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Abstract

Background

In an increasing number of countries, patients are given online record access (ORA) to their clinical notes (“open notes”). In many places, psychotherapy notes are exempt, even if patients explicitly wish to read them. Previous research suggests that psychotherapists (PTs) have reservations that are not yet fully understood.

Objective

To investigate the attitudes and perceived effects of open notes on psychotherapeutic care, patients, and individual psychotherapeutic practice in Germany.

Methods

Psychological and medical therapists were invited to participate in a national online survey. Sociodemographic characteristics such as gender, age, professional group, and psychotherapeutic school were gathered. Descriptive statistics were used to analyze the 51-item survey.

Results

129 PTs completed the survey. Only a small proportion of respondents (30 out of 129, 23.3%) suspected that open notes would improve the efficiency of psychotherapeutic care. On the one hand, participants assumed that patients gain more control over their treatment (59 out of 129, 45.7%) and are better able to remember therapy goals (55 out of 129, 42.6%), although this was considered unlikely to lead to greater engagement in the therapy process (94 out of 129, 72.9%). On the other hand, PTs expected patients to misunderstand their notes, feel offended (98 out of 129, 76.0%), and approach them with questions (107 out of 129, 82.9%) or requests for changes (94 out of 129, 72.9%). The respondents also anticipated being less honest when writing (95 out of 129, 73.6%) and reported they needed more time for documentation (99 out of 129, 76.7%). A meaningful use of open notes for working with relatives was envisaged (101 out of 129, 78.3%).

Conclusion

PTs in Germany tend to have a negative attitude towards patients’ ORA on open notes. Further research on clinical efficacy and feasibility is necessary to demonstrate whether open notes add value in the context of psychotherapy.

Keywords

Electronic health record open notes patient portal online record access psychotherapy psychiatry

Background

In a growing number of countries, patients are being granted online record access (ORA) to their clinical notes from practitioners, known as “open notes.”¹ This practice has been extensively tested and researched and is at least partially implemented in various healthcare systems worldwide, including the US, Canada, and Australia.² In Sweden, ORA including open notes has been implemented in all regions since 2018,³ and in the UK, general practitioners have been required to provide open notes and lab results via ORA since 2023.⁴ International studies show that patients report predominantly positive experiences with open notes, and parameters such as patient health literacy and treatment adherence improve.² In addition, some studies demonstrate that clinicians often hold negative expectations, which may reduce after implementation.^5,6

In the field of mental health, reservations regarding the beneficial use of open notes and fears about possible harm are particularly frequent among healthcare professionals (HCPs) and ethicists.^7–10 This cautious attitude has resulted in a generally restrictive approach to mental health clinical notes in many countries: In the USA, psychotherapy notes are completely exempted from the 21st Century Cures Act which mandates ORA.¹¹ In Sweden, a temporary block on ORA during acute phases of mental illness has been tested.³ However, study results suggest that fears and precautions may be unfounded.⁸ Opening clinical notes, especially in cases of mental health conditions (MHCs), could lead to an improvement in patient autonomy and an increase in perceived control.¹² Patients reported feeling more involved in their mental health care, experiencing more trust in the therapeutic relationship, and being better prepared for psychiatric contacts.⁷ Regarding omissions and errors in the notes, the results are inconsistent. Bärkas et al.¹³ found that patients with MHC noticed significantly more inaccuracies, felt attacked more often by the content of the notes, and did not notice any increase in shared decision-making compared to those without MHC. Whereas another study showed that patients with MHC were rarely worried or angry after reading open notes.¹⁴ Inconsistencies in shared notes were usually not reported back to the HCP and no further action was taken.¹³ Relatives had a largely positive attitude towards open notes as they helped them better understand MHCs and how to support affected family members.⁷

Studies investigating the use of open notes in psychotherapy or which at least included psychotherapists (PTs) as study participants are scarce.^7,15,16 Some non-empirical articles suggest that open notes could be useful in acceptance and commitment therapy and have the potential to improve patient autonomy.^17,18 Supporting this, a survey of patients who read their psychotherapy notes confirmed their significant interest and the importance of open notes in psychotherapy. Patients reported an improvement in perceived control over their treatment, trust in the therapist, and self-care. Only a very small proportion reported feeling judged or offended by the content of the notes.¹⁹ However, the authors of this research paper are aware of only two empirical studies that exclusively examine the views of PTs.^20,21 In both studies—in the US and Switzerland—the PT surveyed were generally positive, although some concerns were raised regarding potential adverse effects on the therapeutic alliance, patient well-being, and work processes.

