Traber Davis Giardina

Electronic health record-based surveillance of diagnostic errors in primary care

Background Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice. Methods The authors conducted a retrospective study of primary care visit records ‘triggered’ through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician–reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer. Results Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)). Conclusions While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians

Background Although misdiagnosis in the outpatient setting leads to significant patient harm and wasted resources, it is not well studied. The authors surveyed primary care physicians (PCPs) about barriers to timely diagnosis in the outpatient setting and assessed their perceptions of diagnostic difficulty. Methods Surveys of PCPs practicing in an integrated health system across 10 geographically dispersed states in 2005. The survey elicited information on key cognitive failures (including in clinical knowledge or judgement) for a specific case, and solicited strategies for reducing diagnostic delays. Content analysis was used to categorise cognitive failures and strategies for improvement. The authors examined the extent and predictors of diagnostic difficulty, defined as reporting >5% patients difficult to diagnose. Results Of 1817 physicians surveyed, 1054 (58%) responded; 848 (80%) respondents primarily practiced in outpatient settings and had an assigned patient panel (inclusion sample). Inadequate knowledge (19.9%) was the most commonly reported cognitive factor. Half reported >5% of their patients were difficult to diagnose; more experienced physicians reported less diagnostic difficulty. In adjusted analyses, problems with information processing (information availability and time to review it) and the referral process were associated with greater diagnostic difficulty. Strategies for improvement most commonly involved workload issues (panel size, non-visit tasks). Conclusions PCPs report a variety of reasons for diagnostic difficulties in primary care practice. In this study, knowledge gaps appear to be a prominent concern. Interventions that address these gaps as well as practice level issues such as time to process diagnostic information and better subspecialty input may reduce diagnostic difficulties in primary care.

Should Patients Get Direct Access to Their Laboratory Test Results?: An Answer With Many Questions

IN THE OUTPATIENT SETTING, BETWEEN 8% AND 26% OF abnormal test results, including those suspicious for malignancy, are not followed up in a timely manner. Despite the use of electronic health records (EHRs) to facilitate communication of test results, follow-up remains a significant safety challenge. In an effort to mitigate delays, some systems have adopted a time-delayed direct notification of test results to patients (ie, releasing them after 3 to 7 days to allow physicians to review them). On September 14, 2011, the Department of Health and Human Services jointly with the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and the Office for Civil Rights proposed a rule allowing patients to access test results directly from the laboratory by request (paper or electronic). The proposal will affect 39 states and territories in which either no current laws regulate direct test-result delivery to patients, or the practice is banned outright by state law. The rule ensures that all Clinical Laboratory Improvement Amendments (CLIAs) and CLIA-exempt clinical laboratories abide by Health Insurance Portability and Accountability Act (HIPAA) regulations, thus standardizing patients’ rights to access protected health information. The rule does not specify a waiting period before sending results or specify which types of tests would require physician review first. Although the new rule could be considered a monumental step forward to improve the safety of test-result follow-up, there is lack of consensus in the literature about best practices in direct patient notification of abnormal results. To our knowledge, there is also no empirical evidence as to how physicians in systems that currently perform direct notification have perceived and adapted to this strategy. In this commentary, we consider patient and clinician perspectives on the potential effects of this approach and lay groundwork for issues to consider in the implementation of this proposed rule. Patient Perspectives Patients have expressed interest in being involved in medical decision making and desire access to their health information. Patients want to be notified of their test results, including normal and abnormal results, in less time than current norms. Although prompt direct notification of test results might help patients make decisions about their care, adequate data to support this idea are lacking. To our knowledge, only one US study has evaluated the effectiveness of direct notification (mailing of bone density test results in this case), but the study included a follow-up telephone call by a nurse educator. Patients who received this intervention were more likely to perceive timely reporting than patients who received usual care, but the effect on actual treatment received after 3 months was minimal. Patients prefer direct telephone contact with their physicians for notification of their abnormal test results. However, in the proposed new rule, this patient-centered approach to delivery of abnormal test results is not addressed. More importantly, questions remain as to whether patients will know what’s best to do when they receive the results. Although several Web sites offer explanations of laboratory test results, such results are often interpreted within a patient’s individual context and personalized goals. It is unlikely that patients will receive any coaching or personalized information on interpretation of results directly from the laboratory. The proposal also raises questions about patient responsibility for follow-up. Proponents of this strategy could argue that direct access to test results may empower patients to actively plan follow-up. Currently, however, it is unknown what effect dual patient-clinician notification might have on follow-up rates if physicians more explicitly share the ownership of patients’ test results and shift responsibility for initiating follow-up care to patients. For example, when both the primary care practitioners and the ordering clinician are no-

