Reducing diagnostic errors through effective communication: harnessing the power of information technology

"What Else Could It Be?" A Scoping Review of Questions for Patients to Ask Throughout the Diagnostic Process

BACKGROUND

Diagnostic errors are a global patient safety challenge. Over 75% of diagnostic errors in ambulatory care result from breakdowns in patient-clinician communication. Encouraging patients to speak up and ask questions has been recommended as one strategy to mitigate these failures.

OBJECTIVES

The goal of the scoping review was to identify, summarize, and thematically map questions patients are recommended to ask during ambulatory encounters along the diagnostic process. This is the first step in a larger study to co-design a patient-facing question prompt list for patients to use throughout the diagnostic process.

METHODS

Medline and Google Scholar were searched to identify question lists in the peer-reviewed literature. Organizational websites and a search engine were searched to identify question lists in the gray literature. Articles and resources were screened for eligibility and data were abstracted. Interrater reliability (K = 0.875) was achieved.

RESULTS

A total of 5509 questions from 235 resources met inclusion criteria. Most questions (n = 4243, 77.02%) were found in the gray literature. Question lists included an average of 23.44 questions. Questions were most commonly coded along the diagnostic process categories of treatment (2434 questions from 250 resources), communication of the diagnosis (1160 questions, 204 resources), and outcomes (766 questions, 172 resources).

CONCLUSIONS

Despite recommendations for patients to ask questions, most question prompt lists focus on later stages of the diagnostic process such as communication of the diagnosis, treatment, and outcomes. Further research is needed to identify and prioritize diagnostic-related questions from the patient perspective and to develop simple, usable guidance on question-asking to improve patient safety across the diagnostic continuum.

Blood test result communication in primary care: mixed-methods systematic review protocol

BACKGROUND

After testing, ensuring test results are communicated and actioned is important for patient safety, with failure or delay in diagnosis the most common cause of malpractice claims in primary care worldwide. Identifying interventions to improve test communication from the decision to test through to sharing of results has important implications for patient safety, GP workload, and patient engagement.

AIM

To assess the factors around communication of blood test results between primary care providers (for example GPs, nurses, reception staff) and their patients and carers.

DESIGN & SETTING

A mixed methods systematic review including primary studies involving communication of blood test results in primary care.

METHOD

The review will use a segregated convergent synthesis method. Qualitative information will be synthesised using a meta-aggregative approach, and quantitative data will be meta-analysed or synthesised if pooling of studies is appropriate and data are available. If not, data will be presented in tabular and descriptive summary form.

CONCLUSION

This review has the potential to provide conclusions about blood test result communication interventions and factors important to stakeholders, including barriers and facilitators to improved communication.

Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review

BACKGROUND

Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms.

METHODS

We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12-1.24) to 4.5 (1.8-11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies.

CONCLUSIONS

This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations.

TRIAL REGISTRATION NUMBER

The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.

Understanding diagnostic conversations in clinical practice: A systematic review

OBJECTIVE

Summarize frameworks to understand diagnostic conversations and assessments of diagnostic conversations in practice.

METHODS

We systematically searched MEDLINE, Scopus, Cochrane, and other databases from inception to July 2022 for reports of diagnostic conversations. Two authors independently reviewed studies for eligibility, assessed methodological quality with the mixed methods appraisal tool and extracted information related to study characteristics, frameworks and components evaluated in assessments of diagnostic conversations and results.

RESULTS

Eight studies were included. One study reported an empiric framework of diagnostic conversations that included the following components: identifying the problem that requires diagnosis, obtaining information, and delivering the diagnosis and treatment plan. Thematic analyses highlighted communication between patients and clinicians as central in diagnostic conversations as it allows a) patient's presentation of their symptoms which guide subsequent diagnostic steps, b) negotiation of the significance of the patient's symptoms through conversation and c) introducing and resolving diagnostic uncertainty.

CONCLUSION

Despite the importance of diagnostic conversation only one empiric framework described its components. Additionally, limited available evidence suggests patients can have an important role in the diagnostic process that expands beyond patients as an information source.

PRACTICE IMPLICATIONS

Patients should be included as active partners in co-development of diagnostic plans of care.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process

OBJECTIVES

Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions.

METHODS

We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model.

RESULTS

We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions).

CONCLUSIONS

Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Collaborative Diagnostic Conversations Between Clinicians, Patients, and Their Families: A Way to Avoid Diagnostic Errors

Objective

To identify the components of the collaborative diagnostic conversations between clinicians, patients, and their families and how deficiencies in these conversations can lead to diagnostic errors.

Patients and Methods

We purposively selected 60 video recordings of clinical encounters that included diagnosis conversations. These videos were obtained from the internal medicine, and family medicine services at Mayo Clinic's campus in Rochester, Minnesota. These clinical encounters were recorded between November 2017, and December 2021, during the conduct of studies aiming at developing or testing shared decision-making interventions. We followed a critically reflective approach model for data analysis.

Results

We identified 3 components of diagnostic conversations as follows: (1) recognizing diagnostic situations, (2) setting priorities, and (3) creating and reconciling a diagnostic plan. Deficiencies in diagnostic conversations could lead to framing issues in a way that sets diagnostic activities off in an incorrect or undesirable direction, incorrect prioritization of diagnostic concerns, and diagnostic plans of care that are not feasible, desirable, or productive.

Conclusion

We identified 3 clinician-and-patient diagnostic conversation components and mapped them to potential diagnostic errors. This information may inform additional research to identify areas of intervention to decrease the frequency and harm associated with diagnostic errors in clinical practice.

Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders

Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.

Exploring the Recent Trends in Management of Dementia and Frailty: Focus on Diagnosis and Treatment

Dementia and frailty increase health adversities in older adults, which are topics of growing research interest. Frailty is considered to correspond to a biological syndrome associated with age. Frail patients may ultimately develop multiple dysfunctions across several systems, including stroke, transient ischemic attack, vascular dementia, Parkinson's disease, Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies, cortico-basal degeneration, multiple system atrophy, amyotrophic lateral sclerosis, and Creutzfeldt-Jakob disease. Patients with dementia and frailty often develop malnutrition and weight loss. Rigorous nutritional, pharmacological, and non-pharmacological interventions generally are required for these patients, which is a challenging issue for healthcare providers. A healthy diet and lifestyle instigated at an early age can reduce the risk of frailty and dementia. For optimal treatment, accurate diagnosis involving clinical evaluation, cognitive screening, essential laboratory evaluation, structural imaging, functional neuroimaging, and neuropsychological testing is necessary. Diagnosis procedures best apply the clinical diagnosis, identifying the cause(s) and the condition(s) appropriate for treatment. The patient's history, caregiver's interview, physical examination, cognitive evaluation, laboratory tests, and structural imaging should best be involved in the diagnostic process. Varying types of physical exercise can aid the treatment of these disorders. Nutrition maintenance is a particularly significant factor, such as exceptionally high-calorie dietary supplements and a Mediterranean diet to support weight gain. The core purpose of this article is to investigate trends in the management of dementia and frailty, focusing on improving diagnosis and treatment. Substantial evidence builds the consensus that a combination of balanced nutrition and good physical activity is an integral part of treatment. Notably, more evidence-based medicine knowledge is required.

