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LaPlante R, Claeys KC, Bork JT, Banoub M, Noval M. Evaluating the Follow-up of Post-discharge Positive Sterile Site Cultures and the Impact on Infection-Related Complications. Infect Dis Ther 2023; 12:989-996. [PMID: 36884212 PMCID: PMC10017885 DOI: 10.1007/s40121-023-00786-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Numerous patients have cultures pending at discharge which, if not addressed, may delay diagnosis and initiation of appropriate antimicrobials. The purpose of the study is to evaluate the appropriateness of discharge antimicrobial therapy and result documentation in patients with positive cultures finalized post-discharge. METHODS This was a cross-sectional cohort study of patients admitted from July 1 to December 31, 2019 with positive sterile-site microbiologic cultures finalized post-discharge. Pertinent inclusion and exclusion factors were admission ≥ 48 h and non-sterile sites, respectively. The primary objective was to determine the frequency of discharged patients warranting antimicrobial changes based on finalized cultures. Secondary objectives included prevalence and timeliness of result documentation and rates of 30-day readmission, among intervention warranted versus not warranted. Chi-squared or Fisher's exact tests were used as appropriate. Binary multivariable logistic regression was completed for 30-day readmission stratified by infectious disease (ID) involvement due to the potential for effect modification. RESULTS A total of 208 of 768 patients screened were included. Most patients were discharged from a surgical service (45.7%); deep tissue and blood were the most common culture sites (29.3%). Change in discharge antimicrobial was warranted in 36.5% of patients (n = 76). Result documentation was overall low (35.5%). Time to documentation was significantly shorter in patients warranting antimicrobial intervention (4 days vs. 9 days, P = 0.039), although rates of hospital readmission were higher in this group (32.9% vs. 22.7%, P = 0.109). Finally, in patients not being followed by ID, documentation of finalized results was associated with decreased odds of 30-day readmission (aOR 0.19; 95% CI 0.07-0.53). CONCLUSIONS A significant number of patients with cultures finalized post-discharge warranted antimicrobial intervention. Acknowledgment of finalized culture results may decrease the risk of 30-day hospital readmission, particularly in patients not followed by ID. Quality improvement efforts should focus on methods to improve documentation and action on pending cultures to positively impact patient outcomes.
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Affiliation(s)
- Reid LaPlante
- Department of Pharmacy, University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD, 21201, USA
| | - Kimberly C Claeys
- Department of Pharmacy, University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD, 21201, USA.,Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jacqueline T Bork
- Department of Medicine, University of Maryland Medical Center, Baltimore, MD, USA.,Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD, 21201, USA
| | - Mandee Noval
- Department of Pharmacy, University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD, 21201, USA. .,Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA.
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2
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Singh H, Tang T, Steele Gray C, Kokorelias K, Thombs R, Plett D, Heffernan M, Jarach CM, Armas A, Law S, Cunningham HV, Nie JX, Ellen ME, Thavorn K, Nelson MLA. Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review. JMIR Aging 2022; 5:e35929. [PMID: 35587874 PMCID: PMC9164100 DOI: 10.2196/35929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions. Objective To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions. Methods This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1. Results In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions. Conclusions This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes. International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2020-045596
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Affiliation(s)
- Hardeep Singh
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,March of Dimes Canada, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Carolyn Steele Gray
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kristina Kokorelias
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rachel Thombs
- Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Donna Plett
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Matthew Heffernan
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Carlotta M Jarach
- Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alana Armas
- March of Dimes Canada, Toronto, ON, Canada.,Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Susan Law
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Jason Xin Nie
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Moriah E Ellen
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Michelle LA Nelson
- March of Dimes Canada, Toronto, ON, Canada.,Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Zimolzak AJ, Shahid U, Giardina TD, Memon SA, Mushtaq U, Zubkoff L, Murphy DR, Bradford A, Singh H. Why Test Results Are Still Getting "Lost" to Follow-up: a Qualitative Study of Implementation Gaps. J Gen Intern Med 2022; 37:137-144. [PMID: 33907982 PMCID: PMC8739406 DOI: 10.1007/s11606-021-06772-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/29/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm. OBJECTIVE As part of a larger project to implement change strategies to improve follow-up of diagnostic test results, this study sought to identify specifically where implementation gaps exist, as well as possible solutions identified by front-line staff. DESIGN We used a semi-structured interview guide to collect qualitative data from Veterans Affairs (VA) facility staff who had experience with test results management and patient safety. SETTING Twelve VA facilities across the USA. PARTICIPANTS Facility staff members (n = 27), including clinicians, lab and imaging professionals, nursing staff, patient safety professionals, and leadership. APPROACH We conducted a content analysis of interview transcripts to identify perceived barriers and high-risk areas for effective test result management, as well as recommendations for improvement. RESULTS We identified seven themes to guide further development of interventions to improve test result follow-up. Themes related to trainees, incidental findings, tracking systems for electronic health record notifications, outdated contact information, referrals, backup or covering providers, and responsibility for test results pending at discharge. Participants provided recommendations for improvement within each theme. CONCLUSIONS Perceived barriers and recommendations for improving test result follow-up often reflected previously known problems and their corresponding solutions, which have not been consistently implemented in practice. Better policy solutions and improvement methods, such as quality improvement collaboratives, may bridge the implementation gaps between knowledge and practice.