To determine the meaningful use and implementation of patients’ open notes in psychotherapy, it is crucial to explore the perspective of therapists whose practice is directly affected by open notes. This understanding will help to prepare for safe and appropriate implementation and provide insight into the benefits and harms that therapists consider most relevant.

Therefore this timely study examines the following questions from the perspectives of psychological and medical PT:

What general effects are open notes expected to have on psychotherapy care in general?

What are the expected effects on patients?

What consequences do open notes have on individual psychotherapeutic treatment practice?

We aimed to investigate these questions about the use of open notes in PT in Germany. The research questions seem particularly relevant here due to the gradual development and expansion of ORA that has been in place since 2021, including access to laboratory results and medication plans from 2025. Although patients currently do not have access to open notes through ORA, there is a growing debate in Germany on the topic.^22–25

Material and methods

Study design and setting

To investigate current opinions and attitudes of PT towards open notes and to show what expectations and concerns are widespread, an online survey was used.²⁶ It was conducted according to “The Checklist for Reporting Results of Internet E-Surveys (CHERRIES)” used to fulfill basic quality criteria of online survey studies.^27,28 As noted, the survey was conducted in Germany with the aim of exploring a convenience sample of PTs who currently work in clinical practice.

Questionnaire and procedure

The study team adapted a Survey instrument originally developed to explore US primary care physicians’ views and experiences with open notes which has been used in several studies.^29,30 The authors of this study have obtained all necessary authorizations to use the questionnaire and tools (here: LimeSurvey, LimeSurvey GmbH, Germany). The questionnaire (see Supplemental Material 1) is divided into four sections: (1) sociodemographic data, (2) expectations and effects of open notes on psychotherapeutic care in general, (3) patients, and (4) own work. The questionnaire includes a total of 47 items (Multiple Choice/Single Choice), as well as four free-text response options. The qualitative data were analyzed separately from the quantitative data and are being published elsewhere.²¹ The questions were summarized using a five-point Likert scale, ranging from “I disagree,” “I somewhat disagree,” “I don’t know” to “I somewhat agree” and “I agree.” The questions were spread over 26 pages and the order was consistent for all participants. Questions on specifics regarding the profession, such as psychotherapeutic schools, could be accessed individually after selecting the professional group. It was possible to return to the previous page and leave questions unanswered. No cookies or internet protocol (IP) addresses were used to prevent duplicate participation (see “Strengths and limitations” section). The survey allowed respondents to choose the option “I prefer not to answer” for questions regarding gender and age, while the option “I don’t know” was available for questions using Likert scales.

The survey was conducted using LimeSurvey, a web-based software with a server located in Germany. Before administering the questionnaire, a pretest with PT (n = 5) was carried out to assess the content, functionality, and understandability of the items. The time taken for survey was 15 min. As survey questions were unchanged after the pretest the pretest data was not included in the analysis. Once the survey was completed, the collected data was stored in an anonymized Excel spreadsheet, making it impossible to identify the participants or revoke their participation. The data was encrypted and will be stored on servers at Brandenburg Medical School (MHB) for up to a decade. The online questionnaire was active for seven and a half months, from 15 September 2022 to 31 March 2023. Participants were informed that their answers were anonymous and voluntary and that they could withdraw their participation at any time during the completion process. Due to the anonymized data storage, it was not possible to withdraw after submitting the completed survey. Study participants were also informed that they would not receive any remuneration for the short online survey.

Study participants

The sample for our study consisted of psychological and medical PTs working in mental health care in Germany. Our survey was advertised in newsletters and on the websites of 18 psychiatric and psychotherapeutic associations and societies. This made the questionnaire theoretically accessible to around 75.261 people. Of these, 129 people completed the questionnaire, resulting in a response rate of 0.1714%.