A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology

OBJECTIVE

This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients.

METHODS

Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design.

RESULTS

Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication.

CONCLUSIONS

The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.

Tackling Ambulatory Safety Risks Through Patient Engagement: What 10,000 Patients and Families Say About Safety-Related Knowledge, Behaviors, and Attitudes After Reading Visit Notes

BACKGROUND

Ambulatory safety risks including delayed diagnoses or missed abnormal test results are difficult for clinicians to see, because they often occur in the space between visits. Experts advocate greater patient engagement to improve safety, but strategies are limited. Patient access to clinical notes ("OpenNotes") may help close the safety gap between visits.

METHODS

We surveyed patients and families who logged on to the patient portal and had at least one ambulatory note available in the past 12 months at two academic hospitals during June to September 2016, focusing on patient-reported effects of OpenNotes on safety knowledge, behaviors, and attitudes.

RESULTS

A total of 6913 (28%) of 24,722 patients at an adult hospital and 3672 (17%) of 21,579 participants at the children's hospital submitted surveys. Approximately 75% of patients and parents each reported that reading notes helped them understand the reason for both tests and referrals, and approximately 50% felt that it helped them complete tests and referrals. Roughly 75% of participants were more likely to check and understand test results. Overall, 97% of participants reported that trust in the provider, activation, patient-provider goal alignment, and teamwork were each better or the same after reading 1 note or more. Nonwhite participants and those with high school education or less were 30% to 50% more likely to report that reading notes helped them complete tests compared with white and more educated respondents, respectively.

CONCLUSIONS

Overall, the majority of more than 10,000 patients and parents reported reading notes helped them understand and follow through on tests and referrals. As information transparency spreads, OpenNotes can help activate patients and families, facilitate safety behaviors, and forge stronger partnerships with clinicians.

What Contributes to Diagnostic Error or Delay? A Qualitative Exploration Across Diverse Acute Care Settings in the United States

OBJECTIVES

Diagnostic error and delay is a prevalent and impactful problem. This study was part of a mixed-methods approach to understand the organizational, clinician, and patient factors contributing to diagnostic error and delay among acutely ill patients within a health system, as well as recommendations for the development of tailored, targeted, feasible, and effective interventions.

METHODS

We did a multisite qualitative study using focus group methodology to explore the perspectives of key clinician stakeholders. We used a conceptual framework that characterized diagnostic error and delay as occurring within 1 of 3 stages of the patient's diagnostic journey-critical information gathering, synthesis of key information, and decision making and communication. We developed our moderator guide based on the sociotechnical frameworks previously described by Holden and Singh for understanding noncognitive factors that lead to diagnostic error and delay. Deidentified focus group transcripts were coded in triplicate and to consensus over a series of meetings. A final coded data set was then uploaded into NVivo software. The data were then analyzed to generate overarching themes and categories.

RESULTS

We recruited a total of 64 participants across 4 sites from emergency departments, hospital floor, and intensive care unit settings into 11 focus groups. Clinicians perceive that diverse organizational, communication and coordination, individual clinician, and patient factors interact to impede the process of making timely and accurate diagnoses.

CONCLUSIONS

This study highlights the complex sociotechnical system within which individual clinicians operate and the contributions of systems, processes, and institutional factors to diagnostic error and delay.

Education Research: NeuroBytes: A New Rapid, High-Yield e-Learning Platform for Continuing Professional Development in Neurology

OBJECTIVE

To determine whether NeuroBytes is a helpful e-Learning tool in neurology through usage, viewer type, estimated time and cost of development, and postcourse survey responses.

BACKGROUND

A sustainable Continuing Professional Development (CPD) system is vital in neurology due to the field's expanding therapeutic options and vulnerable patient populations. In an effort to offer concise, evidence-based updates to a wide range of neurology professionals, the American Academy of Neurology (AAN) launched NeuroBytes in 2018. NeuroBytes are brief (<5 minutes) videos that provide high-yield updates to AAN members.

METHODS

NeuroBytes was beta tested from August 2018 to December 2018 and launched for pilot circulation from January 2019 to April 2019. Usage was assessed by quantifying course enrollment and completion rates; feasibility by cost and time required to design and release a module; appeal by user satisfaction; and effect by self-reported change in practice.

RESULTS

A total of 5,130 NeuroBytes enrollments (1,026 ± 551/mo) occurred from January 11, 2019, to May 28, 2019, with a median of 588 enrollments per module (interquartile range, 194-922) and 37% course completion. The majority of viewers were neurologists (54%), neurologists in training (26%), and students (8%). NeuroBytes took 59 hours to develop at an estimated $77.94/h. Of the 1,895 users who completed the survey, 82% were "extremely" or "very likely" to recommend NeuroBytes to a colleague and 60% agreed that the depth of educational content was "just right."

CONCLUSIONS

NeuroBytes is a user-friendly, easily accessible CPD product that delivers concise updates to a broad range of neurology practitioners and trainees. Future efforts will explore models where NeuroBytes combines with other CPD programs to affect quality of training and clinical practice.

Impact of electronic health records on predefined safety outcomes in patients admitted to hospital: a scoping review

OBJECTIVES

Review available evidence for impact of electronic health records (EHRs) on predefined patient safety outcomes in interventional studies to identify gaps in current knowledge and design interventions for future research.

DESIGN

Scoping review to map existing evidence and identify gaps for future research.

DATA SOURCES

PubMed, the Cochrane Library, EMBASE, Trial registers.

STUDY SELECTION

Eligibility criteria: We conducted a scoping review of bibliographic databases and the grey literature of randomised and non-randomised trials describing interventions targeting a list of fourteen predefined areas of safety. The search was limited to manuscripts published between January 2008 and December 2018 of studies in adult inpatient settings and complemented by a targeted search for studies using a sample of EHR vendors. Studies were categorised according to methodology, intervention characteristics and safety outcome.Results from identified studies were grouped around common themes of safety measures.

RESULTS

The search yielded 583 articles of which 24 articles were included. The identified studies were largely from US academic medical centres, heterogeneous in study conduct, definitions, treatment protocols and study outcome reporting. Of the 24 included studies effective safety themes included medication reconciliation, decision support for prescribing medications, communication between teams, infection prevention and measures of EHR-specific harm. Heterogeneity of the interventions and study characteristics precluded a systematic meta-analysis. Most studies reported process measures and not patient-level safety outcomes: We found no or limited evidence in 13 of 14 predefined safety areas, with good evidence limited to medication safety.

