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Sloane JF, Donkin C, Newell BR, Singh H, Meyer AND. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda. J Gen Intern Med 2023; 38:1526-1531. [PMID: 36697925 PMCID: PMC10160308 DOI: 10.1007/s11606-022-08019-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/29/2022] [Indexed: 01/27/2023]
Abstract
Interruptions are an inevitable occurrence in health care. Interruptions in diagnostic decision-making are no exception and can have negative consequences on both the decision-making process and well-being of the decision-maker. This may result in inaccurate or delayed diagnoses. To date, research specific to interruptions on diagnostic decision-making has been limited, but strategies to help manage the negative impacts of interruptions need to be developed and implemented. In this perspective, we first present a modified model of interruptions to visualize the interruption process and illustrate where potential interventions can be implemented. We then consider several empirically tested strategies from the fields of health care and cognitive psychology that can lay the groundwork for additional research to mitigate effects of interruptions during diagnostic decision-making. We highlight strategies to minimize the negative impacts of interruptions as well as strategies to prevent interruptions altogether. Additionally, we build upon these strategies to propose specific research priorities within the field of diagnostic safety. Identifying effective interventions to help clinicians better manage interruptions has the potential to minimize diagnostic errors and improve patient outcomes.
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Affiliation(s)
- Jennifer F Sloane
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- School of Psychology, University of New South Wales Sydney, Kensington, Australia.
| | - Chris Donkin
- School of Psychology, University of New South Wales Sydney, Kensington, Australia
- Ludwig Maximilian University of Munich, Munich, Germany
| | - Ben R Newell
- School of Psychology, University of New South Wales Sydney, Kensington, Australia
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Strachna O, Asan O, Stetson PD. Managing Critical Patient-Reported Outcome Measures in Oncology Settings: System Development and Retrospective Study. JMIR Med Inform 2022; 10:e38483. [PMID: 36326801 PMCID: PMC9672998 DOI: 10.2196/38483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/27/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Remote monitoring programs based on the collection of patient-reported outcome (PRO) data are being increasingly adopted in oncology practices. Although PROs are a great source of patient data, the management of critical PRO data is not discussed in detail in the literature. OBJECTIVE This first-of-its-kind study aimed to design, describe, and evaluate a closed-loop alerting and communication system focused on managing PRO-related alerts in cancer care. METHODS We designed and developed a novel solution using an agile software development methodology by incrementally building new capabilities. We evaluated these new features using participatory design and the Fit between Individuals, Task, and Technology framework. RESULTS A total of 8 questionnaires were implemented using alerting features, resulting in an alert rate of 7.82% (36,838/470,841) with 13.28% (10,965/82,544) of the patients triggering at least one alert. Alerts were reviewed by 501 staff members spanning across 191 care teams. All the alerts were reviewed with a median response time of 1 hour (SD 185 hours) during standard business hours. The most severe (red) alerts were documented 56.83% (2592/4561) of the time, whereas unlabeled alerts were documented 27.68% (1298/4689) of the time, signaling clinician concordance with the alert thresholds. CONCLUSIONS A PRO-based alert and communication system has some initial benefits in reviewing clinically meaningful PRO data in a reasonable amount of time. We have discussed key system design considerations, workflow integration, and the mitigation of potential impact on the burden of care teams. The introduction of a PRO-based alert and communication system provides a reliable mechanism for care teams to review and respond to patient symptoms quickly. The system was standardized across many different oncology settings, demonstrating system flexibility. Future studies should focus on formally evaluating system usability through qualitative methods.
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Affiliation(s)
- Olga Strachna
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, United States
- Division of Digital Products and Informatics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Peter D Stetson
- Division of Digital Products and Informatics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Pichardo-Lowden AR, Haidet P, Umpierrez GE, Lehman EB, Quigley FT, Wang L, Rafferty CM, DeFlitch CJ, Chinchilli VM. Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay. Diabetes Care 2022; 45:2526-2534. [PMID: 36084251 PMCID: PMC9679255 DOI: 10.2337/dc21-0829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Paul Haidet
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Humanities and the Woodward Center for Excellence in Health Sciences Education, Penn State College of Medicine, Hershey, PA
| | | | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Francis T. Quigley
- Department of Medicine, Penn State Health St. Joseph Medical Center, Reading, PA
| | - Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Colleen M. Rafferty
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Christopher J. DeFlitch
- Department of Emergency Medicine, Office of the Chief Medical Information Officer, Penn State Health, Hershey, PA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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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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Zomerlei T, Carraher A, Chao A, Vink S, Chandawarkar R. When no news is bad news: Improving diagnostic testing communication through patient engagement. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211044586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Importance Up to 17% of diagnostic test results are missed, lost or ignored despite conventional fixes such as electronic physician reminders – naïvely, patients assume: ‘No-News-is-Good-News’. These lapses can result in poor outcomes, complications, and even death. In response, Centers for Medicare and Medicaid Services (CMS)-led physician quality reporting system measure#265 emphasizes prevention. This study aims to improve the timely review of results through increasing patient engagement. Design and Participants Ninety patients undergoing diagnostic testing were included in this Internal Review Board (IRB)-approved study. Two groups, group-A (patients with medical chart access through our EHR, n = 40); and group-B (controls, n = 50) were included. Group-A was reminded via written AVS and EHR portal messages to ask about their test results at their next appointment. Controls were sent no reminders, mimicking the status- quo. Main Outcomes At subsequent visits whether patients ‘asked’ or ‘did not ask’ about their results was recorded and analyzed. Study group participants were also surveyed on their preferences for reminder communication. Results Patients that were sent reminders were up to twenty times more likely to ask their provider regarding their test results than the control group ( p < 0.0001). Eighty-one percent indicated that the reminders were helpful with 90% indicating they were ‘necessary’. Neither gender nor age seemed predictive factors of patient engagement. Conclusions and Relevance This pilot study demonstrates that engaging patients in their own care through already-existing tools (AVS, EHR portal messages) improves patient-physician communication, and could lead to lower rates of missed diagnostic tests.
