. Sponsored by the Robert Wood Johnson Foundation, this initiative allows patients to have immediate access to clinical summaries of their sessions.


With OpenNotes, patients see notes on their own time. Photo: Joel G Goodman

Beginning in 2010, BIDMC and two other sites adopted the use of OpenNotes for their primary care patients.  A study of the program published in 2012 in the Annals of Internal Medicine found that these patients felt more in control of their health care, understood their conditions better, and took medication more appropriately when allowed access to their providers’ notes.

And providers at BIDMC and two other sites responded positively to the shared notes system. They were pleased to find that their workflow was largely uninterrupted by the new practice and that patients were not offended or troubled by what was written about them. Interestingly, while most of the providers didn’t change the language or tone of their written records, some reported that they modified language related to “four potentially charged topics: cancer, mental health, substance abuse, and obesity.”

However, one of the leaders of this initiative at BIDMC, psychiatrist Michael Kahn,  discussed the substantial benefits he’d seen from sharing mental health notes with patients in a recent Boston Globe article. Not only can patients correct errors in their notes, he said, but the practice of sharing also encourages the use of more careful language that describes the whole person, rather than just the symptoms.

Instead of “paranoid,” for instance, which can carry negative connotations, Kahn might write “persecutory anxiety”—a term that recognizes the suffering of paranoia without labeling the person.

Benefits for mental health patient and provider

Bill Schmelter, Lead Clinical & Collaborative Documentation Consultant at the National Council for Behavioral Health argues that collaborative documentation benefits both client and therapist. From the point of view of a clinician, Schmelter explains that current documentation practices—notes written after a session, away from the client’s eyes—separate treatment and documentation on fundamental levels.

The “clinicians’ ‘Paper Life’ is divorced from their ‘Clinical Life,’” says Schmelter.

Among the consequences of this division are notes that lack real meaning. Paperwork is fulfilled only to meet minimum audit requirements, rather than used as a valuable resource in therapy.

But if these two can be integrated, as BIDMC is now doing, the benefits are substantial:

Documentation becomes timely, and thus provides “value for risk-management, care coordination, and compliance [with best-practice standards].”

Treatment plans improve through the strength of shared narrative: clients can relate to the objectives and goals as real processes, rather than as “just a signature or check box.”

The therapeutic alliance is strengthened because of greater levels of trust.  “Many patients,” says Kahn, “silently fear that their treater ‘will think I’m crazy/whining/lazy/boring’; seeing in print that the treater does not see them that way—and in fact recognizes and documents their strengths—can be an enormous relief and might therefore enhance the therapeutic alliance.”

And clinicians can better identify and treat SUDs through the use of note-sharing.  “Patients with addictions are often so used to being lectured that they tune out real-time discussions of harmful consequences of their behavior, no matter how tactful the clinician,” Kahn notes.

However, because OpenNote allows patients to read session notes on their own time, their defenses may soften. “Offering patients time, ” Kahn continues, “for unpressured review of the clinician’s assessment in a private setting may diminish the need for defensive maneuvers (such as evasiveness, minimization, or denial) that guard against feeling exposed and stigmatized, thereby affording the patient opportunity to get closer to acknowledging an addiction.”

And when “change” language is used and recorded for both clients and clinicians to see, collaborative documentation may provide insight and motivation.

Finally, collaborative documentation can increase patient agency, responsibility, and self-efficacy—all, incidentally, important aspects of the recovery process.

Schmelter defines this process of sharing notes as “person-driven”—not just “person-centered”—in that it involves the patient actively directing the plan of care.

A patient with hypertension and her physician discuss the benefits of shared notes.  Can you imagine how these benefits might extend to behavioral health?  What might some of the differences be? 

 Collaborative documentation in Pennsylvania

In April, the Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS) issued a policy clarification stating that collaborative documentation is not a billable portion of the therapeutic episode, as an administrative rather than therapeutic activity.  The clarification raised hackles among Pennsylvania providers and advocacy groups and, after discussions with stakeholders, OMHSAS issued a follow-up policy clarification on May 23.

In it, OMHSAS recognized the importance of  therapists and clients working “collaboratively toward the development of the goals documented in the individual service plan and review and revis[ing] those goals as needed.”

“This collaboration,” according to the follow-up policy clarification, “can be part of the billable time spent with an individual receiving Peer Support and other services.”  To further delineate the difference between  goal-setting and assessment considered part of the therapeutic relationship as opposed to the kind of documentation that is administrative and non-billable, OMHSAS is convening a short-term work group to develop practice guidelines and training suggestions for the field.

Response from professionals

We spoke with experienced clinicians in the fields of social work, psychology, and addiction treatment about this practice and received a range of responses.  Many saw cause for caution, but also imagined tangible benefits from the use of collaborative documentation.

amy shanahan

peter luongo

scott mcmillin

Jim aiello

victor barbetti

billy jo

 Recommended Resources

Perspective: The Road toward Fully Transparent Medical Records (NEJM, 2014)

 Achieve Compliance with Collaborative Documentation (The National Council, 2013)