CONCLUSIONS

Published evidence for EHR impact on safety outcomes from interventional studies is limited and does not permit firm conclusions regarding the full safety impact of EHRs or support recommendations about ideal design features. The review highlights the need for greater transparency in quality assurance of existing EHRs and further research into suitable metrics and study designs.

A practical system that enables physicians to respond expeditiously to significant unexpected findings (SUFs) in radiological reports

PURPOSE

To demonstrate effectiveness of our present radiological report check flowchart enabling physicians to respond to significant unexpected findings (SUFs), by comparing the response periods from the examination date to the action date on untreated SUFs between the previous and present versions of our flowchart.

METHODS

In the flowchart's previous version used February-October 2019, SUFs, which were notified by email, were audited every month. The physician received a phone call and was asked to act on the untreated SUF. In the flowchart's present version used from November 2019 to May 2020, SUFs were audited every 2 weeks. The physician and his/her chief were asked to return a written response to the untreated SUF. We evaluated the difference in the response periods between the previous and present versions of the flowchart.

RESULTS

With the previous flowchart's use, untreated SUFs were 43 of 229 SUFs (18.8%) with the present flowchart untreated SUFs were 22 of 130 SUFs (16.9%). All SUFs in both periods were eventually responded. The present flowchart (median/range, 25/11-70 days) significantly had shorter response periods than the previous flowchart (70/16-290 days) (p < 0.0001).

CONCLUSION

The present flowchart employing a shortened primary audit interval, a written response, and the department chief's intervention, helped reduce the response periods.

Recommendations From the Twitter Hashtag #DoctorsAreDickheads: Qualitative Analysis

BACKGROUND

The social media site Twitter has 145 million daily active users worldwide and has become a popular forum for users to communicate their health care concerns and experiences as patients. In the fall of 2018, a hashtag titled #DoctorsAreDickheads emerged, with almost 40,000 posts calling attention to health care experiences.

OBJECTIVE

This study aims to identify common health care conditions and conceptual themes represented within the phenomenon of this viral Twitter hashtag.

METHODS

We analyzed a random sample of 5.67% (500/8818) available tweets for qualitative analysis between October 15 and December 31, 2018, when the hashtag was the most active. Team coders reviewed the same 20.0% (100/500) tweets and the remainder individually. We abstracted the user's health care role and clinical conditions from the tweet and user profile, and used phenomenological content analysis to identify prevalent conceptual themes through sequential open coding, memoing, and discussion of concepts until an agreement was reached.

RESULTS

Our final sample comprised 491 tweets and unique Twitter users. Of this sample, 50.5% (248/491) were from patients or patient advocates, 9.6% (47/491) from health care professionals, 4.3% (21/491) from caregivers, 3.7% (18/491) from academics or researchers, 1.0% (5/491) from journalists or media, and 31.6% (155/491) from non-health care individuals or other. The most commonly mentioned clinical conditions were chronic pain, mental health, and musculoskeletal conditions (mainly Ehlers-Danlos syndrome). We identified 3 major themes: disbelief in patients' experience and knowledge that contributes to medical errors and harm, the power inequity between patients and providers, and metacommentary on the meaning and impact of the #DoctorsAreDickheads hashtag.

CONCLUSIONS

People publicly disclose personal and often troubling health care experiences on Twitter. This adds new accountability for the patient-provider interaction, highlights how harmful communication affects diagnostic safety, and shapes the public's viewpoint of how clinicians behave. Hashtags such as this offer valuable opportunities to learn from patient experiences. Recommendations include developing best practices for providers to improve communication, supporting patients through challenging diagnoses, and promoting patient engagement.

Assessment of Health Information Technology-Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System: A Qualitative Study of Aggregated Root Cause Analysis Data

IMPORTANCE

Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged.

OBJECTIVE

To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018.

MAIN OUTCOMES AND MEASURES

Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved.

RESULTS

Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.

CONCLUSIONS AND RELEVANCE

This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.

Improving the Healthcare Effectiveness: The Possible Role of EHR, IoMT and Blockchain

New types of patient health records aim to help physicians shift from a medical practice, often based on their personal experience, towards one of evidence based medicine, thus improving the communication among patients and care providers and increasing the availability of personal medical information. These new records, allowing patients and care providers to share medical data and clinical information, and access them whenever they need, can be considered enabling Ambient Assisted Living technologies. Furthermore, new personal disease monitoring tools support specialists in their tasks, as an example allowing acquisition, transmission and analysis of medical images. The growing interest around these new technologies poses serious questions regarding data integrity and transaction security. The huge amount of sensitive data stored in these new records surely attracts the interest of malicious hackers, therefore it is necessary to guarantee the integrity and the maximum security of servers and transactions. Blockchain technology can be an important turning point in the development of personal health records. This paper discusses some issues regarding the management and protection of health data exchanged through new medical or diagnostic devices.

Evaluating Radiology Result Communication in the Emergency Department

PURPOSE

To assess the pattern of result communication that occurs between radiologists and referring physicians in the emergency department setting.

METHODS

An institutional review board-approved prospective study was performed at a large academic medical center with 24/7 emergency radiology cover. Emergency radiologists logged information regarding all result-reporting communication events that occurred over a 168-hour period.

RESULTS

A total of 286 independent result communication events occurred during the study period, the vast majority of which occurred via telephone (232/286). Emergency radiologists spent 10% of their working time communicating results. Similar amounts of time were spent discussing negative and positive cross-sectional imaging examinations. In a small minority of communication events, additional information was gathered through communication that resulted in a change of interpretation from a normal to an abnormal study.

CONCLUSIONS

Effective and efficient result communication is critical to care delivery in the emergency department setting. Discussion regarding abnormal cases, both in person and over the phone, is encouraged. However, in the emergency setting, time spent on routine direct communication of negative examination results in advance of the final report may lead to increased disruptions, longer turnaround times, and negatively impact patient care. In very few instances, does the additional information gained from the communication event result in a change of interpretation?

Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework

Objective

To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors.

Materials and Methods

This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework.

Results

Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology.

Discussion

Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging.

Conclusion

Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

The associations between query-based and directed health information exchange with potentially avoidable use of health care services

OBJECTIVE

To quantify the impact of two approaches (directed and query-based) to health information exchange (HIE) on potentially avoidable use of health care services.

DATA SOURCES/STUDY SETTING

Data on ambulatory care providers' adoption of HIE were merged with Medicare fee-for-service claims from 2008 to 2014. Providers were from 13 counties in New York served by the Rochester Regional Health Information Organization (RHIO).

STUDY DESIGN

Linear regression models with provider and year fixed effects were used to estimate changes in the probability of utilization outcomes for Medicare beneficiaries attributed to providers adopting directed and/or query-based HIE compared with beneficiaries attributed to providers who had not adopted HIE.

DATA COLLECTION

Providers' HIE adoption status was determined through Rochester RHIO registration records. RHIO and claims data were linked via National Provider Identifiers.

