Test results management and distributed cognition in electronic health record-enabled primary care

Distributed cognition: Theoretical insights and practical applications to health professions education: AMEE Guide No. 159

Distributed cognition (DCog) is a member of the family of situativity theories that widens the lens of cognition from occurring solely inside the head to being socially, materially and temporally distributed within a dynamic system. The concept of extending the view of cognition to outside the head of a single health professional is relatively new in the healthcare system. DCog has been increasingly used by researchers to describe many ways in which health professionals perform in teams within structured clinical environments to deliver healthcare for patients. In this Guide, we expound ten central tenets of the macro (grand) theory of DCog (1. Cognition is decentralized in a system; 2. The unit of analysis is the system; 3. Cognitive processes are distributed; 4. Cognitive processes emerge from interactions; 5. Cognitive processes are interdependent; 6. Social organization is a cognitive architecture; 7. Division of labour; 8. Social organization is a system of communication; 9. Buffering and filtering; 10. Cognitive processes are encultured) to provide theoretical insights as well as practical applications to the field of health professions education.

Electronic Health Records' Support for Primary Care Physicians' Situation Awareness: A Metanarrative Review

OBJECTIVE

Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making.

METHOD

We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers.

RESULTS

From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload.

CONCLUSION

Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.

Narrowing the mindware gap in medicine

Medical error is now recognized as one of the leading causes of death in the United States. Of the medical errors, diagnostic failure appears to be the dominant contributor, failing in a significant number of cases, and associated with a high degree of morbidity and mortality. One of the significant contributors to diagnostic failure is the cognitive performance of the provider, how they think and decide about the process of diagnosis. This thinking deficit in clinical reasoning, referred to as a mindware gap, deserves the attention of medical educators. A variety of specific approaches are outlined here that have the potential to close the gap.

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review

Background

Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes.

Methods

A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design.

Results

Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up.

Conclusions

Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08100-3.

Variation in electronic test results management and its implications for patient safety: A multisite investigation

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.

Patient groups, clinicians and healthcare professionals agree - all test results need to be seen, understood and followed up

Background Diagnostic testing provides integral information for the prevention, diagnosis, treatment and management of disease. Inadequate test result reporting and follow-up is a major risk to patient safety. Factors contributing to failure to follow-up test results include unclear delineation of responsibility about who is meant to act on a test result; poor coordination across different levels of care; and the absence of integrated health information systems for the efficient information communication. Methods A 2016 Australian Stakeholder Forum brought together over 30 representatives from 14 different consumer, clinical and management stakeholder organisations to discuss safe and effective test result communication, management and follow-up. Thematic analysis was conducted drawing on multimodal data collected in the form of observational fieldnotes and document artefacts produced by participants. Results The forum identified major challenges which pose immediate risks to patient safety. Participants recommended priorities for addressing issues relating to: (i) the governance of test result management processes; (ii) integration of health care processes through the utilisation of effective digital health solutions; and (iii) involving patients as key partners in the decision-making and care process. Conclusions Stakeholder groups diverged slightly in their priorities. Consumers highlighted the lack of patient involvement in the test result management process but were less concerned about standardisation of reports and critical result thresholds than pathologists. The forum foregrounded the need for a systems approach, capable of identifying and addressing interconnections and multiple factors that contribute to poor test result follow-up, with a strong emphasis on enhancing the contribution of patients.

Improving diagnosis by improving education: a policy brief on education in healthcare professions

Diagnostic error is increasingly recognized as a major patient safety concern. Efforts to improve diagnosis have largely focused on safety and quality improvement initiatives that patients, providers, and health care organizations can take to improve the diagnostic process and its outcomes. This educational policy brief presents an alternative strategy for improving diagnosis, centered on future healthcare providers, to improve the education and training of clinicians in every health care profession. The hypothesis is that we can improve diagnosis by improving education. A literature search was first conducted to understand the relationship of education and training to diagnosis and diagnostic error in different health care professions. Based on the findings from this search we present the justification for focusing on education and training, recommendations for specific content that should be incorporated to improve diagnosis, and recommendations on educational approaches that should be used. Using an iterative, consensus-based process, we then developed a driver diagram that categorizes the key content into five areas. Learners should: 1) Acquire and effectively use a relevant knowledge base, 2) Optimize clinical reasoning to reduce cognitive error, 3) Understand system-related aspects of care, 4) Effectively engage patients and the diagnostic team, and 5) Acquire appropriate perspectives and attitudes about diagnosis. These domains echo recommendations in the National Academy of Medicine’s report Improving Diagnosis in Health Care. The National Academy report suggests that true interprofessional education and training, incorporating recent advances in understanding diagnostic error, and improving clinical reasoning and other aspects of education, can ultimately improve diagnosis by improving the knowledge, skills, and attitudes of all health care professionals.