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Affiliation(s)
- Andrew J Zimolzak
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Umber Shahid
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sahar A Memon
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Umair Mushtaq
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Lisa Zubkoff
- Birmingham/Atlanta VA GRECC, and Division of Preventive Medicine, Department of Veterans Affairs and Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Andrea Bradford
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA. .,Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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Koh D, Wee T, Fong M, Tan X, Tan R, Menon S, Goh J, Teo S, Chia J, Kristanto W, Lim GH. Improving Results Management Processes in an Acute Hospital Using a Multi-Faceted Approach. Int J Qual Health Care 2021; 34:6485219. [PMID: 34962273 DOI: 10.1093/intqhc/mzab158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/25/2021] [Accepted: 12/16/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Radiological examinations and laboratory tests are routinely ordered by hospital physicians as part of the care plan to diagnose and treat patients. However, the failure to actively review and follow-up on these results pose a significant problem to patient safety. A study team was formed to mitigate the clinical risks of poor results management, which was identified as a top clinical risk in our organisation, in order to make improvements to the results management process and to ensure the timely review, acknowledgement, and follow-up of test results. METHODS The institutional expectations of results management were set and published as a hospital policy, which was communicated to all clinical departments for compliance. Improvements to the electronic medical records system were made to facilitate the results acknowledgement process, and physicians were engaged to educate them on the importance of results management. RESULTS The study team observed a decrease in unacknowledged results from approximately 16,000 in March 2017 to 2673 in December 2020. The compliance rate for acknowledgement results increased from a monthly average of 83.7% (from March to December 2017) to a monthly average of 99.3% (in 2020). The risk score for results management decreased from 16 to 6.5, and was excluded from the organisation's top clinical risks. CONCLUSION This study showed the importance of both system improvements and culture changes that are required to improve the process of results management, and provides a step forward for the hospital to safeguard patient safety and mitigate clinical risk.
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Affiliation(s)
- Darrel Koh
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Tracy Wee
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Michelle Fong
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Xiaohui Tan
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Rudyanna Tan
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Shalini Menon
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Joey Goh
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Stephanie Teo
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Joanna Chia
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - William Kristanto
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
| | - Ghee Hian Lim
- Department of Medical Affairs, Ng Teng Fong General Hospital, JurongHealth Campus, A member of National University Health System, Singapore
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5
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Shriner AR, Baker RM, Ellis A, Dixon R, Saysana M. Improving Follow-Up of Tests Pending at Discharge. Hosp Pediatr 2021; 11:1363-1369. [PMID: 34849927 DOI: 10.1542/hpeds.2021-006000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Follow-up on results of inpatient tests pending at discharge (TPAD) must occur to ensure patient safety and high-quality care continue after discharge. We identified a need to improve follow-up of TPAD and began a quality improvement initiative with an aim of reducing the rate of missed follow-up of TPAD to ≤20% within 12 months. METHODS The team used the Plan-Do-Study-Act method of quality improvement and implemented a process using reminder messages in the electronic health record. We collected data via retrospective chart review for the 6 months before the intervention and monthly thereafter. The primary outcome measure was the percentage of patients with missed follow-up of TPAD, defined as no documented follow-up within 72 hours of a result being available. The use of a reminder message was monitored as a process measure. RESULTS We reviewed charts of 764 discharged patients, and 216 (28%) were noted to have TPAD. At baseline, the average percentage of patients with missed follow-up was 80%. The use of reminder messages was quickly adopted. The average percentage of patients with missed follow-up of TPAD after beginning the quality improvement interventions was 35%. CONCLUSIONS We had significant improvement in follow-up after our interventions. Additional work is needed to ensure continued and sustained improvement, focused on reducing variability in performance between providers and investing in technology to allow for automation of the follow-up process.
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Affiliation(s)
- Andrew R Shriner
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
| | - Richelle M Baker
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
| | - Andrew Ellis
- Mercy Children's Hospital, St Louis, Missouri.,Department of Child Health School of Medicine, University of Missouri, Columbia, Missouri
| | - Rebecca Dixon
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
| | - Michele Saysana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
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Georgiou A, Li J, Thomas J, Dahm MR, Westbrook JI. The impact of health information technology on the management and follow-up of test results - a systematic review. J Am Med Inform Assoc 2020; 26:678-688. [PMID: 31192362 PMCID: PMC6562156 DOI: 10.1093/jamia/ocz032] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/21/2019] [Accepted: 02/28/2019] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To investigate the impact of health information technology (IT) systems on clinicians' work practices and patient engagement in the management and follow-up of test results. MATERIALS AND METHODS A search for studies reporting health IT systems and clinician test results management was conducted in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, ScienceDirect, ProQuest, and Scopus from January 1999 to June 2018. Test results follow-up was defined as provider follow-up of results for tests that were sent to the laboratory and radiology services for processing or analysis. RESULTS There are some findings from controlled studies showing that health IT can improve the proportion of tests followed-up (15 percentage point change) and increase physician awareness of test results that require action (24-28 percentage point change). Taken as whole, however, the evidence of the impact of health IT on test result management and follow-up is not strong. DISCUSSION The development of safe and effective test results management IT systems should pivot on several axes. These axes include 1) patient-centerd engagement (involving shared, timely, and meaningful information); 2) diagnostic processes (that involve the integration of multiple people and different clinical settings across the health care spectrum); and 3) organizational communications (the myriad of multi- transactional processes requiring feedback, iteration, and confirmation) that contribute to the patient care process. CONCLUSION Existing evidence indicates that health IT in and of itself does not (and most likely cannot) provide a complete solution to issues related to test results management and follow-up.