Ethical considerations

The ethics committee of the MHB approved the implementation of the survey, which is part of a larger clinical study about patients’ ORA to open notes in Germany (PEPPPSY study; trial registration: German Clinical Trial Register; registration number: DRKS00030188, URL of registry: https://drks.de/search/en/trial/DRKS00030188). All study participants provided online informed consent to participate. Additionally, participants were informed about anonymity and data storage and had to agree to the privacy policy to take part in the survey. Participation was entirely voluntary, and no personal information was collected that could be used to identify a participant.

Data analysis and statistics

The quantitative survey responses were analyzed using descriptive statistics with SPSS software (version 25; IBM Corp.). Only completed questionnaires were analyzed. The evaluations were carried out for each question individually and without statistical corrections. The results were visualized as stacked bar charts, whereby the questions in the thematic groups of the survey were presented together. Due to the small sample size and the fact that each surveyed parameter was stored individually, we did not investigate correlations between sociodemographics and response behavior.

Results

Demographic characteristics

A total of 129 participants responded including psychological PT (n = 86) and medical PT (n = 34). The former consisted of medical specialists in the fields of adult (n = 21) or child and adolescent psychiatry (n = 7), psychosomatics (n = 4) and neurology (n = 2). The psychological PTs practiced predominantly in adult psychotherapy (n = 74) and child and adolescent psychology (n = 12). On average, the participants’ professional experience as PT was 17.93 years (minimum = 2 years; maximum = 40 years; SD = 11.16). Table 1 displays the complete demographic information of the participants.

Table 1.

Demographic information for survey respondents (n = 129).

Parameter	n (%)
Gender
Female	80 (62.02)
Male	41 (31.78)
Other	1 (0.78)
Age
18–29 years	2 (1.55)
30–39 years	33 (25.58)
40–49 years	26 (20.16)
50–59 years	32 (24.81)
60+ years	27 (20.93)
Professional group
Psychology	86 (66.66)
Medicine	34 (26.36)
Psychotherapeutic approach
Cognitive-behavioral therapy	45 (34.88)
Psychodynamic psychotherapy (depth-psychology-based)	17 (13.18)
Psychodynamic psychotherapy (psychoanalysis)	12 (9.30)
Systemic psychotherapy	4 (3.10)
Others	6 (4.66)
Current work setting (multiple choice; n = 143)
Inpatient closed ward	9 (7.56)
Inpatient open ward	15 (12.61)
Day-care	10 (8.40)
Outpatient	102 (85.71)
Outreach	7 (5.88)
Experiences with paper-based sharing of electronic health records with patients
Yes	47 (36.43)
No	44 (34.11)
Shared parts of the electronic health record (multiple choice; n = 77)
Medical history	9 (11.69)
Clinical notes	6 ( 7.79)
Psychopathological findings	9 (11.69)
Doctor's letters	22 (28.57)
Medication schedules	13 (16.88)
Laboratory results	11 (14.29)
Others	7 (9.09)

Note: The percentages for no response are not shown, which means that the values do not always add up to 100%. The percentages refer to the entire sample (n = 129).

General effects on psychotherapeutic care

PT expressed predominantly negative views about the expected effects of open notes on psychotherapeutic care (Figure 1). This negativity was observed across all items surveyed, from the basic idea of making clinical notes available to influence the effectiveness of care, patient safety, satisfaction, and communication, as well as health literacy and participatory decision-making.

Figure 1.

Percentage distribution of responses regarding the effects on psychotherapeutic care in general.

Expected effects on patients

The expected effects of using open notes in psychotherapy on patients were predominantly negative, as shown in Figure 2. Clinicians assumed that open notes may increase patients’ perceived control during treatment and slightly improve their ability to remember treatment goals. The surveyed PT anticipated that open notes do not alter the patient's comprehension of the illness, are not more likely to adhere to treatment recommendations, and instead would lead to more confusion and worry. They did not anticipate any improvement in treatment adherence either.

Figure 2.

Percentage distribution of responses regarding the expected effects on patients (part I).

Apart from the slightly higher proportion of therapists who expected patients to agree with the content of open notes, all other effects on patients shown in Figure 3 were evaluated as predominantly negative.

Figure 3.

Percentage distribution of responses regarding the expected effects on patients (part II).

