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Publication Briefs

Study Examines VA HIT-Related Outpatient Diagnostic Delays

Diagnostic delays are a major threat to outpatient safety. Health information technology (HIT) can reduce delays by reliably transmitting and tracking test results, supporting intelligent test selection, improving information access and display, and facilitating electronic communication. However, problems persist despite electronic health record (EHR) implementation and new unintended safety concerns have emerged, spurring efforts to understand the impact of HIT on diagnosis. Addressing diagnostic delays in the context of HIT requires improved understanding of complex systems that account for interactions between technology, its users, involved workflows, and organizational policies and procedures. This retrospective study evaluated the role of HIT in the root cause analyses (RCAs) of outpatient diagnostic delays submitted to the VA National Center for Patient Safety (NCPS), which leads patient safety initiatives and uses RCAs of adverse events and close calls to promote learning across the VA healthcare system. Investigators examined all RCAs categorized by the terms "delay" and "outpatient" between January 2013 and July 2018 (n=214).


  • Of the 214 RCAs included in this study, 88 involved HIT-related safety factors in diagnostic delays. In the majority of these RCAs (n=64), the primary process breakdown was due to inadequate follow-up of one or more abnormal test results.
  • Delays involved the diagnosis of serious conditions, including cancers, infections, and cardiovascular disease.
  • Most safety concerns (83%) involved problems with the safe use of HIT, mainly sociotechnical factors associated with workflow and communication, people, and a poorly designed human-computer interface.
  • Five key high-risk areas for diagnostic delays emerged: 1) managing electronic health record inbox notifications and communication, 2) gathering diagnostic information, 3) technical problems, 4) data entry problems, and 5) failure of a system to track test results.


  • Study findings suggest multiple interventions to reduce outpatient diagnostic delays through improved design, configuration, and use of HIT. Interventions should aim to: 1) Redesign EHR inboxes and message workflow; 2) Develop safety nets to identify missed results; 3) Improve the display of diagnostic information; 4) Track referrals; 5) Optimize order entry design; and 6) Pursue interoperability between VA and non-VA care settings.


  • This study sample was limited by voluntary reporting and may not be representative of all types of diagnostic delays.

This study was partly funded by HSR&D and NCPS. Dr. Singh is part of HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX.

Powell L, Sittig D, Chrouser K, and 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 Network Open. June 25, 2020;3(6):e206752.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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