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Affiliation(s)
- Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Judith Thomas
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Maria R Dahm
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Wiley KK, Hilts KE, Ancker JS, Unruh MA, Jung HY, Vest JR. Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange. JAMIA Open 2020; 3:611-618. [PMID: 33623895 PMCID: PMC7886547 DOI: 10.1093/jamiaopen/ooaa065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/04/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Event notification systems are an approach to health information exchange (HIE) that notifies end-users of patient interactions with the healthcare system through real-time automated alerts. We examined associations between organizational capabilities and perceptions of event notification system use. MATERIALS AND METHODS We surveyed representatives (n = 196) from healthcare organizations (n = 96) that subscribed to 1 of 3 Health Information Organizations' event notification services in New York City (response rate = 27%). The survey was conducted in Fall 2017 and Winter 2018. Surveys measured respondent characteristics, perceived organizational capabilities, event notification use, care coordination, and care quality. Exploratory factor analysis was used to identify relevant independent and dependent variables. We examined the relationship between organizational capabilities, care coordination, and care quality using multilevel linear regression models with random effects. RESULTS Respondents indicated that the majority of their organizations provided follow-up care for emergency department visits (66%) and hospital admissions (73%). Perceptions of care coordination were an estimated 57.5% (β = 0.575; P < 0.001) higher among respondents who reported event notifications fit within their organization's existing workflows. Perceptions of care quality were 46.5% (β = 0.465; P < 0.001) higher among respondents who indicated event notifications fit within existing workflows and 23.8% (β = 0.238; P < 0.01) higher where respondents reported having supportive policies and procedures for timely response and coordination of event notifications. DISCUSSION AND CONCLUSION Healthcare organizations with specific workflow processes and positive perceptions of fit are more likely to use event notification services to improve care coordination and care quality. In addition, event notification capacity and patient consent procedures influence how end-users perceive event notification services.
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Affiliation(s)
- Kevin K Wiley
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, Indiana 46202-2872, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Katy Ellis Hilts
- School of Nursing, Indiana University, Indianapolis, Indiana, USA
| | - Jessica S Ancker
- Division of Health Policy and Economics, Weill-Cornell Medicine, New York, New York, USA
| | - Mark A Unruh
- Division of Health Policy and Economics, Weill-Cornell Medicine, New York, New York, USA
| | - Hye-Young Jung
- Division of Health Policy and Economics, Weill-Cornell Medicine, New York, New York, USA
| | - Joshua R Vest
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, Indiana 46202-2872, USA
- Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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Early Impact of Pennsylvania Act 112 on Follow-up of Abnormal Imaging Findings. J Am Coll Radiol 2020; 17:1676-1683. [DOI: 10.1016/j.jacr.2020.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023]
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Thomas J, Dahm MR, Li J, Smith P, Irvine J, Westbrook JI, Georgiou A. Variation in electronic test results management and its implications for patient safety: A multisite investigation. J Am Med Inform Assoc 2020; 27:1214-1224. [PMID: 32719839 PMCID: PMC7481032 DOI: 10.1093/jamia/ocaa093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 05/06/2020] [Indexed: 11/15/2022] Open
Abstract
Objective The management and follow-up of diagnostic test results is a major patient safety concern. The aim of this qualitative study was to explore how clinicians manage test results on an everyday basis (work-as-done) in a health information technology–enabled emergency department setting. The objectives were to identify (1) variations in work-as-done in test results management and (2) the strategies clinicians use to ensure optimal management of diagnostic test results. Materials and Methods Qualitative interviews (n = 26) and field observations were conducted across 3 Australian emergency departments. Interview data coded for results management (ie, tracking, acknowledgment, and follow-up), and artifacts, were reviewed to identify variations in descriptions of work-as-done. Thematic analysis was performed to identify common themes. Results Despite using the same test result management application, there were variations in how the system was used. We identified 5 themes relating to electronic test results management: (1) tracking test results, (2) use and understanding of system functionality, (3) visibility of result actions and acknowledgment, (4) results inbox use, and (5) challenges associated with the absence of an inbox for results notifications for advanced practice nurses. Discussion Our findings highlight that variations in work-as-done can function to overcome perceived impediments to managing test results in a HIT-enabled environment and thus identify potential risks in the process. By illuminating work-as-done, we identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality. Conclusions Test results tracking and follow-up is a priority area in need of health information technology development and training to improve team-based collaboration/communication of results follow-up and diagnostic safety.