PRINCIPAL FINDINGS

Query-based HIE adoption was associated with a 0.2 percentage point reduction in the probability of an ambulatory care sensitive hospitalization and a 1.1 percentage point decrease in the likelihood of an unplanned readmission. Directed HIE adoption was not associated with any outcome.

CONCLUSIONS

The Centers for Medicare & Medicaid Services' (CMS) EHR certification criteria includes requirements for directed HIE, but not query-based HIE. Pending further research, certification criteria should place equal weight on facilitating query-based and directed exchange.

Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process

Background Diagnosis requires that clinicians communicate and share patient information in an efficient manner. Advances in electronic health records (EHRs) and health information technologies have created both challenges and opportunities for such communication. Methods We conducted a multi-method, focused ethnographic study of physicians on general medicine inpatient units in two teaching hospitals. Physician teams were observed during and after morning rounds to understand workflow, data sharing and communication during diagnosis. To validate findings, interviews and focus groups were conducted with physicians. Field notes and interview/focus group transcripts were reviewed and themes identified using content analysis. Results Existing communication technologies and EHR-based data sharing processes were perceived as barriers to diagnosis. In particular, reliance on paging systems and lack of face-to-face communication among clinicians created obstacles to sustained thinking and discussion of diagnostic decision-making. Further, the EHR created data overload and data fragmentation, making integration for diagnosis difficult. To improve diagnosis, physicians recommended replacing pagers with two-way communication devices, restructuring the EHR to facilitate access to key information and improving training on EHR systems. Conclusions As advances in health information technology evolve, challenges in the way clinicians share information during the diagnostic process will rise. To improve diagnosis, changes to both the technology and the way in which we use it may be necessary.

The influence of mobile health applications on patient - healthcare provider relationships: A systematic, narrative review

OBJECTIVE

To explore the influence of mobile health applications on various dimensions of patient and healthcare provider relationships.

METHODS

A systematic, narrative review of English literature reporting experiences and outcomes of using mobile health applications was performed, evaluating communication and relationships between patients and healthcare professionals. Findings were framed thematically within the four dimensions of relationship-centred care. The methodological quality of included articles was appraised.

RESULTS

Thirty-seven articles were included, all of them meeting tenets of relationship-centred care. After adopting mobile health applications patients perceived an overall positive impact on their relationship with healthcare providers, indicating they are ready to transition from traditional clinical ecounters to a different modality. Use of the applications supported patients in assuming active roles in the management of their health in collaboration with health professionals. Reluctance of providers to using mobile health needs to be acknowledged and addressed when encouraging wider use of applications in clinical practice.

CONCLUSION

The use of mobile health applications can influence communication and relationships between patients and providers positively, facilitating relationship-centered healthcare.

PRACTICE IMPLICATION

Implementation of mobile health can support patients' self-efficacy, improve access to healthcare services and improve relationships between patients and providers in ambulatory and hospital settings.

Test Result Management Practices of Canadian Internal Medicine Physicians and Trainees

BACKGROUND

Missed test results are a cause of medical error. Few studies have explored test result management in the inpatient setting.

OBJECTIVE

To examine test result management practices of general internal medicine providers in the inpatient setting, examine satisfaction with practices, and quantify self-reported delays in result follow-up.

DESIGN

Cross-sectional survey.

PARTICIPANTS

General internal medicine attending physicians and trainees (residents and medical students) at three Canadian teaching hospitals.

MAIN MEASURES

Methods used to track test results; satisfaction with these methods; personal encounters with results respondents "wish they had known about sooner."

KEY RESULTS

We received surveys from 33/51 attendings and 99/108 trainees (response rate 83%). Only 40.9% of respondents kept a record of all tests they order, and 50.0% had a system to ensure ordered tests were completed. Methods for tracking test results included typed team sign-out lists (40.7%), electronic health record (EHR) functionality (e.g., the electronic "inbox") (38.9%), and personal written or typed lists (14.8%). Almost all trainees (97.9%) and attendings (81.2%) reported encountering at least one test result they "wish they had known about sooner" in the past 2 months (p = 0.001). A higher percentage of attendings kept a record of tests pending at hospital discharge compared to trainees (75.0% vs. 35.7%, p < 0.001), used EHR functionality to track tests (71.4% vs. 27.5%, p = 0.004), and reported higher satisfaction with result management (42.4% vs. 12.1% satisfied or very satisfied, p < 0.001).

CONCLUSIONS

Canadian physicians report an array of problems managing test results in the inpatient setting. In the context of prior studies from the outpatient setting, our study suggests a need to develop interventions to prevent missed results and avoid potential patient harms.

A Concept Analysis of Organizational Health and Communication

Concepts of communication and organizational health were analyzed using the parameters set forth by Walker and Avant, including conceptual selection; clarification; synthesis; attribute exploration and identification; and review of corresponding events. Concept synthesis was initiated through exploration of medical and social science journals, and current literature regarding communication and organizational health was scrutinized to aid conceptual clarification. Concept analysis was informed by using the search engines CINAHL, PubMed, and PsycINFO, with inclusion criteria of "hospital," "communication," and "organizational health." Reenvisioning communication through the lens of organizational health will illuminate issues of false centrality, thus leading to improved interdisciplinary communication in hospitals.

Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study

AIMS

To examine the prevalence and person-level predictors of undiagnosed Type 2 diabetes among adults with elevated HbA1c values.

METHODS

We identified adults without diabetes who had a first elevated HbA1c (index HbA1c ≥ 48 mmol/mol; ≥ 6.5%) between January 2014 and December 2015, and classified them by Type 2 diabetes diagnosis status at 1 year following this result. Multilevel modelling techniques were used to examine the association of individual demographic, clinical, and utilization characteristics with remaining undiagnosed. We quantified differences in early Type 2 diabetes care between diagnosed and undiagnosed individuals.

RESULTS

Of the 18 356 adults with a first elevated index HbA1c , 30.2% remained undiagnosed with Type 2 diabetes 1 year later. Individuals with lower index HbA1c values [adjusted odds ratio (aOR) 5.95, 95% confidence interval (CI) 5.21-6.78 for 48 to <53 mmol/mol (6.5% to 7.0%); referent 53 to <64 mmol/mol (7.0% to <8.0%)], who were ≥ 70 years old (aOR 1.40, 95% CI 1.24-1.59; referent 50-59 years), and who had a prior prediabetes diagnosis (aOR 1.35, 95% CI 1.24-1.47; referent no prediabetes) had increased odds of remaining undiagnosed. After adjusting for age, race, and index HbA1c , remaining undiagnosed was associated with lower odds of initiating metformin (aOR 0.06, 95% CI 0.05-0.07).

CONCLUSIONS

Almost one-third of adults with an elevated HbA1c value were not diagnosed with Type 2 diabetes within 1 year. Undiagnosed Type 2 diabetes, in turn, was associated with differences in early care. Strategies that leverage the electronic health record to facilitate earlier diagnosis may help reduce delays and allow for early intervention towards the goal of improved outcomes.