Emergency Physicians’ Views of Direct Notification of Laboratory and Radiology Results to Patients Using the Internet: A Multisite Survey

Background Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions. Objective The aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. Methods A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. Results The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). Conclusions Although patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Resilient actions in the diagnostic process and system performance

Objectives Systemic issues can adversely affect the diagnostic process. Many system-related barriers can be masked by ‘resilient’ actions of frontline providers (ie, actions supporting the safe delivery of care in the presence of pressures that the system cannot readily adapt to). We explored system barriers and resilient actions of primary care providers (PCPs) in the diagnostic evaluation of cancer. Methods We conducted a secondary data analysis of interviews of PCPs involved in diagnostic evaluation of 29 lung and colorectal cancer cases. Cases covered a range of diagnostic timeliness and were analysed to identify barriers for rapid diagnostic evaluation, and PCPs’ actions involving elements of resilience addressing those barriers. We rated these actions according to whether they were usual or extraordinary for typical PCP work. Results Resilient actions and associated barriers were found in 59% of the cases, in all ranges of timeliness, with 40% involving actions rated as beyond typical. Most of the barriers were related to access to specialty services and coordination with patients. Many of the resilient actions involved using additional communication channels to solicit cooperation from other participants in the diagnostic process. Discussion Diagnostic evaluation of cancer involves several resilient actions by PCPs targeted at system deficiencies. PCPs’ actions can sometimes mitigate system barriers to diagnosis, and thereby impact the sensitivity of ‘downstream’ measures (eg, delays) in detecting barriers. While resilient actions might enable providers to mitigate system deficiencies in the short run, they can be resource intensive and potentially unsustainable. They complement, rather than substitute for, structural remedies to improve system performance. Measures to detect and fix system performance issues targeted by these resilient actions could facilitate diagnostic safety.

Postreferral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis.

Background: Delays in diagnosis of colorectal cancer (CRC) are one of the most common reasons for malpractice claims and lead to poor outcomes. However, they are not well studied. Aims: We used a mixed quantitative-qualitative approach to analyze postreferral colonoscopy delays in CRC patients and explored referring physicians perception of processes surrounding these delays. Methods: Two physician-raters conducted independent electronic health record reviews of new CRC cases in a large integrated safety-net system to determine postreferral colonoscopy delays, which we defined as failures to perform colonoscopy within 60 days of referral for an established indication(s). To explore perceptions of colonoscopy processes, we conducted semistructured interviews with a sample of primary care physicians (PCPs) and used a content analysis approach. Results: Of 104 CRC cases that met inclusion criteria, reviewers agreed on the presence of postreferral colonoscopy delays in 35 (33.7%) cases; &kgr; = 0.99 (95% CI, 0.83–0.99). The median time between first referral and completion of colonoscopy was 123.0 days (range 62.0–938.0; interquartile range = 90.0 days). In about two-thirds of instances (64.8%), the reason for delay was a delayed future appointment with the gastroenterology service. On interviews, PCPs attributed long delays in scheduling to reduced endoscopic capacity and inefficient processes related to colonoscopy referral and scheduling, including considerable ambiguity regarding referral guidelines. Many suggested that navigation models be applied to streamline CRC diagnosis. Conclusion: Postreferral delays in CRC diagnosis are potentially preventable. A comprehensive mixed-methods methodology might be useful for others to identify the steps in the diagnostic process that are in most need for improvement.

Patient perceptions of receiving test results via online portals: a mixed-methods study