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Affiliation(s)
- Judith Thomas
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Maria R Dahm
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Peter Smith
- Emergency Medicine, Illawarra Shoalhaven Local Health District, New South Wales, Australia.,Graduate School of Medicine, University of Wollongong, New South Wales, Australia
| | - Jacqui Irvine
- Emergency Medicine, Illawarra Shoalhaven Local Health District, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
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Spiewak TA, Yan SL, Tejaswi S. Impact of EMR Automated Results Routing Tool Implementation on Notification of Inpatient Endoscopy Biopsy Results. Jt Comm J Qual Patient Saf 2020; 46:321-325. [PMID: 32402762 DOI: 10.1016/j.jcjq.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Mucosal biopsies are often obtained during inpatient endoscopies to aid diagnosis. Up to 75% of patients are reported to have pending test results at discharge. Incomplete result communication to patients can lead to patient anxiety and poor outcomes. This study aimed to evaluate the impact of a systemwide electronic medical record (EMR) update on result communication. METHODS The researchers retrospectively reviewed 100 inpatient endoscopies pending histopathology results at discharge to see if finalized results were communicated to the patients within 30 days. The same metric was studied after implementation of an EMR update that automatically routed results to the supervising endoscopist, by reviewing another 100 inpatient endoscopies during which biopsies were obtained. Follow-up rate pre- and post-EMR update was compared. RESULTS Prior to the update, 47/77 (61.0%) histopathology results were communicated to the patients. Of the 30 nonreported cases, 17 showed nonspecific/chronic inflammation, 8 had no abnormal findings, 3 showed hyperplastic colon polyps, and 2 had colonic tubular adenomas. Following the EMR update, 65/71 (91.5%) of pathology results were communicated, demonstrating an increase of 30.5 percentage points in the rate of follow-up (95% confidence interval [CI] = 17.7-43.0, p < 0.0001). CONCLUSION This study observed that 39.0% of inpatient endoscopic mucosal biopsy results in one health care system were not communicated to the patients. Implementation of a systemwide EMR intervention reduced this to 8.5% by shifting the responsibility of result communication to the endoscopy team. Similar EMR enhancements can be applied to other pending test results in health care systems with similar issues.
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Vest JR, Hilts KE, Ancker JS, Unruh MA, Jung HY. Usage of query-based health information exchange after event notifications. JAMIA Open 2020; 2:291-295. [PMID: 31984363 PMCID: PMC6951916 DOI: 10.1093/jamiaopen/ooz028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/17/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives This study sought to quantify the association between event notifications and subsequent query-based health information exchange (HIE) use among end users of three different community health information organizations. Materials and Methods Using system-log data merged with user characteristics, regression-adjusted estimates were used to describe the association between event notifications and subsequent query-based HIE usage. Results Approximately 5% of event notifications were associated with query-based HIE usage within 30 days. In adjusted models, odds of query-based HIE usage following an event notification were higher for older patients and for alerts triggered by a discharge event. Query-based HIE usage was more common among specialty clinics and Federally Qualified Health Centers than primary care organizations. Discussion and Conclusion In this novel combination of data, 1 in 20 event notifications resulted in subsequent query-based HIE usage. Results from this study suggest that event notifications and query-based HIE can be applied together to address clinical and population health use cases.
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Affiliation(s)
- Joshua R Vest
- Indiana University Richard M. Fairbanks School of Public Health, Department of Health Policy & Management, Indiana, USA.,Regenstrief Institute Inc., Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Katy Ellis Hilts
- Indiana University Richard M. Fairbanks School of Public Health, Department of Health Policy & Management, Indiana, USA
| | - Jessica S Ancker
- Weill Cornell Medical College, Department of Healthcare Policy & Research, New York City, New York, USA
| | - Mark Aaron Unruh
- Weill Cornell Medical College, Department of Healthcare Policy & Research, New York City, New York, USA
| | - Hye-Young Jung
- Weill Cornell Medical College, Department of Healthcare Policy & Research, New York City, New York, USA
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Whitehead NS, Williams L, Meleth S, Kennedy S, Epner P, Singh H, Wooldridge K, Dalal AK, Walz SE, Lorey T, Graber ML. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med 2018; 13:631-636. [PMID: 29489926 PMCID: PMC9491200 DOI: 10.12788/jhm.2944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/29/2017] [Accepted: 12/17/2017] [Indexed: 01/25/2023]
Abstract
Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, eight met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published Laboratory Medicine Best Practices (LMBP™) A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.