Expected effects on their clinical practice

Overall, negative expectations and the lack of positive effects of open notes on their own psychotherapeutic practice predominate (Figure 4). Even if the respondents do not assume that patients will disagree with what is written in their notes, PTs expect patient contacts to become longer as a result of open notes. Furthermore, it is anticipated that additional questions will arise from patients beyond the therapeutic sessions. In principle, additional documentation work, potential for conflict, and less honest documentation are expected as a result of open notes. Meaningful opportunities for informing and working with relatives are not anticipated. When asked to what extent open notes influence the risk of patients taking legal action against PT, around ⅓ of respondents (32.6%; 42 out of 129) assumed an increase. A similarly large proportion of respondents (36.4%; 47 out of 129) assumed that open notes would have no influence on the initiation of legal action; a very small proportion (0.78%; 1 out of 129) assumed that the initiation of legal action would decrease.

Figure 4.

Percentage distribution of responses regarding the expected effects on one's own clinical practice.

Hopes and ideas about open notes

The participants evaluated possible hopes and ideas with respect to the implementation and further development of open notes in psychotherapeutic care in Germany (Figure 5). The majority were in favor of (1) keeping closed notes, (2) being able to decide in individual cases which patients receive access to psychotherapy notes and (3) allowing patients to decide which third-party practitioners receive access to open notes. Responses to statements that patients should be able to comment on and add to the open notes were split with a slight tendency towards respondents rejecting the proposition. When asked whether relatives, parents of non-adult patients, or legal guardians should receive ORA, most respondents were negative (Figure 6).

Figure 5.

Percentage distribution of responses regarding hopes and ideas about open notes.

Figure 6.

Percentage distribution of responses regarding third-party access to electronic health records.

Discussion

Summary of principal findings

In general, this online survey of PTs in Germany revealed predominantly negative attitudes about open notes. The only anticipated positive effects among our participants were increased patient control during treatment and improved recall of the treatment plan and therapy goals. Otherwise, PT did not expect that open notes would improve the efficiency of treatment, adherence, self-care, or patient engagement in therapy, nor did PT expect that greater therapy progress would occur because of this innovation. Instead, PT assumed that patients would be confused after reading their open notes, that misunderstandings may arise, and that more questions would be directed to PT. Therapists also anticipated that they would be less candid when documenting sessions and anticipated an increased workload.

Comparison with other studies

Our findings echo those of surveys conducted with HCP including a recent survey of PT trainees in Switzerland.²¹ Approximately only one in three of our respondents consider open notes a good idea. An even smaller proportion believed that open notes could enhance healthcare efficiency or other important patient-related outcomes, such as patient satisfaction. This assessment was shared to a similar extent by clinicians from different specialties and countries.^15,30,32,33 However, when HCPs themselves gain practical experience with open notes, their initially negative attitude towards the researched innovation often changes appearing to become more positive.^7,32 In contrast, surveys show that patients generally view open notes more positively, regardless of whether they have used them or have an MHC.^2,19 Regarding the impact of open notes on patients, PT, similar to other mental HCPs, our participants primarily anticipated patient concerns.^29,30 In line with this, the results of a qualitative study indicate that patients suffering from severe mental illness rejected ORA (including open notes) because they feared being emotionally burdened by reading the notes.³⁴

At the same time, respondents in our study did predict that patients would feel more in control of their treatment and remember therapy goals better after access. Albeit preliminary evidence among patients receiving cognitive-behavioral or psychodynamic psychotherapy who have read their open notes confirms this.¹⁹ It is also worth noting that patients often forget a significant portion (approximately 40%–80%) of what is discussed in therapy sessions.³⁵ Although this is a natural process, forgetting can also indicate repression or a lack of will to change. Nevertheless, open notes can serve as a helpful tool to supplement what was learned in cognitive-behavioral therapy. Moreover, such use of open notes is explicitly desired by patients.^17,34 In line with this, recent studies in cognitive-behavioral therapy research suggest that patients are more likely to implement “homework” when it is provided in written form.³⁶ Despite these promising findings, the majority of PT respondents in our study held a more skeptical view: they appeared to believe that improved recall would not lead to increased implementation of treatment recommendations, such as more reliable medication intake. The skepticism appears understandable in two senses: On the one hand, explicit “learning” and “homework” are not the primary goals of systemic or psychodynamic psychotherapy, which make up a significant proportion of the respondents. On the other hand, PTs in Germany do not prescribe medication, which may result in medication playing a relatively minor role in psychotherapy. Conversely, it is not surprising that physicians attribute a higher influence on medication adherence to ORA and open notes.³⁰

