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Diagnostic errors (i.e., diagnoses that are delayed,
wrong, or missed) are increasingly recognized
as a patient safety concern in ambulatory care. Although multiple factors influence the diagnostic process, communication is a central theme. From the initial patient-provider encounter
to confirmation of a diagnosis through diagnostic testing, procedures, or subspecialty referrals, good communication is essential to timely and accurate diagnosis. Accordingly, communication breakdowns are emerging as a leading preventable cause of diagnostic errors and are the focus of our current work. In this brief, we discuss some of the early lessons and challenges in this work.
Most ambulatory malpractice claims data suggests
that diagnostic errors are the largest category among U.S. malpractice claims.1 Outpatient
diagnostic errors may not necessarily involve only rare diseases or unusual disease presentations,2 but also relatively common conditions
such as cancer, ischemic heart disease, and infection. Many such errors involve communication
breakdowns, which are at times complex and difficult to define. It is not surprising
that those breakdowns occur—ambulatory care involves several settings of care and is longitudinal
in nature, making it increasingly chaotic for information processing.
Communication challenges are virtually a given in ambulatory care settings, where barriers
include time and workload pressures on busy clinicians, the sheer volume of both verbal
and electronic communication among providers,
and several patient factors that affect information transfer.1 Identifying the point(s) at which critical communication breakdowns occur is a first step in understanding the origins of error. It is important to recognize that, in health care settings, communication is often intended not only to transmit information
but also to elicit some response from the recipient. For instance, when providers receive
notification of abnormal test results, they might order follow-up diagnostic tests, notify patients, or refer to subspecialists. Thus, the desired outcomes of communication can be viewed in steps: message transmission (sending
accurate, complete, and unambiguous information);
message reception (perceiving the information accurately and taking appropriate next steps); and message acknowledgment (providing feedback that the message has been received and/or acted upon).3 Pinpointing the weakest links in those steps can help prioritize interventions.
Our work has shown that errors in the diagnostic
process span five interactive dimensions, each of which is closely related to one or more aspects of communication.
- Patient-provider encounter: Problems with history, physical exam, or ordering diagnostic tests for further work-up.
- Diagnostic tests: Problems with ordered tests either not performed or performed/interpreted incorrectly.
- Follow-up and tracking: Problems with follow-up of abnormal diagnostic test results or scheduling of follow-up visits.
- Referrals: Lack of appropriate actions on requested consultation or communication breakdown between consultant and referring provider.
- Patient factors: Delay in seeking care or non-adherence to appointments.
Challenges Despite Technology
Integrated electronic health records (EHRs) readily address certain problems that are endemic
to paper-based record systems, such as illegible handwriting, misplaced documents, and distance barriers between providers. However, the EHR must resolve communication problems
that might contribute to errors in any of the five interactive dimensions above, which is a challenge of itself. Meanwhile, we must also remain vigilant for communication breakdowns that are uncovered or introduced by new technologies.
While clinical decision support (CDS) interventions in the EHR can enhance communication
by prompting important questions or actions during the diagnostic work-up, we need to ensure that these interventions fit into providers' clinical workflow in order to achieve maximal benefit.2
Similarly, the EHR eliminates the need for a physical "paper trail" for referral communication and replaces it with referral requests and results that are always accessible electronically. However,
remaining communication vulnerabilities to prevent patients from being lost to follow-up in the referral process must also be addressed.1, 3
Multidisciplinary interventions that take into account both technology as well as patient and provider behavior in complex care settings are needed to ensure good communication practices that lead to diagnostic error reduction.2 Our ongoing
work, for instance, applies a multifaceted approach to improving EHR-based communication
and emphasizes integration of key lessons learned into systems, policies, and procedures.
Finally, advances in provider-patient communication
are also needed. Personal health records and secure messaging to improve patient-provider communication are a few such innovations that merit further study. Bringing
patients into the communication loop is a potentially powerful but underdeveloped strategy to help ensure the quality and safety of care in the outpatient setting.
Singh H, Weingart S. Diagnostic Errors in Ambulatory
Care: Dimensions and Preventive Strategies, Advances in Health Sciences Education Theory and Practice 2009; V14S1:57-61.
- Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting: Are Electronic Medical Records Achieving their Potential? Archives of Internal Medicine 2009; 169:1578-86.
Singh H, Naik A, Rao R, Petersen L. Reducing Diagnostic
Errors Through Effective Communication: Harnessing the Power of Information Technology, Journal of General Internal Medicine 2008; 23:489-94.