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Affiliation(s)
| | - Laurina Williams
- Centers for Disease Control and Prevention, Atlanta, Georgia
- Author for correspondence: Laurina Williams, PhD, MPH, Centers for Disease Control and Prevention, Center for Surveillance, Epidemiology, and Laboratory Services, Division of Laboratory Systems,1600 Clifton Road, NE, MS G25, Atlanta, GA 30329; Telephone: 404-498-2267; Fax: 404-498-2215,
| | | | - Sara Kennedy
- RTI International, Research Triangle Park, North Carolina
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas
| | | | - Anuj K. Dalal
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Tom Lorey
- Kaiser Permanente Northern California, Berkeley, California
| | - Mark L. Graber
- RTI International, Research Triangle Park, North Carolina
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Dalal AK, Schaffer A, Gershanik EF, Papanna R, Eibensteiner K, Nolido NV, Yoon CS, Williams D, Lipsitz SR, Roy CL, Schnipper JL. The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial. J Gen Intern Med 2018; 33:1043-1051. [PMID: 29532297 PMCID: PMC6025668 DOI: 10.1007/s11606-018-4393-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/03/2018] [Accepted: 02/01/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up. KEY RESULTS Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03). CONCLUSIONS Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern. CLINICAL TRIALS IDENTIFIER NCT01153451.
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Affiliation(s)
- Anuj K Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Adam Schaffer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, MA, USA
| | - Esteban F Gershanik
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ranganath Papanna
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katyuska Eibensteiner
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Nyryan V Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy S Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah Williams
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Partners HealthCare, Inc., Boston, MA, USA
| | - Stuart R Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christopher L Roy
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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O'Connor SD, Khorasani R, Pochebit SM, Lacson R, Andriole KP, Dalal AK. Semiautomated System for Nonurgent, Clinically Significant Pathology Results. Appl Clin Inform 2018; 9:411-421. [PMID: 29874687 DOI: 10.1055/s-0038-1654700] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND Failure of timely test result follow-up has consequences including delayed diagnosis and treatment, added costs, and potential patient harm. Closed-loop communication is key to ensure clinically significant test results (CSTRs) are acknowledged and acted upon appropriately. A previous implementation of the Alert Notification of Critical Results (ANCR) system to facilitate closed-loop communication of imaging CSTRs yielded improved communication of critical radiology results and enhanced adherence to institutional CSTR policies. OBJECTIVE This article extends the ANCR application to pathology and evaluates its impact on closed-loop communication of new malignancies, a common and important type of pathology CSTR. MATERIALS AND METHODS This Institutional Review Board-approved study was performed at a 150-bed community, academically affiliated hospital. ANCR was adapted for pathology CSTRs. Natural language processing was used on 30,774 pathology reports 13 months pre- and 13 months postintervention, identifying 5,595 reports with malignancies. Electronic health records were reviewed for documented acknowledgment for a random sample of reports. Percent of reports with documented acknowledgment within 15 days assessed institutional policy adherence. Time to acknowledgment was compared pre- versus postintervention and postintervention with and without ANCR alerts. Pathologists were surveyed regarding ANCR use and satisfaction. RESULTS Acknowledgment within 15 days was documented for 98 of 107 (91.6%) pre- and 89 of 103 (86.4%) postintervention reports (p = 0.2294). Median time to acknowledgment was 7 days (interquartile range [IQR], 3, 11) preintervention and 6 days (IQR, 2, 10) postintervention (p = 0.5083). Postintervention, median time to acknowledgment was 2 days (IQR, 1, 6) for reports with ANCR alerts versus 6 days (IQR, 2.75, 9) for reports without alerts (p = 0.0351). ANCR alerts were sent on 15 of 103 (15%) postintervention reports. All pathologists reported that the ANCR system positively impacted their workflow; 75% (three-fourths) felt that the ANCR system improved efficiency of communicating CSTRs. CONCLUSION ANCR expansion to facilitate closed-loop communication of pathology CSTRs was favorably perceived and associated with significant improved time to documented acknowledgment for new malignancies. The rate of adherence to institutional policy did not improve.