Clinical Dental Faculty Members' Perceptions of Diagnostic Errors and How to Avoid Them

Diagnostic errors are increasingly recognized as a source of preventable harm in medicine, yet little is known about their occurrence in dentistry. The aim of this study was to gain a deeper understanding of clinical dental faculty members' perceptions of diagnostic errors, types of errors that may occur, and possible contributing factors. The authors conducted semi-structured interviews with ten domain experts at one U.S. dental school in May-August 2016 about their perceptions of diagnostic errors and their causes. The interviews were analyzed using an inductive process to identify themes and key findings. The results showed that the participants varied in their definitions of diagnostic errors. While all identified missed diagnosis and wrong diagnosis, only four participants perceived that a delay in diagnosis was a diagnostic error. Some participants perceived that an error occurs only when the choice of treatment leads to harm. Contributing factors associated with diagnostic errors included the knowledge and skills of the dentist, not taking adequate time, lack of communication among colleagues, and cognitive biases such as premature closure based on previous experience. Strategies suggested by the participants to prevent these errors were taking adequate time when investigating a case, forming study groups, increasing communication, and putting more emphasis on differential diagnosis. These interviews revealed differing perceptions of dental diagnostic errors among clinical dental faculty members. To address the variations, the authors recommend adopting shared language developed by the medical profession to increase understanding.

Identifying quality improvement targets to facilitate colorectal cancer screening completion

The colorectal cancer (CRC) screening process involves multiple interfaces (communication exchanges and transfers of responsibility for specific actions) among primary care and gastroenterology providers, laboratory, and administrative staff. After a retrospective electronic health record (EHR) analysis discovered substantial clinic variation and low CRC screening prevalence overall in an urban, integrated safety-net system, we launched a qualitative analysis to identify potential quality improvement targets to enhance fecal immunochemical test (FIT) completion, the system's preferred screening modality. Here, we report examination of organization-, clinic-, and provider-level interfaces over a three-year period (December 2011-October 2014). We deployed in parallel 3 qualitative data collection methods: (1) structured observation (90+ hours, 10 sites); (2) document analysis (n > 100); and (3) semi-structured interviews (n = 41) and conducted iterative thematic analysis in which findings from each method cross-informed subsequent data collection. Thematic analysis was guided by a conceptual model and applied deductive and inductive codes. There was substantial variation in protocols for distributing and returning FIT kits both within and across clinics. Providers, clinic and laboratory staff had differing access to important data about FIT results based on clinical information system used and this affected results reporting. Communication and coordination during electronic referrals for diagnostic colonoscopy was suboptimal particularly for co-morbid patients needing anesthesia clearance. Our multi-level approach elucidated organizational deficiencies not evident by quantitative analysis alone. Findings indicate potential quality improvement intervention targets including: (1) best-practices implementation across clinics; (2) detailed communication to providers about FIT results; and (3) creation of EHR alerts to resolve pending colonoscopy referrals before they expire.

Communicating laboratory results through a Web site: Patients' priorities and viewpoints

BACKGROUND

Patients can access laboratory results using various technologies. The aim of this study was to integrate the laboratory results into the hospital Web site based on patients' viewpoints and priorities and to measure patients' satisfaction.

METHODS

This descriptive-analytical study was conducted in 2015. First, a questionnaire was distributed among 200 patients to assess patients' priorities to receive laboratory results through the Web site. Second, those who agreed (n = 95) to receive their laboratory results through the Web site were identified. Then, the required changes were made to the hospital Web site based on patients' viewpoints and priorities. Third, patients were divided into two groups. The first group received their laboratory results through the Web site on the date had been announced during their visit to the laboratory. The second group was informed by SMS once their results were shown on the Web site. After receiving laboratory results, patients' satisfaction was evaluated.

RESULTS

More than half of the participants (n = 53, 55.8%) were highly satisfied with receiving the results electronically. The higher number of people in SMS group (n = 9, 20.9%) reported that they were satisfied with time-saving compared to other group (n = 2, 3.8%) (P = .04). Participants after receiving the results through the Web site considered the functionalities of reprinting (P < .0001) and timeliness (P = .017) more important.

CONCLUSION

Integrating laboratory results into the hospital Web site based on the patients' viewpoints and priorities can improve patient satisfaction and lower the patients' concern regarding confidentiality of their results.

Assessing the Burden of Abnormal LFTs and the Role of the Electronic Health Record: A Retrospective Study

BACKGROUND

Primary care clinicians encounter abnormal liver function tests (LFTs) frequently. This study assesses the prevalence of abnormal LFTs and patient follow-up patterns in response.

METHODS

This is a retrospective study from 2007-2016 of adult patients with abnormal LFTs seen in an internal medicine clinic. The proportion of patients with follow-up testing and the time (in days) to repeat LFTs were the primary outcomes measured. Results were evaluated before and after the implementation of the institution's electronic health record (EHR).

RESULTS

This study identified a period prevalence for abnormal LFTs of 39%. Of these, 9,545 unique patients met inclusion criteria, with 8,415 patients (88.2%) possessing follow-up LFTs and no significant difference in the proportion of patients receiving follow-up by degree of initial abnormality. Median time to follow-up in mild abnormalities (1-2 times normal) was 138 days, compared to 21 days for severe abnormalities (>4 times normal, P < 0.0001). Reduced time to repeat testing across all spectrums of abnormality was observed following EHR implementation, but proportions of missing follow-up did not improve. A multivariable logistic regression model identified younger age, poverty, living over 50 miles from clinic, recent cohort entry and a lower magnitude of abnormality as predictors for missing repeat LFT testing (area under the curve = 0.838 [95% CI: 0.827-0.849]).

CONCLUSIONS

Abnormal LFTs were detected in 39% of all patients seen. The degree of LFT abnormality did not influence rates of follow-up testing, but does appear to play a role in the timing of repeat testing, when obtained. Follow-up rates did not improve with EHR implementation.

Diagnostic evaluation of patients presenting with hematuria: An electronic health record-based study

BACKGROUND

To gain new insights into the origin and prevention of diagnostic delays in the evaluation of hematuria in an electronic health record (EHR)-based integrated care setting.

METHODS

We performed a retrospective review of 298 consecutive patients with new-onset hematuria at a Veterans Affairs facility from January 1, 2011 to December 31, 2013 excluding those where diagnostic evaluation was unnecessary (i.e., cystoscopy within 3 years prior). We collected data on presentation, such as red flags of painless gross hematuria (PGH) or asymptomatic microhematuria (AMH) and subsequent evaluation (imaging, urologic referral, and cystoscopy). Delay was defined when evaluation was not completed within 60 days. Logistic regression was performed to identify predictors of delay.