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Affiliation(s)
- Terri Zomerlei
- The Department of Plastic Surgery and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Amanda Carraher
- The Department of Plastic Surgery and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Albert Chao
- The Department of Plastic Surgery and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shonda Vink
- The Department of Clinical Applications, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rajiv Chandawarkar
- The Department of Plastic Surgery and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Engaging patients and families in pediatric radiology. Pediatr Radiol 2020; 50:1492-1498. [PMID: 32935240 DOI: 10.1007/s00247-020-04742-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/17/2020] [Accepted: 05/22/2020] [Indexed: 10/23/2022]
Abstract
While patient and family-centered care (PFCC) is currently a hot topic in medicine, it has long been a specific focus of pediatrics. The concept of PFCC includes a change in culture where physicians and patients move away from paternalism and instead view patients and families as partners in care. Although there are many ways in which adult-focused radiologists can learn from pediatric radiologists as leaders in PFCC, there remain many opportunities for improvement for all radiologists.
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Powell L, Sittig DF, Chrouser K, Singh H. 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. JAMA Netw Open 2020; 3:e206752. [PMID: 32584406 PMCID: PMC7317596 DOI: 10.1001/jamanetworkopen.2020.6752] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Lauren Powell
- Veterans Affairs (VA) National Center for Patient Safety, Ann Arbor, Michigan
| | - Dean F Sittig
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
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Benton W, Snyder ED, Estrada CA, Bryan TJ. Signed, Sealed, Delivered: Increasing Patient Notification of Test Results in an Internal Medicine Resident Continuity Clinic. South Med J 2019; 112:85-88. [PMID: 30708371 DOI: 10.14423/smj.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Informing patients of their test results is an important patient safety issue, yet many physicians perform dismally in this regard. Residents often face additional barriers to communicating test results to patients. We wanted to determine whether streamlining the notification process, communicating expectations, and having residents audit their performance would increase result notification rates. METHODS We used a quasi-experimental design, and a single-group before-and-after intervention. Our multifold intervention consisted of development and standardization of a notification process in the electronic medical record, an education component, and a self-audit component. During a 15-minute session, we educated residents on the use of the new process. We also restated expectations regarding notifying patients of their results. Residents audited their own charts for a period before the intervention and during a second, postintervention period. An independent review of notification rates took place simultaneously as well as during an additional period several months later. RESULTS In total, 87 residents were eligible for participation. All 87 completed the project, giving a 100% participation rate. Resident-reported laboratory test notification rates increased from 16% to 91%; other test result rates increased from 33% to 84%. The three independent reviews showed laboratory test notification rates increased from 18.5% to 71.7% to 87.1%, and notification of other test results increased from 23.5% to 66.7% to 91.7%. CONCLUSIONS Baseline rates of notification for diagnostic tests results were low, but streamlining the notification process, clearly stating expectations for using it, and using resident self-audit can improve notification rates.
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Affiliation(s)
- William Benton
- From the Department of Internal Medicine, Louisiana State University Health Sciences Center, Baton Rouge, the Department of Medicine, University of Alabama, Birmingham, and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Erin D Snyder
- From the Department of Internal Medicine, Louisiana State University Health Sciences Center, Baton Rouge, the Department of Medicine, University of Alabama, Birmingham, and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Carlos A Estrada
- From the Department of Internal Medicine, Louisiana State University Health Sciences Center, Baton Rouge, the Department of Medicine, University of Alabama, Birmingham, and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Teresa J Bryan
- From the Department of Internal Medicine, Louisiana State University Health Sciences Center, Baton Rouge, the Department of Medicine, University of Alabama, Birmingham, and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
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Blease CR, Bell SK. Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety. Diagnosis (Berl) 2019; 6:213-221. [DOI: 10.1515/dx-2018-0106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/08/2019] [Indexed: 12/21/2022]
Abstract
Abstract
Error resulting from missed, delayed, or wrong diagnoses is estimated to occur in 10–15% of ambulatory and inpatient encounters, leading to serious harm in around half of such cases. When it comes to conceptualizing diagnostic error, most research has focused on factors pertaining to: (a) physician cognition and (b) ergonomic or systems factors related to the physician’s working environment. A third factor – the role of patients in diagnostic processes – remains relatively under-investigated. Yet, as a growing number of researchers acknowledge, patients hold unique knowledge about themselves and their healthcare experience, and may be the most underutilized resource for mitigating diagnostic error. This opinion article examines recent findings from patient surveys about sharing visit notes with patients online. Drawing on these survey results, we suggest three ways in which sharing visit notes with patients might enhance diagnostic processes: (1) avoid delays and missed diagnoses by enhancing timely follow up of recommended tests, results, and referrals; (2) identify documentation errors that may undermine diagnostic accuracy; and (3) strengthen patient-clinician relationships thereby creating stronger bidirectional diagnostic partnerships. We also consider the potential pitfalls or unintended consequences of note transparency, and highlight areas in need of further research.