Abstract Objective Online portals provide patients with access to their test results, but it is unknown how patients use these tools to manage results and what information is available to promote understanding. We conducted a mixed-methods study to explore patients’ experiences and preferences when accessing their test results via portals. Materials and Methods We conducted 95 interviews (13 semistructured and 82 structured) with adults who viewed a test result in their portal between April 2015 and September 2016 at 4 large outpatient clinics in Houston, Texas. Semistructured interviews were coded using content analysis and transformed into quantitative data and integrated with the structured interview data. Descriptive statistics were used to summarize the structured data. Results Nearly two-thirds (63%) did not receive any explanatory information or test result interpretation at the time they received the result, and 46% conducted online searches for further information about their result. Patients who received an abnormal result were more likely to experience negative emotions (56% vs 21%; P = .003) and more likely to call their physician (44% vs 15%; P = .002) compared with those who received normal results. Discussion Study findings suggest that online portals are not currently designed to present test results to patients in a meaningful way. Patients experienced negative emotions often with abnormal results, but sometimes even with normal results. Simply providing access via portals is insufficient; additional strategies are needed to help patients interpret and manage their online test results. Conclusion Given the absence of national guidance, our findings could help strengthen policy and practice in this area and inform innovations that promote patient understanding of test results.

Online public reactions to frequency of diagnostic errors in US outpatient care

Abstract Background: Diagnostic errors pose a significant threat to patient safety but little is known about public perceptions of diagnostic errors. A study published in BMJ Quality & Safety in 2014 estimated that diagnostic errors affect at least 5% of US adults (or 12 million) per year. We sought to explore online public reactions to media reports on the reported frequency of diagnostic errors in the US adult population. Methods: We searched the World Wide Web for any news article reporting findings from the study. We then gathered all the online comments made in response to the news articles to evaluate public reaction to the newly reported diagnostic error frequency (n=241). Two coders conducted content analyses of the comments and an experienced qualitative researcher resolved differences. Results: Overall, there were few comments made regarding the frequency of diagnostic errors. However, in response to the media coverage, 44 commenters shared personal experiences of diagnostic errors. Additionally, commentary centered on diagnosis-related quality of care as affected by two emergent categories: (1) US health care providers (n=79; 63 commenters) and (2) US health care reform-related policies, most commonly the Affordable Care Act (ACA) and insurance/reimbursement issues (n=62; 47 commenters). Conclusion: The public appears to have substantial concerns about the impact of the ACA and other reform initiatives on the diagnosis-related quality of care. However, policy discussions on diagnostic errors are largely absent from the current national conversation on improving quality and safety. Because outpatient diagnostic errors have emerged as a major safety concern, researchers and policymakers should consider evaluating the effects of policy and practice changes on diagnostic accuracy.

Methods for Patient-Centered Interface Design of Test Result Display in Online Portals

Objectives: Patients have unique information needs to help them interpret and make decisions about laboratory test results they receive on web-based portals. However, current portals are not designed in a patient-centered way and little is known on how best to harness patients’ information needs to inform user-centered interface design of portals. We designed a patient-facing laboratory test result interface prototype based on requirement elicitation research and used a mixed-methods approach to evaluate this interface. Methods: After designing an initial test result display prototype, we used multiple evaluation methods, including focus group review sessions, expert consultation, and user testing, to make iterative design changes. For the user testing component, we recruited 14 patient-users to collect and analyze three types of data: comments made during testing sessions, responses to post-session questionnaires, and system usability scores. Results: Our initial patient-centered interface design included visual ranges of laboratory values, nontechnical descriptions of the test and result, and access to features to help patients interpret and make decisions about their results. Findings from our evaluation resulted in 6 design iterations of the interface. Results from user testing indicate that the later versions of the interface fulfilled patient’s information needs, were perceived as usable, and provided access to information and techniques that facilitated patient’s ability to derive meaning from each test result. Conclusions: Requirement elicitation studies can inform the design of a patient-facing test result interface, but considerable user-centered design efforts are necessary to create an interface that patients find useful. To promote patient engagement, health information technology designers and developers can use similar approaches to enhance user-centered software design in patient portals.

Teaching philosophies and practices in social work education: do the core competencies influence our consciousness?

ABSTRACT Assessing the mechanisms by which EPAS core competencies are embodied in classroom teaching is important for comprehensively examining EPAS’ success. This case study of one program presents emergent findings about perceptions of teaching, and the influence of core competencies, derived from interviews conducted with faculty members at a graduate social work program. Participants were asked about their teaching philosophies and practices, and the influence of social work core competencies in framing their philosophies and practices. Four primary themes emerged: (1) engaging students in learning, (2) linking the classroom and field, (3) critical thinking, and (4) core competencies are not evident at a conscious level. Participants described strong ambiguity about how the core competencies consciously influence teaching approaches, while clearly stating goals for interacting with students, integrating field experiences in the classroom, and helping students build critical thinking skills. Implications for social work education are described.