RESULTS

Of 201 patients, 149 had delays. PGH was present in 99 patients. These patients had a higher rate of urology referral within 1 year than patients with AMH (86.7% vs. 64.7%; P<0.01) and were more likely to undergo cystoscopy (75.8% vs. 52%; P<0.01). Delays occurred in 67% of PGH patients vs. 81% of AMH patients (OR 0.46; P = 0.02), and roughly a third were related to scheduling/coordination, patient-related issues, or delay in primary care referral. Bladder neoplasms were detected in 18% of patients with PGH and 2% of those with AMH.

CONCLUSION

Delays in evaluation for hematuria occur commonly, regardless of strength of the red-flag. Many delays were preventable and could be targeted with interventions including EHR-based tracking systems or reformed scheduling practices.

Digital Natives Versus Digital Immigrants: Influence of Online Health Information Seeking on the Doctor-Patient Relationship

Ubiquitous Internet access currently revolutionizes the way people acquire information by creating a complex, worldwide information network. The impact of Internet use on the doctor-patient relationship is a moving target that varies across sociodemographic strata and nations. To increase scientific knowledge on the patient-Web-physician triangle in Austria, this study reports findings regarding prevailing online health information-seeking behavior and the respective impact on doctor-patient interactions among a nonprobability convenience sample of Internet users. To investigate digital age group-specific influences, we analyzed whether digital natives and digital immigrants differed in their perspectives. The questionnaire-based online survey collected sociodemographic data and online health information-seeking behavior from a sample of 562 respondents (59% females, mean age 37 ± 15 years, 54% digital natives). Most respondents (79%) referred to the Internet to seek health information, making it the most commonly used source for health information, even more prevalent then the doctor. We found similar predictors for using the Internet as a source for health-related information across digital age groups. Thus, the overall generational gap seems to be small among regular Internet users in Austria. However, study participants expressed a rather skeptical attitude toward electronic exchange of health data between health care professionals and patients, as well as toward reliability of online health information. To improve adoption of electronic doctor-patient communication and patient empowerment, public education and awareness programs are required to promote consumer-centered health care provision and patient empowerment.

Patient portals and health apps: Pitfalls, promises, and what one might learn from the other

Widespread use of health information technology (IT) could potentially increase patients' access to their health information and facilitate future goals of advancing patient-centered care. Despite having increased access to their health data, patients do not always understand this information or its implications, and digital health data can be difficult to navigate when displayed in a small-format, complex interface. In this paper, we discuss two forms of patient-facing health IT tools-patient portals and applications (apps)-and highlight how, despite several limitations of each, combining high-yield features of mobile health (mHealth) apps with portals could increase patient engagement and self-management and be more effective than either of them alone. Patient portal adoption is variable, and due to design and interface limitations and health literacy issues, many people find the portal difficult to use. Conversely, apps have experienced rapid adoption and traditionally have more consumer-friendly features with easy log-in access, real-time tracking, and simplified data display. These features make the applications more intuitive and easy-to-use than patient portals. While apps have their own limitations and might serve different purposes, patient portals could adopt some high-yield features and functions of apps that lead to engagement success with patients. We thus suggest that to improve user experience with future portals, developers could look towards mHealth apps in design, function, and user interface. Adding new features to portals may improve their use and empower patients to track their overall health and disease states. Nevertheless, both these health IT tools should be subjected to rigorous evaluation to ensure they meet their potential in improving patient outcomes.

Assigning responsibility to close the loop on radiology test results

Failure to follow-up on test results represents a serious breakdown point in the diagnostic process which can lead to missed or delayed diagnoses and patient harm. Amidst discussions to ensure fail-safe test result follow-up, an important, yet under-discussed question emerges: how do we determine who is ultimately responsible for initiating follow-up action on the tests that are ordered? This seemingly simple question belies its true complexity. Although many of these complexities are also applicable to other diagnostic specialities, the field of medical imaging provides an ideal context to discuss the challenges of attributing responsibility of test result follow-up. In this review, we summarize several key concepts and challenges in the context of critical results, wet reads, and incidental findings to stimulate further discussion on responsibility issues in radiology. These discussions could help establish reliable closed-loop communication to ensure that every test result is sent, received, acknowledged and acted upon without failure.

Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records

PURPOSE

With this study, we set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement.

METHODS

Using a large national clinical data repository, we identified all patients with a new diagnosis of spinal epidural abscess in the Department of Veterans Affairs (VA) during 2013. Two physicians independently conducted retrospective chart reviews on 250 randomly selected patients and evaluated their records for red flags (eg, unexplained weight loss, neurological deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined as missed opportunities to evaluate red flags in a timely or appropriate manner. Reviewers gathered information about process breakdowns related to patient factors, the patient-provider encounter, test performance and interpretation, test follow-up and tracking, and the referral process. Reviewers also determined harm and time lag between red flags and definitive diagnoses.

RESULTS

Of 250 patients, 119 had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which experienced diagnostic error. Median time to diagnosis in error cases was 12 days, compared with 4 days in cases without error (P <.01). Red flags that were frequently not evaluated in error cases included unexplained fever (n = 57; 86.4%), focal neurological deficits with progressive or disabling symptoms (n = 54; 81.8%), and active infection (n = 54; 81.8%). Most errors involved breakdowns during the patient-provider encounter (n = 60; 90.1%), including failures in information gathering/integration, and were associated with temporary harm (n = 43; 65.2%).

CONCLUSION

Despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses are common and involve inadequate history, physical examination, and test ordering. Solutions should include renewed attention to basic clinical skills.

Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism

BACKGROUND

Delays in following up abnormal test results are a common problem in outpatient settings. Surveillance systems that use trigger tools to identify delayed follow-up can help reduce missed opportunities in care.

OBJECTIVE

To develop and test an electronic health record (EHR)-based trigger algorithm to identify instances of delayed follow-up of abnormal thyroid-stimulating hormone (TSH) results in patients being treated for hypothyroidism.

DESIGN

We developed an algorithm using structured EHR data to identify patients with hypothyroidism who had delayed follow-up (>60 days) after an abnormal TSH. We then retrospectively applied the algorithm to a large EHR data warehouse within the Department of Veterans Affairs (VA), on patient records from two large VA networks for the period from January 1, 2011, to December 31, 2011. Identified records were reviewed to confirm the presence of delays in follow-up.

KEY RESULTS

During the study period, 645,555 patients were seen in the outpatient setting within the two networks. Of 293,554 patients with at least one TSH test result, the trigger identified 1250 patients on treatment for hypothyroidism with elevated TSH. Of these patients, 271 were flagged as potentially having delayed follow-up of their test result. Chart reviews confirmed delays in 163 of the 271 flagged patients (PPV = 60.1%).

CONCLUSIONS

An automated trigger algorithm applied to records in a large EHR data warehouse identified patients with hypothyroidism with potential delays in thyroid function test results follow-up. Future prospective application of the TSH trigger algorithm can be used by clinical teams as a surveillance and quality improvement technique to monitor and improve follow-up.