In our study, respondents reported mixed opinions regarding whether the majority of patients would disagree with the content of their notes or find significant errors. These concerns are substantiated by studies indicating that individuals with MHC report finding significantly more inaccuracies and errors in open notes than patients in general healthcare settings.^13,14 This may be due to the subjective nature of MHC or subjective interpretations of mental health states making them harder to quantify and consequently increasing the likelihood of contradictions and misunderstandings. Furthermore, notes from psychodynamic therapists may include hypotheses, transference feelings, associations, and fantasies that are not always synchronized with the therapy process.³⁷ As long as these are not explained or read without context, they might potentially be misunderstood. It is therefore understandable that PTs, more so than other HCPs, fear that their patients may feel attacked or offended.^13,30

The anticipated consequences of open notes on individual psychotherapeutic practice are directly linked to the effects discussed earlier on patients. Unlike physicians in other specialties, PT did not expect significantly longer treatment sessions due to open notes.³⁰ This could be related to the predetermined session duration in psychotherapy, which is typically transparently communicated to patients. While physicians also generally have predetermined appointment durations, these are usually not communicated clearly and are often much shorter, constrained by the volume of patient concerns and the time limits of the physician. PTs, however, are worried that concerns related to open notes may displace psychotherapeutic conversation topics, as evidenced by a participant's statement in our survey's free-text responses (published elsewhere).³¹ Accordingly, “more misunderstandings are to be expected, which in turn require more time for clarification, resulting in less time for actual treatment.”³¹ The aforementioned concerns appear justified as patients with MHC often desire continuous communication and discussion with their healthcare providers regarding the contents of their open notes.³⁴ To counteract this, PTs may be less candid in documentation, engage in more self-censorship, and create a second unofficial record (referred to as “closed notes”).¹⁶ However, this practice is likely to result in information loss,³⁸ as “the actual documentation, which is helpful for work and also includes personal aspects such as the dynamics of transference events,” is no longer documented.³¹ However, Chimowitz et al.'s²⁰ study presents opposing considerations: They suggest that PT may feel positively pressured by open notes to communicate the content of their documentation in a timely manner, which may not have occurred, or would have occurred significantly later, without open notes.

The PTs in our study were skeptical, regarding the potential impacts of open notes on psychotherapeutic work with relatives, such as better awareness. Notwithstanding safeguarding issues, in some instances, studies do demonstrate numerous positive care effects of ORA for relatives or informal caregivers.^39,40 This may be particularly clear among some therapy approaches that involve regular intensive involvement from relatives, such as systemic approaches. From this perspective alone, it would be fair to provide relatives with access to the open notes of sessions in which they participated. Regarding the sharing of psychotherapy notes with third-party care providers, PT see conflict potential, while at the same time, they recognize the patient's competence to decide whether third-party practitioners may read the open notes. Other studies report that PT felt increasingly controlled by third-party access and threatened to reduce the informational content of the open notes they authored as a result.^20,31

Implications of the findings

Our findings suggest that PTs in Germany share similar concerns with their psychotherapeutic colleagues, as well as their counterparts in other professions, both domestically and internationally. Although there are no comparable studies on PTs’ attitudes toward open notes in Germany, international evidence shows that HCPs who do not currently use open notes are initially hesitant, but their opinions tend to become more positive following practical application. Studies from various countries show that open notes in PT neither reduce treatment efficiency nor jeopardize patient safety.^2,14 The perspective of patients differs insofar as they already have generally positive opinions about open notes a priori, which are largely confirmed in practice.⁷

To comprehensively assess PT’s expectations toward open notes, larger-scale surveys are necessary. These surveys would help to elucidate differences between age groups, settings, psychotherapeutic professional groups (medicine, psychology, and social work), and psychotherapy schools. While Erlingsdóttir and co-worker^15,16 have partially addressed this issue, their results from the Swedish healthcare system cannot be readily extrapolated to Germany. Moreover, it is necessary to conduct larger-scale implementation studies on open notes in PT to confirm or, if possible, alleviate the expressed concerns. These studies could aid in establishing guidelines for handling inaccuracies and errors in open notes, as well as addressing transference feelings and developing general guidelines for constructing or structuring psychotherapeutic open notes.^18,41,42