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Shah T, Patel-Teague S, Kroupa L, Meyer AND, Singh H. Impact of a national QI programme on reducing electronic health record notifications to clinicians. BMJ Qual Saf 2019; 28:10-14. [PMID: 29507122 PMCID: PMC6365918 DOI: 10.1136/bmjqs-2017-007447] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 01/08/2018] [Accepted: 01/19/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emerging evidence suggests electronic health record (EHR)-related information overload is a risk to patient safety. In the US Department of Veterans Affairs (VA), EHR-based 'inbox' notifications originally intended for communicating important clinical information are now cited by 70% of primary care practitioners (PCPs) to be of unmanageable volume. We evaluated the impact of a national, multicomponent, quality improvement (QI) programme to reduce low-value EHR notifications. METHODS The programme involved three steps: (1) accessing daily PCP notification load data at all 148 facilities operated nationally by the VA; (2) standardising and restricting mandatory notification types at all facilities to a recommended list; and (3) hands-on training for all PCPs on customising and processing notifications more effectively. Designated leaders at each of VA's 18 regional networks led programme implementation using a nationally developed toolkit. Each network supervised technical requirements and data collection, ensuring consistency. Coaching calls and emails allowed the national team to address implementation challenges and monitor effects. We analysed notification load and mandatory notifications preintervention (March 2017) and immediately postintervention (June-July 2017) to assess programme impact. RESULTS Median number of mandatory notification types at each facility decreased significantly from 15 (IQR: 13-19) to 10 (IQR: 10-11) preintervention to postintervention, respectively (P<0.001). Mean daily notifications per PCP decreased significantly from 128 (SEM=4) to 116 (SEM=4; P<0.001). Heterogeneity in implementation across sites led to differences in observed programme impact, including potentially beneficial carryover effects. CONCLUSIONS Based on prior estimates on time to process notifications, a national QI programme potentially saved 1.5 hours per week per PCP to enable higher value work. The number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Nevertheless, our project suggests feasibility of using large-scale 'de-implementation' interventions to reduce unintended safety or efficiency consequences of well-intended electronic communication systems.
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Affiliation(s)
- Tina Shah
- TNT Health Enterprises, Atlanta, GA (previously Department of Veterans Affairs, Washington, District of Columbia), USA
| | - Shilpa Patel-Teague
- VA Sunshine Network, Department of Veterans Affairs, St Petersburg, Florida, USA
| | - Laura Kroupa
- VA Heartland Network, Department of Veterans Affairs, Kansas City, Missouri and Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Dahm MR, Georgiou A, Westbrook JI, Greenfield D, Horvath AR, Wakefield D, Li L, Hillman K, Bolton P, Brown A, Jones G, Herkes R, Lindeman R, Legg M, Makeham M, Moses D, Badmus D, Campbell C, Hardie RA, Li J, McCaughey E, Sezgin G, Thomas J, Wabe N. Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol. BMJ Open 2018; 8:e020235. [PMID: 29449297 PMCID: PMC5829886 DOI: 10.1136/bmjopen-2017-020235] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/03/2017] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems. METHODS AND ANALYSIS This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings. ETHICS AND DISSEMINATION Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences.