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Affiliation(s)
- Stacy D O'Connor
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ramin Khorasani
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Stephen M Pochebit
- Department of Pathology, Brigham and Women's Faulkner Hospital, Boston, Massachusetts, United States
| | - Ronilda Lacson
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Katherine P Andriole
- Center for Evidence-Based Imaging and Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Anuj K Dalal
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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15
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A Systematic Review of Interventions to Follow-Up Test Results Pending at Discharge. J Gen Intern Med 2018; 33:750-758. [PMID: 29352419 PMCID: PMC5910344 DOI: 10.1007/s11606-017-4290-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 07/12/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients are frequently discharged from the hospital before all test results have been finalized. Thirty to 40% of tests pending at discharge (TPADs) return potentially actionable results that could necessitate change in the patients' management, often unbeknownst to their physicians. Delayed follow-up of TPADs can lead to patient harm. We sought to synthesize the existing literature on interventions intended to improve the management of TPADs, including interventions designed to enhance documentation of TPADs, increase physician awareness when TPAD results finalize post-discharge, decrease adverse events related to missed TPADs, and increase physician satisfaction with TPAD management. METHODS We searched Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Controlled Clinical Trials and Medline (January 1, 2000-November 10, 2016) for randomized controlled trials and prospective, controlled observational studies that evaluated interventions to improve follow-up of TPADs for adult patients discharged from acute care hospitals or emergency department settings. From each study we extracted characteristics of the intervention being evaluated and its impact on TPAD management. RESULTS Nine studies met the criteria for inclusion. Six studies evaluated electronic discharge summary templates with a designated field for documenting TPADs, and three of six of these studies reported a significant improvement in documentation of TPADs in discharge summaries in pre- and post-intervention analysis. One study reported that auditing discharge summaries and providing feedback to physicians were associated with improved TPAD documentation in discharge summaries. Two studies found that email alerts when TPADs were finalized improved physicians' awareness of the results and documentation of their follow-up actions. Of the four studies that assessed patient morbidity, two showed a positive effect; however, none specifically measured the impact of their interventions on downstream patient harm due to delayed follow-up of TPADs. Three studies surveyed physicians' attitudes towards the interventions, of which two studies reported improved physician satisfaction with TPAD management with the implementation of an enhanced discharge template and a notification system when TPADs finalize. DISCUSSION Discharge summary templates, educational interventions for discharging physicians, and email alerts when TPAD results are finalized show promise in improving management of TPADs. Given the complexity of the processes necessary to ensure follow-up of TPADs, rigorous evaluations of multifaceted interventions (e.g., improved discharge documentation of TPADs combined with email alerts when results become available) is needed.
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Unruh MA, Jung HY, Kaushal R, Vest JR. Hospitalization event notifications and reductions in readmissions of Medicare fee-for-service beneficiaries in the Bronx, New York. J Am Med Inform Assoc 2018; 24:e150-e156. [PMID: 28395059 DOI: 10.1093/jamia/ocw139] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/23/2016] [Indexed: 11/14/2022] Open
Abstract
Objective Follow-up with a primary care provider after hospital discharge has been associated with a reduced likelihood of readmission. However, primary care providers are frequently unaware of their patients' hospitalizations. Event notification may be an effective tool for reducing readmissions by notifying primary care providers when their patients have been admitted to and discharged from a hospital. Materials and Methods We examined the effect of an event notification system on 30-day readmissions in the Bronx, New York. The Bronx has among the highest readmission rates in the country and is a particularly challenging setting to improve care due to the low socioeconomic status of the county and high rates of poor health behaviors among its residents. The study cohort included 2559 Medicare fee-for-service beneficiaries associated with 14 141 hospital admissions over the period January 2010 through June 2014. Linear regression models with beneficiary-level fixed-effects were used to estimate the impact of event notifications on readmissions by comparing the likelihood of rehospitalization for a beneficiary before and after event notifications were active. Results The unadjusted 30-day readmission rate when event notifications were not active was 29.5% compared to 26.5% when alerts were active. Regression estimates indicated that active hospitalization alert services were associated with a 2.9 percentage point reduction in the likelihood of readmission (95% confidence interval: -5.5, -0.4). Conclusions Alerting providers through event notifications may be an effective tool for improving the quality and efficiency of care among high-risk populations.
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Affiliation(s)
- Mark Aaron Unruh
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Hye-Young Jung
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Rainu Kaushal
- Department of Healthcare Policy and Research, Department of Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY, 10065, USA
| | - Joshua R Vest
- Department of Healthcare Policy & Management, Indiana University Richard M. Fairbanks School of Public Health - Indianapolis, Affiliated Scientist, Regenstrief Institute, Inc., Indianapolis, IN, USA
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Cassell BE, Walker T, Alghamdi S, Bill J, Blais P, Boutté H, Brown JW, Sayuk GS, Gyawali CP. Do Consultants Follow Up on Tests They Recommend? Insights from an Academic Inpatient Gastrointestinal Consult Service. Dig Dis Sci 2017; 62:1448-1454. [PMID: 28391419 PMCID: PMC5890923 DOI: 10.1007/s10620-017-4563-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/30/2017] [Indexed: 12/09/2022]
Abstract
BACKGROUND Inpatient care is a fundamental part of gastroenterology training and involves the recommendation, performance, and interpretation of diagnostic tests. However, test results are not always communicated to patients or treating providers. We determined the process of communication of test results and recommendations in our inpatient gastroenterology (GI) consult service. METHODS Test recommendations on 304 consecutive new GI consults (age 60.2 ± 1.0 year) over a 2-month period were recorded. Demographic factors (age, race, gender, zip code, insurance status) were extracted from the electronic medical record (EMR). Charts were independently reviewed 6 months later to determine results of recommended tests, follow-up of actionable test results, 30-day readmission rates, and predictors of suboptimal communication. RESULTS Of 490 recommended tests, 437 (89.2%) were performed, and 199 (45.5%) had actionable findings. Of these, 48 (24.1%) did not have documented follow-up. Failure of follow-up was higher for upper endoscopy (31.9%) compared to colonoscopy (18.0%, p = 0.07). Women (p = 0.07), patients on Medicare (p = 0.05), and procedures supervised by advanced GI fellows (p = 0.06) were less likely to receive follow-up. Median income and identification of a primary provider did not influence follow-up rates; 30-day readmission rates were not impacted. Female gender, insurance (Medicare) status, and attending type remained independent predictors of failure of follow-up on multivariate regression (p ≤ 0.03). CONCLUSIONS Failure to follow up test results on inpatient services at a large academic center was unacceptably high. Maximizing personnel participation together with diligence and technology (EMR) will be required to improve communication.