The global burden of diagnostic errors in primary care

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.

Teaching for Reducing Diagnostic Errors

Diagnostic errors, constituted by a missed, wrong, or delayed diagnosis detected later by additional tests or findings, are one of the most vexing issues in medicine. They are one of the commonest causes of patient- harm and also medical negligence claims. Although a variety of constructs have been proposed to explain diagnostic errors, the complex interplay of cognitive- and system-factors that underlie these errors is rarely clear to the clinicians. In this write-up, we discuss the reasons for diagnostic errors and how medical students can be trained to avoid such errors. The errors have been classified as Cognitive errors, System errors, and No-fault errors, and cognitive interventions to address each of these are detailed.

Anti-MDA5-Positive Dermatomyositis Presenting as Fever of Unknown Origin

Dermatomyositis is a chronic systemic autoimmune disease characterized by inflammatory infiltrates in the skin and muscle. The wide variability in clinical and serologic presentation poses a diagnostic challenge for the internist. Appreciation of the clinical variants of dermatomyositis allows for expedient diagnosis and avoidance of diagnostic error. We illustrate these challenges with the case of a 51-year-old Vietnamese-American man who initially presented with fever of unknown origin in the absence of overt skin and muscle manifestations. The diagnosis of dermatomyositis was not evident on several clinical encounters due to the absence of these hallmark symptoms. We review the variable clinical manifestations of a subtype of dermatomyositis associated with an autoantibody against melanoma differentiation-associated protein 5 (anti-MDA5) and suggest consideration of dermatomyositis as a diagnosis in patients presenting with systemic illness and markedly elevated ferritin, even in the absence of elevated muscle enzymes and classic autoantibodies.

ICT and the future of health care: aspects of doctor-patient communication

OBJECTIVES

The current digital revolution is particularly relevant for interactions of healthcare providers with patients and the community as a whole. The growing public acceptance and distribution of new communication tools such as smart mobile phones provide the prerequisite for information and communication technology (ICT) -assisted healthcare applications. The present study aimed at identifying specifications and perceptions of different interest groups regarding future demands of ICT-supported doctor-patient communication in Austria.

METHODS

German-speaking Austrian healthcare experts (n = 73; 74 percent males; mean age, 43.9 years; SD 9.4) representing medical professionals, patient advocates, and administrative personnel participated in a 2-round online Delphi process. Participants evaluated scenario-based benefits and obstacles for possible prospect introduction as well as degree of innovation, desirability, and estimated implementation dates of two medical care-related future set ups.

RESULTS

Panelists expected the future ICT-supported doctor-patient dialogue to especially improve the three factors doctors-patient relationship, patients' knowledge, and quality of social health care. However, lack of acceptance by doctors, data security, and monetary aspects were considered as the three most relevant barriers for ICT implementation. Furthermore, inter-group comparison regarding desirability of future scenarios showed that medical professionals tended to be more skeptical about health-related technological innovations (p < .001).

CONCLUSIONS

The findings of this survey revealed different expectations among interest groups. Thus, we suggest building taskforces and using workshops for establishing a dialogue between stakeholders to positively shape the future of ICT-supported collaboration and communication between doctors and patients.

Determinants of out-of-hours service users' potentially inappropriate referral or non-referral to an emergency department: a retrospective cohort study in a local health authority, Veneto Region, Italy

BACKGROUND

A growing presence of inappropriate patients has been recognised as one of the main factors influencing emergency department (ED) overcrowding, which is a very widespread problem all over the world. On the other hand, out-of-hours (OOH) physicians must avoid delaying the diagnostic and therapeutic course of patients with urgent medical conditions. The aim of this study was to analyse the appropriateness of patient management by OOH services, in terms of their potentially inappropriate referral or non-referral of non-emergency cases to the ED.

METHODS

This was an observational retrospective cohort study based on data collected in 2011 by the local health authority No. 4 in the Veneto Region (Italy). After distinguishing between patients contacting the OOH service who were or were not referred to the ED, and checking for patients actually presenting to the ED within 24 hours thereafter, these patients' medical management was judged as potentially appropriate or inappropriate.

RESULTS

The analysis considered 22 662 OOH service contacts recorded in 2011. The cases of potentially inappropriate non-referral to the ED were 392 (1.7% of all contacts), as opposed to 1207 potentially inappropriate referrals (5.3% of all contacts). Age, nationality, type of disease and type of intervention by the OOH service were the main variables associated with the appropriateness of patient management.

CONCLUSIONS

These findings may be useful for pinpointing the factors associated with a potentially inappropriate patient management by OOH services and thus contribute to improving the deployment of healthcare and the quality of care delivered by OOH services.

Workarounds and Test Results Follow-up in Electronic Health Record-Based Primary Care

BACKGROUND

Electronic health records (EHRs) have potential to facilitate reliable communication and follow-up of test results. However, limitations in EHR functionality remain, leading practitioners to use workarounds while managing test results. Workarounds can lead to patient safety concerns and signify indications as to how to build better EHR systems that meet provider needs.

OBJECTIVE

To understand why primary care practitioners (PCPs) use workarounds to manage test results by analyzing data from a previously conducted national cross-sectional survey on test result management.

METHODS

We conducted a secondary data analysis of quantitative and qualitative data from a national survey of PCPs practicing in the Department of Veterans Affairs (VA) and explored the use of workarounds in test results management. We used multivariate logistic regression analysis to examine the association between key sociotechnical factors that could affect test results follow-up (e.g., both technology-related and those unrelated to technology, such as organizational support for patient notification) and workaround use. We conducted a qualitative content analysis of free text survey data to examine reasons for use of workarounds.

RESULTS

Of 2554 survey respondents, 1104 (43%) reported using workarounds related to test results management. Of these 1028 (93%) described the type of workaround they were using; 719 (70%) reported paper-based methods, while 230 (22%) used a combination of paper- and computer-based workarounds. Primary care practitioners who self-reported limited administrative support to help them notify patients of test results or described an instance where they personally (or a colleague) missed results, were more likely to use workarounds (p=0.02 and p=0.001, respectively). Qualitative analysis identified three main reasons for workaround use: 1) as a memory aid, 2) for improved efficiency and 3) for facilitating internal and external care coordination.

CONCLUSION

Workarounds to manage EHR-based test results are common, and their use results from unmet provider information management needs. Future EHRs and the respective work systems around them need to evolve to meet these needs.