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Affiliation(s)
- Maria R Dahm
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - David Greenfield
- Australian Institute of Health Service Management, University of Tasmania, Sydney, New South Wales, Australia
| | - Andrea R Horvath
- Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Clinical Chemistry and Endocrinology, Prince of Wales Hospital, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Denis Wakefield
- Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Centre for Immunology, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Ken Hillman
- The Simpson Centre for Health Services Research, SWS Clinical School, University of New South Wales, Kensington, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Patrick Bolton
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Anthony Brown
- Health Consumers New South Wales, Sydney, New South Wales, Australia
- Men's Health Information and Resource Centre, Western Sydney University, Penrith, New South Wales, Australia
| | - Graham Jones
- Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- SydPath, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Robert Herkes
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | | | - Michael Legg
- Michael Legg & Associates, Bulli, New South Wales, Australia
- Faculty of Engineering & Information Science, University of Wollongong, Wollongong, New South Wales, Australia
| | - Meredith Makeham
- Australian Digital Health Agency, Sydney, New South Wales, Australia
| | - Daniel Moses
- Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Medical Imaging Department, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Dauda Badmus
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Craig Campbell
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Clinical Chemistry and Endocrinology, Prince of Wales Hospital, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Rae-Anne Hardie
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Euan McCaughey
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Neuroscience Research Australia (NeuRA), University of New South Wales, Kensington, New South Wales, Australia
| | - Gorkem Sezgin
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Judith Thomas
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Nasir Wabe
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Moore CR, Farrag A, Ashkin E. Using Natural Language Processing to Extract Abnormal Results From Cancer Screening Reports. J Patient Saf 2018; 13:138-143. [PMID: 25025472 DOI: 10.1097/pts.0000000000000127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Numerous studies show that follow-up of abnormal cancer screening results, such as mammography and Papanicolaou (Pap) smears, is frequently not performed in a timely manner. A contributing factor is that abnormal results may go unrecognized because they are buried in free-text documents in electronic medical records (EMRs), and, as a result, patients are lost to follow-up. By identifying abnormal results from free-text reports in EMRs and generating alerts to clinicians, natural language processing (NLP) technology has the potential for improving patient care. The goal of the current study was to evaluate the performance of NLP software for extracting abnormal results from free-text mammography and Pap smear reports stored in an EMR. METHODS A sample of 421 and 500 free-text mammography and Pap reports, respectively, were manually reviewed by a physician, and the results were categorized for each report. We tested the performance of NLP to extract results from the reports. The 2 assessments (criterion standard versus NLP) were compared to determine the precision, recall, and accuracy of NLP. RESULTS When NLP was compared with manual review for mammography reports, the results were as follows: precision, 98% (96%-99%); recall, 100% (98%-100%); and accuracy, 98% (96%-99%). For Pap smear reports, the precision, recall, and accuracy of NLP were all 100%. CONCLUSIONS Our study developed NLP models that accurately extract abnormal results from mammography and Pap smear reports. Plans include using NLP technology to generate real-time alerts and reminders for providers to facilitate timely follow-up of abnormal results.
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Affiliation(s)
- Carlton R Moore
- From the *Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, †The North Carolina Translational and Clinical Sciences Center, and ‡Department of family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Gleason KT, Davidson PM, Tanner EK, Baptiste D, Rushton C, Day J, Sawyer M, Baker D, Paine L, Himmelfarb CRD, Newman-Toker DE. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2017-0015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractNurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses’ engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses’ ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.
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Gregory ME, Russo E, Singh H. Electronic Health Record Alert-Related Workload as a Predictor of Burnout in Primary Care Providers. Appl Clin Inform 2017; 8:686-697. [PMID: 28678892 DOI: 10.4338/aci-2017-01-ra-0003] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/21/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Electronic health records (EHRs) have been shown to increase physician workload. One EHR feature that contributes to increased workload is asynchronous alerts (also known as inbox notifications) related to test results, referral responses, medication refill requests, and messages from physicians and other health care professionals. This alert-related workload results in negative cognitive outcomes, but its effect on affective outcomes, such as burnout, has been understudied. OBJECTIVES To examine EHR alert-related workload (both objective and subjective) as a predictor of burnout in primary care providers (PCPs), in order to ultimately inform interventions aimed at reducing burnout due to alert workload. METHODS A cross-sectional questionnaire and focus group of 16 PCPs at a large medical center in the southern United States. RESULTS Subjective, but not objective, alert workload was related to two of the three dimensions of burnout, including physical fatigue (p = 0.02) and cognitive weariness (p = 0.04), when controlling for organizational tenure. To reduce alert workload and subsequent burnout, participants indicated a desire to have protected time for alert management, fewer unnecessary alerts, and improvements to the EHR system. CONCLUSIONS Burnout associated with alert workload may be in part due to subjective differences at an individual level, and not solely a function of the objective work environment. This suggests the need for both individual and organizational-level interventions to improve alert workload and subsequent burnout. Additional research should confirm these findings in larger, more representative samples.
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Affiliation(s)
- Megan E Gregory
- Megan E. Gregory, Ph.D., Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, 2450 Holcombe Blvd, Suite 01Y, Houston, Texas 77021, , Phone: (713) 794-8601 ext. 10232
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Russo E, Sittig DF, Murphy DR, Singh H. Challenges in patient safety improvement research in the era of electronic health records. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 4:285-290. [PMID: 27473472 DOI: 10.1016/j.hjdsi.2016.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 06/06/2016] [Accepted: 06/18/2016] [Indexed: 02/08/2023]
Abstract
Electronic health record (EHR) data repositories contain large volumes of aggregated, longitudinal clinical data that could allow patient safety researchers to identify important safety issues and conduct comprehensive evaluations of health care delivery outcomes. However, few health systems have successfully converted this abundance of data into useful information or knowledge for safety improvement. In this paper, we use a case study involving a project on missed/delayed follow-up of test results to discuss real-world challenges in using EHR data for patient safety research. We identify three types of challenges that pose as barriers to advance patient safety improvement research: 1) gaining approval to access/review EHR data; 2) interpreting EHR data; 3) working with local IT/EHR personnel. We discuss the complexity of these challenges, all of which are unlikely to be unique to this project, and outline some key next steps that must be taken to support research that uses EHR data to improve safety. We recognize that all organizations face competing priorities between clinical operations and research. However, to leverage EHRs and their abundant data for patient safety improvement research, many current data access and security policies and procedures must be rewritten and standardized across health care organizations. These efforts are essential to help make EHRs and EHR data useful for progress in our journey to safer health care.