Strengths and limitations

This is the first survey on PT’s expectations towards open notes in Germany and one of the first studies on this field of healthcare. The questionnaire used is therefore exploratory and has not been tested for validity, reliability, and construct validity. At the same time, its practicability and comparability can be regarded as given, as the instrument has already been used successfully in other studies.²¹ The timing of the survey is pertinent, given the rollout of the practice, and the impending introduction of ORA and open notes in Germany. Nonetheless, the study has several limitations due to a non-probability sample and its small sample size. Of the approximately 47,000 PT in Germany, we assume that the majority theoretically had access to the survey,⁴³ as it was advertised to psychotherapeutic associations with a total of 75,261 members. However, the response rate was only 0.1714%. Therefore, the results cannot be generalized to the population of German PT. Conspicuously, psychoanalytically and group therapy-oriented associations were particularly underrepresented in our study. This is consistent with existing research that suggests psychodynamically oriented PTs are particularly hesitant towards transparent patient communication in the light of challenges associated with plain-language informed consent to these treatment modalities.^17,44,45 Further research should examine the views of PTs aligned with distinctive psychotherapy modalities.

Another limitation is that the survey was conducted online and no invitation link was sent to individual potential participants, so the veracity of the responses can be questioned. Likewise, no measures such as IP blocking were taken to prevent duplicate participation. The latter can therefore not be ruled out and therefore limits the results. Data were also collected separately for privacy reasons. Consequently, only descriptive statistics could be performed, and no correlation analyses were possible. Despite the small sample, it would have been instructive, even for hypothesis-generating work, to investigate any relationship between the sociodemographic characteristics of the participants and their response behavior, particularly regarding potential differences between medical and psychological PT and different therapy schools. Notably, a recent survey of PT trainees in Switzerland reported that participants believed open notes would carry different implications depending on therapy modalities.²¹ Additional research is required to investigate this perspective among established PTs and their patients.

Conclusions

In this online survey, the majority of PTs in Germany anticipated predominantly negative effects of open notes on psychotherapeutic care. Specifically, no improvements in efficiency, patient communication, or patient satisfaction were expected. Instead, it was assumed that patients would have multiple concerns, find open notes more confusing than helpful, and confront their PT with additional questions, leading to additional workload outside of therapy sessions. These expectations align with those of other HCPs from various countries. However, surveys of HCPs who work with open notes indicate that negative expectations are not confirmed. Instead, predominantly beneficial experiences were reported. This corresponds with consistently positive experiences of patients with open notes reported in international studies. With the legislatively mandated expansion of ORA to all patients in Germany, it will be crucial to prepare both HCPs and patients for the upcoming changes and the associated transparency including greater professional education about the practice and more guidance offered to prepare prospective patients. Additionally, inevitable challenges arising from the shared documentation of health data in psychotherapy need to be examined including special features of different schools of psychotherapy, the potential for documentation changes, dealing with thoughts of transference, and possible risks to privacy, such as personal data leaks. This will require conducting larger implementation studies in the field of psychotherapy.

Supplemental Material

sj-pdf-1-dhj-10.1177_20552076241271813 - Supplemental material for Psychotherapists’ views on open notes: An online survey from Germany

Supplemental material, sj-pdf-1-dhj-10.1177_20552076241271813 for Psychotherapists’ views on open notes: An online survey from Germany by Julian Schwarz, Katharina Neumann, Eva Meier-Diedrich, Felix Mühlensiepen, Stefan Hochwarter and Charlotte Blease in DIGITAL HEALTH

Footnotes

Acknowledgements

The authors would like to thank the psychological associations that contributed to the visibility of the survey, as well as the participating psychotherapists.

Contributorship

CB and JS contributed to the study design. KN and JS collected the data and conducted data analysis, JS wrote a first draft in German, which EM translated into English language. Successive drafts were revised by CB, KN, and EM. All authors critically reviewed and commented on the manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Brandenburg Medical School publication fund supported by the German Research Foundation and the Ministry of Science, Research and Cultural Affairs of the State of Brandenburg.

Guarantor

JS.

ORCID iDs

Julian Schwarz

Felix Mühlensiepen

Supplemental material

Supplemental material for this article is available online.

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