Missed Opportunities for the Diagnosis of Colorectal Cancer

Objective. To examine patient and medical characteristics which predict a missed diagnostic opportunity (MDO) for colorectal cancer (CRC). Methods. The sample consisted of 252 patients diagnosed with Stages 1–4 CRC who were diagnosed in the prior six months, had experienced symptoms prior to diagnosis, and were not diagnosed through routine screening. Systematic review of all medical records prior to patients' diagnosis was conducted. An MDO was defined as a clinical encounter where, even in the presence of presumptive CRC symptoms, the CRC diagnostic process is not started. Results. 92 patients (36.5%) experienced an MDO. Almost 80% of alternate diagnoses were other GI-GU diseases, including hemorrhoids and diverticulitis. Stomach pain, anemia, and constipation were the most common symptoms experienced by the MDO group. These symptoms, and weight loss and vomiting, were more likely to be noted in the charts of the MDO patients (P < 0.04). Independent risk factors for MDO included age (<50) [OR = 2.29 (1.14–4.60), P = 0.02] and female sex [OR = 2.19 (1.16–4.16), P = 0.03]. Each additional physician seen, more than doubled the MDO risk [OR = 2.05 (1.53–2.74), P < 0.001]. Conclusions. Females, younger patients, and those consulting more physicians were all more likely to experience an MDO. Continued increased training of physicians to enhance knowledge of who is vulnerable to CRC is needed in addition to an increased focus to adherence to screening recommendations.

An adverse event capture and management system for cancer studies

BACKGROUND

Comprehensive capture of Adverse Events (AEs) is crucial for monitoring for side effects of a therapy while assessing efficacy. For cancer studies, the National Cancer Institute has developed the Common Terminology Criteria for Adverse Events (CTCAE) as a required standard for recording attributes and grading AEs. The AE assessments should be part of the Electronic Health Record (EHR) system; yet, due to patient-centric EHR design and implementation, many EHR's don't provide straightforward functions to assess ongoing AEs to indicate a resolution or a grade change for clinical trials.

METHODS

At UAMS, we have implemented a standards-based Adverse Event Reporting System (AERS) that is integrated with the Epic EHR and other research systems to track new and existing AEs, including automated lab result grading in a regulatory compliant manner. Within a patient's chart, providers can launch AERS, which opens the patient's ongoing AEs as default and allows providers to assess (resolution/ongoing) existing AEs. In another tab, it allows providers to create a new AE. Also, we have separated symptoms from diagnoses in the CTCAE to minimize inaccurate designation of the clinical observations. Upon completion of assessments, a physician would submit the AEs to the EHR via a Health Level 7 (HL7) message and then to other systems utilizing a Representational State Transfer Web Service.

CONCLUSIONS

AERS currently supports CTCAE version 3 and 4 with more than 65 cancer studies and 350 patients on those studies. This type of standard integrated into the EHR aids in research and data sharing in a compliant, efficient, and safe manner.

Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis

INTRODUCTION

Optimal critical test result communication is a Joint Commission national patient safety goal and requires documentation of closed-loop communication among care providers in the medical record. Electronic alert notification systems can facilitate an auditable process for creating alerts for transmission and acknowledgement of critical test results. We evaluated the impact of a patient safety initiative with an alert notification system on reducing critical results lacking documented communication, and assessed potential overuse of the alerting system for communicating results.

METHODS

We implemented an alert notification system-Alert Notification of Critical Results (ANCR)-in January 2010. We reviewed radiology reports finalised in 2009-2014 which lacked documented communication between the radiologist and another care provider, and assessed the impact of ANCR on the proportion of such reports with critical findings, using trend analysis over 10 semiannual time periods. To evaluate potential overuse of ANCR, we assessed the proportion of reports with non-critical results among provider-communicated reports.

RESULTS

The proportion of reports with critical results among reports without documented communication decreased significantly over 4 years (2009-2014) from 0.19 to 0.05 (p<0.0001, Cochran-Armitage trend test). The proportion of provider-communicated reports with non-critical results remained unchanged over time before and after ANCR implementation (0.20 to 0.15, p=0.45, Cochran-Armitage trend test).

CONCLUSIONS

A patient safety initiative with an alert notification system reduced the proportion of critical results among reports lacking documented communication between care providers. We observed no change in documented communication of non-critical results, suggesting the system did not promote overuse. Future studies are needed to evaluate whether such systems prevent subsequent patient harm.

Releasing test results directly to patients: A multisite survey of physician perspectives

OBJECTIVE

To determine physician perspectives about direct notification of normal and abnormal test results.

METHODS

We conducted a cross-sectional survey at five clinical sites in the US and Australia. The US-based study was conducted via web-based survey of primary care physicians and specialists between July and October 2012. An identical paper-based survey was self-administered between June and September 2012 with specialists in Australia.

RESULTS

Of 1417 physicians invited, 315 (22.2%) completed the survey. Two-thirds (65.3%) believed that patients should be directly notified of normal results, but only 21.3% were comfortable with direct notification of clinically significant abnormal results. Physicians were more likely to endorse direct notification of abnormal results if they believed it would reduce the number of patients lost to follow-up (OR=4.98, 95%CI=2.21-1.21) or if they had personally missed an abnormal test result (OR=2.95, 95%CI=1.44-6.02). Conversely, physicians were less likely to endorse if they believed that direct notification interfered with the practice of medicine (OR=0.39, 95%CI=0.20-0.74).

CONCLUSION

Physicians we surveyed generally favor direct notification of normal results but appear to have substantial concerns about direct notification of abnormal results.

PRACTICE IMPLICATIONS

Widespread use of direct notification should be accompanied by strategies to help patients manage test result abnormalities they receive.

Next steps for electronic health records to improve the diagnostic process

Electronic health record (EHR) usage is accelerating while preventable diagnostic error persists. EHRs may even contribute to diagnostic error through several pathways including poor usability and an over reliance on electronic chart based communication. The changing context of healthcare delivery offers potential financial incentives for organizations to leverage EHRs to reduce diagnostic error. The lack of standard quality metrics for reporting rates of diagnostic error, a lack of diagnostic feedback systems for physicians and organizations, and a lack of compelling evidence for specific interventions underscore the need for further research in preventing diagnostic error. Many potential strategies exist for EHRs to reduce the likelihood of diagnostic error. Practical next steps for leveraging EHR systems to assist in the diagnostic process are suggested. These include patient engagement strategies, closed loop result tracking, targeted next step reminder systems, and expansion of a list of actionable patient states based on diagnosis triggers.

Dichlorvos induced autoimmune hepatitis: a case report and review of literature

INTRODUCTION

Drug-induced liver injury is a frequent cause of hepatic dysfunction. Several drugs have been identified to cause autoimmune hepatitis (AIH). Environmental chemicals are capable of triggering a certain degree of liver injury. However, toxin induced AIH is rare.

CASE PRESENTATION

We reported a woman with chronic (long-term) exposures to dichlorvos, which resulted in liver injury and cirrhosis. She was diagnosed after a second liver biopsy, which was correlated with laboratory findings. At the same time, she experienced hepatic cortical blindness during her first admission.

CONCLUSIONS

Chronic (long-term) exposures to dichlorvos can lead to AIH. A detailed inquiry of medical history and liver biopsy are necessary for the diagnosis of toxin-induced AIH. Corticosteroid therapy is associated with favorable evolution.