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Affiliation(s)
- Elise Russo
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Dean F Sittig
- University of Texas Health Science Center at Houston's School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX, United States
| | - Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
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Wilkerson ML, Henricks WH, Castellani WJ, Whitsitt MS, Sinard JH. Management of laboratory data and information exchange in the electronic health record. Arch Pathol Lab Med 2015; 139:319-27. [PMID: 25724028 DOI: 10.5858/arpa.2013-0712-so] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the era of the electronic health record, the success of laboratories and pathologists will depend on effective presentation and management of laboratory information, including test orders and results, and effective exchange of data between the laboratory information system and the electronic health record. In this third paper of a series that explores empowerment of pathology in the era of the electronic health record, we review key elements of managing laboratory information within the electronic health record and examine functional issues pertinent to pathologists and laboratories in the exchange of laboratory information between electronic health records and both anatomic and clinical pathology laboratory information systems. Issues with electronic order-entry and results-reporting interfaces are described, and considerations for setting up these interfaces are detailed in tables. The role of the laboratory medical director as mandated by the Clinical Laboratory Improvement Amendments of 1988 and the impacts of discordance between laboratory results and their display in the electronic health record are also discussed.
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Affiliation(s)
- Myra L Wilkerson
- From the Division of Laboratory Medicine, Geisinger Health System, Danville, Pennsylvania (Dr Wilkerson); the Center for Pathology Informatics, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Henricks); the Department of Pathology and Laboratory Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania (Dr Castellani); Diagnostic Intelligence and Health Information Technology Committee, The College of American Pathologists, Northfield, Illinois (Dr Whitsitt); and the Informatics Program, Department of Pathology, Yale University School of Medicine, New Haven, Connecticut (Dr Sinard)
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Callen J, Georgiou A, Li J, Westbrook JI. The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better? EJIFCC 2015; 26:38-46. [PMID: 27683480 PMCID: PMC4975222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The World Health Organization-World Alliance for Patient Safety has identified test result management as a priority area. Poor test result follow-up can have major consequences for the quality of care, including missed diagnoses and suboptimal patient outcomes. Over the last three decades there has been considerable growth in the number of requests for pathology and radiology services which has added to the complexity of how patient care is delivered and test results are managed. This can contribute to a lack of clarity about where and with whom responsibility for test follow-up should reside: a problem that is compounded by a lack of clear definitions about what are critical, unexpected or significantly abnormal results. AIM OF THIS PAPER This paper will present a narrative review highlighting key issues related to the problem of failure to follow up laboratory test results, and outline potential solutions. CONCLUSIONS Information technology (IT) has the potential to enhance the performance and safety of test result management processes. Effective solutions must engage all stakeholders, including consumers, in arriving at decisions about who needs to receive results, how and when they are communicated, and how they are acknowledged and acted upon and the documentation of these actions.
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Affiliation(s)
- Joanne Callen
- Associate Professor, Centre for Health Systems and Safety Research Australian Institute of Health Innovation Macquarie University Level 6, 75 Talavera Road Sydney, 2109 Australia
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Georgiou A, Lymer S, Forster M, Strachan M, Graham S, Hirst G, Callen J, Westbrook JI. Lessons learned from the introduction of an electronic safety net to enhance test result management in an Australian mothers' hospital. J Am Med Inform Assoc 2014; 21:1104-8. [PMID: 24598829 PMCID: PMC4215041 DOI: 10.1136/amiajnl-2013-002466] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/19/2014] [Accepted: 02/17/2014] [Indexed: 11/15/2022] Open
Abstract
This study describes the implementation and impact of an electronic test result acknowledgement (RA) system in the Mater Mothers' Hospital in Brisbane, Australia. The Verdi application electronically records clinicians' acknowledgement of the review of results. Hospital data (August 2011-August 2012) were extracted to measure clinicians' acknowledgement practices. There were 27,354 inpatient test results for 6855 patients. All test results were acknowledged. 60% (95% CI 59% to 61%) of laboratory and 44% (95% CI 40% to 48%) of imaging results were acknowledged within 24 h. The median time between report availability and acknowledgement was 18.1 h for laboratory and 1 day 18 h for imaging results. The median time from when a result was first viewed to its acknowledgement was 7 min for laboratory and 1 min for imaging results. The longest recorded time to acknowledgement was 38 days. Electronic RA provides a safety net to enhance test result management.