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Affiliation(s)
- Benjamin E. Cassell
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA,Division of Gastroenterology and Hepatology, University of Colorado, 1055 Clermont St MS 111-E, Denver, CO 80218, USA
| | - Ted Walker
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Saad Alghamdi
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason Bill
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Pierre Blais
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Harold Boutté
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey W. Brown
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory S. Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA,Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA,John Cochran VA Medical Center, St. Louis, MO, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Initial Effectiveness of a Monitoring System to Correctly Identify Inappropriate Lack of Follow-Up for Abdominal Imaging Findings of Possible Cancer. J Am Coll Radiol 2016; 13:1505-1508.e2. [DOI: 10.1016/j.jacr.2016.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 12/14/2022]
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Cresswell K, Mozaffar H, Shah S, Sheikh A. Approaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:5-17. [DOI: 10.1111/ijpp.12274] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kathrin Cresswell
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | - Hajar Mozaffar
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | | | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
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Dalal AK, Pesterev BM, Eibensteiner K, Newmark LP, Samal L, Rothschild JM. Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. J Am Med Inform Assoc 2015; 22:905-8. [PMID: 25796594 PMCID: PMC6283058 DOI: 10.1093/jamia/ocv007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/15/2014] [Accepted: 01/19/2015] [Indexed: 12/13/2022] Open
Abstract
Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment functionality to ensure follow-up of nonurgent CSTRs.
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Affiliation(s)
- Anuj K Dalal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital
| | - Bailey M Pesterev
- Division of General Medicine and Primary Care, Brigham and Women's Hospital
| | | | - Lisa P Newmark
- Division of General Medicine and Primary Care, Brigham and Women's Hospital Partners HealthCare, Inc
| | - Lipika Samal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital
| | - Jeffrey M Rothschild
- Division of General Medicine and Primary Care, Brigham and Women's Hospital Partners HealthCare, Inc
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Sloan CE, Chadalavada SC, Cook TS, Langlotz CP, Schnall MD, Zafar HM. Assessment of follow-up completeness and notification preferences for imaging findings of possible cancer: what happens after radiologists submit their reports? Acad Radiol 2014; 21:1579-86. [PMID: 25179562 DOI: 10.1016/j.acra.2014.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 02/07/2023]
Abstract
RATIONALE AND OBJECTIVES To understand the reasons leading to potentially inappropriate management of imaging findings concerning for malignancy and identify optimal methods for communicating these findings to providers. MATERIALS AND METHODS We identified all abdominal imaging examinations with findings of possible cancer performed on six randomly selected days in August to December 2013. Electronic medical records (EMR) of one patient group were reviewed 3 months after the index examination to determine whether management was appropriate (completed follow-up or documented reason for no follow-up) or potentially inappropriate (no follow-up or no documented reason). Providers of a second patient group were contacted 5-6 days after imaging examinations to determine notification preferences. RESULTS Among 43 patients in the first group, five (12%) received potentially inappropriate management. Reasons included patient loss to follow-up and provider failure to review imaging results, document known imaging findings, or communicate findings to providers outside the health system. Among 16 providers caring for patients in the second group, 33% were unaware of the findings, 75% preferred to be notified of abnormal findings via e-mail or EMR, 56% wanted an embedded hyperlink enabling immediate follow-up order entry, and only 25% had a system to monitor whether patients had completed ordered testing. CONCLUSIONS One in eight patients did not receive potentially necessary follow-up care within 3 months of imaging findings of possible cancer. Automated notification of imaging findings and follow-up monitoring not only is desired by providers but can also address many of the reasons we found for inappropriate management.
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Affiliation(s)
- Caroline E Sloan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Seetharam C Chadalavada
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tessa S Cook
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Curtis P Langlotz
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mitchell D Schnall
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanna M Zafar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Rhoads DD, Sintchenko V, Rauch CA, Pantanowitz L. Clinical microbiology informatics. Clin Microbiol Rev 2014; 27:1025-47. [PMID: 25278581 PMCID: PMC4187636 DOI: 10.1128/cmr.00049-14] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The clinical microbiology laboratory has responsibilities ranging from characterizing the causative agent in a patient's infection to helping detect global disease outbreaks. All of these processes are increasingly becoming partnered more intimately with informatics. Effective application of informatics tools can increase the accuracy, timeliness, and completeness of microbiology testing while decreasing the laboratory workload, which can lead to optimized laboratory workflow and decreased costs. Informatics is poised to be increasingly relevant in clinical microbiology, with the advent of total laboratory automation, complex instrument interfaces, electronic health records, clinical decision support tools, and the clinical implementation of microbial genome sequencing. This review discusses the diverse informatics aspects that are relevant to the clinical microbiology laboratory, including the following: the microbiology laboratory information system, decision support tools, expert systems, instrument interfaces, total laboratory automation, telemicrobiology, automated image analysis, nucleic acid sequence databases, electronic reporting of infectious agents to public health agencies, and disease outbreak surveillance. The breadth and utility of informatics tools used in clinical microbiology have made them indispensable to contemporary clinical and laboratory practice. Continued advances in technology and development of these informatics tools will further improve patient and public health care in the future.