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Affiliation(s)
- Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia
| | - Sharyn Lymer
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia
| | - Megan Forster
- Mater Health Services, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Michael Strachan
- Mater Health Services, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Sara Graham
- Mater Health Services, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Geof Hirst
- Mater Health Services, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Joanne Callen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, New South Wales, Australia
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Georgiou A, Hordern A, Dimigen M, Zogovic B, Callen J, Schlaphoff G, Westbrook JI. Effective notification of important non-urgent radiology results: a qualitative study of challenges and potential solutions. J Med Imaging Radiat Oncol 2014; 58:291-7. [PMID: 24460883 DOI: 10.1111/1754-9485.12156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 12/12/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We report on the implementation of a Radiology Notification System (RNS), set up by the medical imaging department of a major Sydney teaching hospital in March 2010. This study aimed to investigate the views of the medical imaging department staff about: (i) the results follow-up problem encountered by the medical imaging department prior to the implementation of the RNS; (ii) what changes occurred following implementation of the RNS; and (iii) suggestions for improving the RNS. METHODS This is a cross-sectional qualitative study incorporating semi-structured interviews with 16 staff (15 radiologists and 1 clerk) after the implementation of the RNS. Interviews were conducted in August/September 2011. RESULTS The reasons behind the development of the RNS were related to: (i) major existing problems with the communication of results between the imaging department and hospital wards; (ii) cumbersome and inefficient paper-based notification systems; and (iii) the absence of standardised guidelines and procedures for radiology test notification and follow-up. The RNS managed to free up a significant proportion of radiologist time, resulting in greater efficiencies. Study participants also highlighted a number of areas for improvement, including the need for a 24-h service, feedback and acknowledgement of test results by clinicians and the standardisation of test management definitions and procedures. CONCLUSION Test management systems can play an important part in enhancing safe and effective communications between wards and hospital departments. However, their uptake and sustainability will require the establishment of a multidisciplinary and hospital-wide collaboration that includes clinicians.
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Affiliation(s)
- Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
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Smith M, Murphy D, Laxmisan A, Sittig D, Reis B, Esquivel A, Singh H. Developing software to "track and catch" missed follow-up of abnormal test results in a complex sociotechnical environment. Appl Clin Inform 2013; 4:359-75. [PMID: 24155789 DOI: 10.4338/aci-2013-04-ra-0019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 07/08/2013] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Abnormal test results do not always receive timely follow-up, even when providers are notified through electronic health record (EHR)-based alerts. High workload, alert fatigue, and other demands on attention disrupt a provider's prospective memory for tasks required to initiate follow-up. Thus, EHR-based tracking and reminding functionalities are needed to improve follow-up. OBJECTIVES The purpose of this study was to develop a decision-support software prototype enabling individual and system-wide tracking of abnormal test result alerts lacking follow-up, and to conduct formative evaluations, including usability testing. METHODS We developed a working prototype software system, the Alert Watch And Response Engine (AWARE), to detect abnormal test result alerts lacking documented follow-up, and to present context-specific reminders to providers. Development and testing took place within the VA's EHR and focused on four cancer-related abnormal test results. Design concepts emphasized mitigating the effects of high workload and alert fatigue while being minimally intrusive. We conducted a multifaceted formative evaluation of the software, addressing fit within the larger socio-technical system. Evaluations included usability testing with the prototype and interview questions about organizational and workflow factors. Participants included 23 physicians, 9 clinical information technology specialists, and 8 quality/safety managers. RESULTS Evaluation results indicated that our software prototype fit within the technical environment and clinical workflow, and physicians were able to use it successfully. Quality/safety managers reported that the tool would be useful in future quality assurance activities to detect patients who lack documented follow-up. Additionally, we successfully installed the software on the local facility's "test" EHR system, thus demonstrating technical compatibility. CONCLUSION To address the factors involved in missed test results, we developed a software prototype to account for technical, usability, organizational, and workflow needs. Our evaluation has shown the feasibility of the prototype as a means of facilitating better follow-up for cancer-related abnormal test results.
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Affiliation(s)
- M Smith
- Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine , Houston, Texas
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Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Sittig DF. Information overload and missed test results in electronic health record-based settings. JAMA Intern Med 2013; 173:702-4. [PMID: 23460235 PMCID: PMC3822526 DOI: 10.1001/2013.jamainternmed.61] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Hardeep Singh
- Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Nancy J. Petersen
- Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Mona K. Sawhney
- Houston VA HSR&D Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Dean F. Sittig
- University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas
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Singh H, Ash JS, Sittig DF. Safety Assurance Factors for Electronic Health Record Resilience (SAFER): study protocol. BMC Med Inform Decis Mak 2013; 13:46. [PMID: 23587208 PMCID: PMC3639028 DOI: 10.1186/1472-6947-13-46] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/06/2013] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Implementation and use of electronic health records (EHRs) could lead to potential improvements in quality of care. However, the use of EHRs also introduces unique and often unexpected patient safety risks. Proactive assessment of risks and vulnerabilities can help address potential EHR-related safety hazards before harm occurs; however, current risk assessment methods are underdeveloped. The overall objective of this project is to develop and validate proactive assessment tools to ensure that EHR-enabled clinical work systems are safe and effective. METHODS/DESIGN This work is conceptually grounded in an 8-dimension model of safe and effective health information technology use. Our first aim is to develop self-assessment guides that can be used by health care institutions to evaluate certain high-risk components of their EHR-enabled clinical work systems. We will solicit input from subject matter experts and relevant stakeholders to develop guides focused on 9 specific risk areas and will subsequently pilot test the guides with individuals representative of likely users. The second aim will be to examine the utility of the self-assessment guides by beta testing the guides at selected facilities and conducting on-site evaluations. Our multidisciplinary team will use a variety of methods to assess the content validity and perceived usefulness of the guides, including interviews, naturalistic observations, and document analysis. The anticipated output of this work will be a series of self-administered EHR safety assessment guides with clear, actionable, checklist-type items. DISCUSSION Proactive assessment of patient safety risks increases the resiliency of health care organizations to unanticipated hazards of EHR use. The resulting products and lessons learned from the development of the assessment guides are expected to be helpful to organizations that are beginning the EHR selection and implementation process as well as those that have already implemented EHRs. Findings from our project, currently underway, will inform future efforts to validate and implement tools that can be used by health care organizations to improve the safety of EHR-enabled clinical work systems.
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Affiliation(s)
- Hardeep Singh
- Houston VA HSR&D Center of Excellence, the Michael E DeBakey Veterans Affairs Medical Center, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA.
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Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2013; 19 Suppl 3:i68-74. [PMID: 20959322 DOI: 10.1136/qshc.2010.042085] [Citation(s) in RCA: 375] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Conceptual models have been developed to address challenges inherent in studying health information technology (HIT). METHOD This manuscript introduces an eight-dimensional model specifically designed to address the sociotechnical challenges involved in design, development, implementation, use and evaluation of HIT within complex adaptive healthcare systems. DISCUSSION The eight dimensions are not independent, sequential or hierarchical, but rather are interdependent and inter-related concepts similar to compositions of other complex adaptive systems. Hardware and software computing infrastructure refers to equipment and software used to power, support and operate clinical applications and devices. Clinical content refers to textual or numeric data and images that constitute the 'language' of clinical applications. The human--computer interface includes all aspects of the computer that users can see, touch or hear as they interact with it. People refers to everyone who interacts in some way with the system, from developer to end user, including potential patient-users. Workflow and communication are the processes or steps involved in ensuring that patient care tasks are carried out effectively. Two additional dimensions of the model are internal organisational features (eg, policies, procedures and culture) and external rules and regulations, both of which may facilitate or constrain many aspects of the preceding dimensions. The final dimension is measurement and monitoring, which refers to the process of measuring and evaluating both intended and unintended consequences of HIT implementation and use. We illustrate how our model has been successfully applied in real-world complex adaptive settings to understand and improve HIT applications at various stages of development and implementation.
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Affiliation(s)
- Dean F Sittig
- UT-Memorial Hermann Center for Healthcare Quality & Safety, University of Texas School of Biomedical Informatics at Houston, 6410 Fannin St UTPB 1100.43, Houston, TX 77030, USA.
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Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Smith MW, Murphy DR, Espadas D, Laxmisan A, Sittig DF. Primary care practitioners' views on test result management in EHR-enabled health systems: a national survey. J Am Med Inform Assoc 2012; 20:727-35. [PMID: 23268489 PMCID: PMC3721157 DOI: 10.1136/amiajnl-2012-001267] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Context Failure to notify patients of test results is common even when electronic health records (EHRs) are used to report results to practitioners. We sought to understand the broad range of social and technical factors that affect test result management in an integrated EHR-based health system. Methods Between June and November 2010, we conducted a cross-sectional, web-based survey of all primary care practitioners (PCPs) within the Department of Veterans Affairs nationwide. Survey development was guided by a socio-technical model describing multiple inter-related dimensions of EHR use. Findings Of 5001 PCPs invited, 2590 (51.8%) responded. 55.5% believed that the EHRs did not have convenient features for notifying patients of test results. Over a third (37.9%) reported having staff support needed for notifying patients of test results. Many relied on the patient's next visit to notify them for normal (46.1%) and abnormal results (20.1%). Only 45.7% reported receiving adequate training on using the EHR notification system and 35.1% reported having an assigned contact for technical assistance with the EHR; most received help from colleagues (60.4%). A majority (85.6%) stayed after hours or came in on weekends to address notifications; less than a third reported receiving protected time (30.1%). PCPs strongly endorsed several new features to improve test result management, including better tracking and visualization of result notifications. Conclusions Despite an advanced EHR, both social and technical challenges exist in ensuring notification of test results to practitioners and patients. Current EHR technology requires significant improvement in order to avoid similar challenges elsewhere.