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Affiliation(s)
- Daniel D Rhoads
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vitali Sintchenko
- Marie Bashir Institute for Infectious Diseases and Biosecurity and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia Centre for Infectious Diseases and Microbiology-Public Health, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Carol A Rauch
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ji Z, Jiang X, Wang S, Xiong L, Ohno-Machado L. Differentially private distributed logistic regression using private and public data. BMC Med Genomics 2014; 7 Suppl 1:S14. [PMID: 25079786 PMCID: PMC4101668 DOI: 10.1186/1755-8794-7-s1-s14] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Privacy protecting is an important issue in medical informatics and differential privacy is a state-of-the-art framework for data privacy research. Differential privacy offers provable privacy against attackers who have auxiliary information, and can be applied to data mining models (for example, logistic regression). However, differentially private methods sometimes introduce too much noise and make outputs less useful. Given available public data in medical research (e.g. from patients who sign open-consent agreements), we can design algorithms that use both public and private data sets to decrease the amount of noise that is introduced. Methodology In this paper, we modify the update step in Newton-Raphson method to propose a differentially private distributed logistic regression model based on both public and private data. Experiments and results We try our algorithm on three different data sets, and show its advantage over: (1) a logistic regression model based solely on public data, and (2) a differentially private distributed logistic regression model based on private data under various scenarios. Conclusion Logistic regression models built with our new algorithm based on both private and public datasets demonstrate better utility than models that trained on private or public datasets alone without sacrificing the rigorous privacy guarantee.
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Roy CL, Rothschild JM, Dighe AS, Schiff GD, Graydon-Baker E, Lenoci-Edwards J, Dwyer C, Khorasani R, Gandhi TK. An initiative to improve the management of clinically significant test results in a large health care network. Jt Comm J Qual Patient Saf 2014; 39:517-27. [PMID: 24294680 DOI: 10.1016/s1553-7250(13)39068-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged. METHODS In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action. RESULTS The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics. CONCLUSIONS This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.
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Dalal AK, Roy CL, Poon EG, Williams DH, Nolido N, Yoon C, Budris J, Gandhi T, Bates DW, Schnipper JL. Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. J Am Med Inform Assoc 2013; 21:473-80. [PMID: 24154834 DOI: 10.1136/amiajnl-2013-002030] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results. METHODS We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction. RESULTS We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention. CONCLUSIONS Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT01153451).
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Affiliation(s)
- Anuj K Dalal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
BACKGROUND Health information technology (HIT) systems have the potential to reduce delayed, missed or incorrect diagnoses. We describe and classify the current state of diagnostic HIT and identify future research directions. METHODS A multi-pronged literature search was conducted using PubMed, Web of Science, backwards and forwards reference searches and contributions from domain experts. We included HIT systems evaluated in clinical and experimental settings as well as previous reviews, and excluded radiology computer-aided diagnosis, monitor alerts and alarms, and studies focused on disease staging and prognosis. Articles were organised within a conceptual framework of the diagnostic process and areas requiring further investigation were identified. RESULTS HIT approaches, tools and algorithms were identified and organised into 10 categories related to those assisting: (1) information gathering; (2) information organisation and display; (3) differential diagnosis generation; (4) weighing of diagnoses; (5) generation of diagnostic plan; (6) access to diagnostic reference information; (7) facilitating follow-up; (8) screening for early detection in asymptomatic patients; (9) collaborative diagnosis; and (10) facilitating diagnostic feedback to clinicians. We found many studies characterising potential interventions, but relatively few evaluating the interventions in actual clinical settings and even fewer demonstrating clinical impact. CONCLUSIONS Diagnostic HIT research is still in its early stages with few demonstrations of measurable clinical impact. Future efforts need to focus on: (1) improving methods and criteria for measurement of the diagnostic process using electronic data; (2) better usability and interfaces in electronic health records; (3) more meaningful incorporation of evidence-based diagnostic protocols within clinical workflows; and (4) systematic feedback of diagnostic performance.
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Affiliation(s)
- Robert El-Kareh
- Division of Biomedical Informatics, UCSD, , San Diego, California, USA
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Improving test result follow-up through electronic health records requires more than just an alert. J Gen Intern Med 2012; 27:1235-7. [PMID: 22790618 PMCID: PMC3445682 DOI: 10.1007/s11606-012-2161-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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