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Affiliation(s)
- Hardeep Singh
- Department of Medicine, Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and Section of Health Services Research, Baylor College of Medicine, Houston, Texas 77030, 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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El-Kareh R, Roy C, Williams DH, Poon EG. Impact of automated alerts on follow-up of post-discharge microbiology results: a cluster randomized controlled trial. J Gen Intern Med 2012; 27:1243-50. [PMID: 22278302 PMCID: PMC3445692 DOI: 10.1007/s11606-012-1986-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 12/16/2011] [Accepted: 12/27/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Failure to follow up microbiology results pending at the time of hospital discharge can delay diagnosis and treatment of important infections, harm patients, and increase the risk of litigation. Current systems to track pending tests are often inadequate. OBJECTIVE To design, implement, and evaluate an automated system to improve follow-up of microbiology results that return after hospitalized patients are discharged. DESIGN Cluster randomized controlled trial. SUBJECTS Inpatient and outpatient physicians caring for adult patients hospitalized at a large academic hospital from February 2009 to June 2010 with positive and untreated or undertreated blood, urine, sputum, or cerebral spinal fluid cultures returning post-discharge. INTERVENTION An automated e-mail-based system alerting inpatient and outpatient physicians to positive post-discharge culture results not adequately treated with an antibiotic at the time of discharge. MAIN MEASURES Our primary outcome was documented follow-up of results within 3 days. Secondary outcomes included physician awareness and assessment of result urgency, impact on clinical assessments and plans, and preferred alerting scenarios. KEY RESULTS We evaluated the follow-up of 157 post-discharge microbiology results from patients of 121 physicians. We found documented follow-up in 27/97 (28%) results in the intervention group and 8/60 (13%) in the control group [aOR 3.2, (95% CI 1.3-8.4); p=0.01]. Of all inpatient physician respondents, 32/82 (39%) were previously aware of the results, 45/77 (58%) felt the results changed their assessments and plans, 43/77 (56%) felt the results required urgent action, and 67/70 (96%) preferred alerts for current or broader scenarios. CONCLUSION Our alerting system improved the proportion of important post-discharge microbiology results with documented follow-up, though the proportion remained low. The alerts were well received and may be expanded in the future.
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Affiliation(s)
- Robert El-Kareh
- Division of Biomedical Informatics, University of California San Diego, 9500 Gilman Dr., no. 0505, La Jolla, San Diego, CA 92093-0505, USA,
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Nakhleh RE, Myers JL, Allen TC, DeYoung BR, Fitzgibbons PL, Funkhouser WK, Mody DR, Lynn A, Fatheree LA, Smith AT, Lal A, Silverman JF. Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med 2012; 136:148-54. [PMID: 21992705 DOI: 10.5858/arpa.2011-0400-sa] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Recognizing the difficulty in applying the concept of critical values to anatomic pathology diagnoses, the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology have chosen to reevaluate the concept of critical diagnoses. OBJECTIVE To promote effective communication of urgent and significant, unexpected diagnoses in surgical pathology and cytology. DESIGN A comprehensive literature search was conducted and reviewed by an expert panel. RESULTS A policy of effective communication of important results in surgical pathology and cytology is desirable to enhance patient safety and to address multiple regulatory requirements. CONCLUSIONS Each institution should create its own policy regarding urgent diagnoses and significant, unexpected diagnoses in anatomic pathology. This policy should be separate from critical results or panic-value policies in clinical pathology, with the expectation of a different time frame for communication. Urgent diagnosis is defined as a medical condition that, in most cases, should be addressed as soon as possible. Significant, unexpected diagnosis is defined as a medical condition that is clinically unusual or unforeseen and should be addressed at some point in the patient's course. Further details of this statement are provided.
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Affiliation(s)
- Raouf E Nakhleh
- Department of Pathology, Mayo Clinic Florida, Jacksonville, 32224, USA.
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Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med 2012; 125:209.e1-7. [PMID: 22269625 DOI: 10.1016/j.amjmed.2011.07.029] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 07/22/2011] [Accepted: 07/25/2011] [Indexed: 02/05/2023]
Abstract
BACKGROUND Asynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer "pop-up" messages are understudied. Our objective was to create an asynchronous alert taxonomy and measure the impact of different alert types on practitioner workload. METHODS We quantified and categorized asynchronous alerts according to the information they conveyed and conducted a time-motion analysis to assess practitioner workload. We reviewed alert information transmitted to all 47 primary care practitioners (PCPs) at a large, tertiary care Veterans Affairs facility over 4 evenly spaced 28-day periods. An interdisciplinary team used content analysis to categorize alerts according to their conveyed information. We then created an alert taxonomy and used it to calculate the mean number of alerts of each type PCPs received each day. We conducted a time-motion study of 26 PCPs while they processed their alerts. We used these data to estimate the uninterrupted time practitioners spend processing alerts each day. RESULTS We extracted 295,792 asynchronously generated alerts and created a taxonomy of 33 alert types categorized under 6 major categories: Test Results, Referrals, Note-Based Communication, Order Status, Patient Status Changes, and Incomplete Task Reminders. PCPs received a mean of 56.4 alerts/day containing new information. Based on 749 observed alert processing episodes, practitioners spent an estimated average of 49 minutes/day processing their alerts. CONCLUSIONS PCPs receive a large number of EHR-based asynchronous alerts daily and spend significant time processing them. The utility of transmitting large quantities and varieties of alerts to PCPs warrants further investigation.
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