Diagnostic Safety in an
EHR-Enabled Health Care System
Mark L. Graber, MD FACP Senior Fellow, RTI International Professor Emeritus, SUNY Stony Brook School of Medicine Founder and President, Society to Improve Diagnosis in Medicine (SIDM)
Gordon D. Schiff, MD Internist Associate Director, Center for Patient Safety Research and Practice Brigham and Women’s Hospital Associate Professor of Medicine Harvard Medical School Hardeep Singh, MD MPH Chief, Health Policy, Quality and
Informatics Program Houston VA Center for Innovations in Quality, Effectiveness and Safety, and Baylor College of Medicine
PATIENT SAFETY AWARENESS WEEK
Introduction
Mark L. Graber, MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook
School of Medicine
Founder and President, Society to
Improve Diagnosis in Medicine (SIDM)
PATIENT SAFETY AWARENESS WEEK
DIAGNOSTIC ERROR WEBCAST SERIES
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Our vision:
Diagnosis should be accurate, timely, efficient, and SAFE.
To learn more:
•
Annual conference: Diagnostic Error in Medicine
•
Dx Error listserv
•
New journal: DIAGNOSIS
Diagnosis and Electronic Medical Records
Its role in promoting
diagnostic quality
Gordy Schiff
Its role in finding and
studying diagnostic errors
Diagnostic Safety in an EHR-Enabled
Health Care System
Gordon D. Schiff, MD
Internist and Associate Director
Center for Patient Safety Research and Practice
Brigham and Women’s Hospital
Associate Professor of Medicine
Harvard Medical School
PATIENT SAFETY AWARENESS WEEK
DIAGNOSTIC ERROR WEBCAST SERIES
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Marshal Wolf -Brigham
Dr. Gregory House
Don Berwick
•
•
Former President and CEO
Institute for Healthcare
Improvement (IHI)
•
Former Director Centers
for Medicare & Medicaid
Services
13
Don Berwick
Boston Globe 7/14/2002
Genius diagnosticians make great stories,
but they don't make great health care.
The idea is to make accuracy reliable,
not heroic
15
Safer practice can only come
about from acknowledging the
potential for error and building in
error reduction strategies at each
stage of clinical practice
Time Pressures, Distractions, Interruptions Pt. Presentation Signal:Noise Ambient Conditions Difficult diagnoses Micro environment: IT,
staff, teamwork, support systems Training Prior Experience Self-awareness limitations Dx Errors
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1. Access/Presentation
Denied care
Delayed presentation
2. History
Failure/delay in
eliciting c
ritical piece of history data
Inaccurate/misinterpretation "
Suboptimal weighing “
Failure/delay to follow-up “
3. Physical Exam
Failure/delay in eliciting critical physical exam finding
Inaccurate/misinterpreted "
Suboptimal weighing “
Failure/delay to follow-up “
4. Tests (Lab/Radiology)
OrderingFailure/delay in ordering needed test(s)
Failure/delay in performing ordered test(s)
Suboptimal test sequencing
Ordering of unnecessary test(s)
Performance
Sample mixup/mislabeled (eg wrong patient)
Technical errors/poor processing of specimen/test
Erroneous lab/radiol reading of test
Failed/delayed communication of test
Clinician processing
Failed/delayed follow-up of test
Erroneous clinician interpretation of test
5. Assessment
Hypothesis GenerationFailure/delay in
considering
important diagnosis
Suboptimal weighing/prioritizing
Too much weight to low(er) probability/priority dx
Too little consideration of high(er) probability/priority dx
Too much weight on
competing
diagnosis
Recognizing Urgency/Complications
Failure to appreciate urgency/acuity of illness
Failure/delay in recognizing complication(s)
6. Referral/Consultation
Failed/Delayed in needed referral
Inappropriate/unneeded referral
Suboptimal consultation diagnostic performance
Failed/delayed communication/followup of consultation
7. Followup
Failure to refer patient to close/safe setting/monitoring
Failure/delay in timely follow-up/rechecking of patient
Where
in Diagnostic Process
(~Anatomic localization)
1. Access/Presentation
Denied care
Delayed presentation
2. History
Failure/delay in
eliciting c
ritical piece of history data
Inaccurate/misinterpretation "
Suboptimal weighing “
Failure/delay to follow-up “
3. Physical Exam
Failure/delay in eliciting critical physical exam finding
Inaccurate/misinterpreted "
Suboptimal weighing “
Failure/delay to follow-up “
4. Tests (Lab/Radiology)
OrderingFailure/delay in ordering needed test(s)
Failure/delay in performing ordered test(s)
Suboptimal test sequencing
Ordering of unnecessary test(s)
Performance
Sample mixup/mislabeled (eg wrong patient)
Technical errors/poor processing of specimen/test
Erroneous lab/radiol reading of test
Failed/delayed communication of test
Clinician processing
Failed/delayed follow-up of test
Erroneous clinician interpretation of test
5. Assessment
Hypothesis GenerationFailure/delay in
considering
important diagnosis
Suboptimal weighing/prioritizing
Too much weight to low(er) probability/priority dx
Too little consideration of high(er) probability/priority dx
Too much weight on
competing
diagnosis
Recognizing Urgency/Complications
Failure to appreciate urgency/acuity of illness
Failure/delay in recognizing complication(s)
6. Referral/Consultation
Failed/Delayed in needed referral
Inappropriate/unneeded referral
Suboptimal consultation diagnostic performance
Failed/delayed communication/followup of consultation
7. Followup
Failure to refer patient to close/safe setting/monitoring
Failure/delay in timely follow-up/rechecking of patient
What
Went Wrong
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Where
in Diagnostic Process
(~Anatomic localization)
1. Access/Presentation
Denied care
Delayed presentation
2. History
Failure/delay in
eliciting c
ritical piece of history data
Inaccurate/misinterpretation "
Suboptimal weighing “
Failure/delay to follow-up “
3. Physical Exam
Failure/delay in eliciting critical physical exam finding
Inaccurate/misinterpreted "
Suboptimal weighing “
Failure/delay to follow-up “
4. Tests (Lab/Radiology)
OrderingFailure/delay in ordering needed test(s)
Failure/delay in performing ordered test(s)
Suboptimal test sequencing
Ordering of unnecessary test(s)
Performance
Sample mixup/mislabeled (eg wrong patient)
Technical errors/poor processing of specimen/test
Erroneous lab/radiol reading of test
Failed/delayed communication of test
Clinician processing
Failed/delayed follow-up of test
Erroneous clinician interpretation of test
5. Assessment
Hypothesis GenerationFailure/delay in
considering
important diagnosis
Suboptimal weighing/prioritizing
Too much weight to low(er) probability/priority dx
Too little consideration of high(er) probability/priority dx
Too much weight on
competing
diagnosis
Recognizing Urgency/Complications
Failure to appreciate urgency/acuity of illness
Failure/delay in recognizing complication(s)
6. Referral/Consultation
Failed/Delayed in needed referral
Inappropriate/unneeded referral
Suboptimal consultation diagnostic performance
Failed/delayed communication/followup of consultation
7. Followup
Failure to refer patient to close/safe setting/monitoring
Failure/delay in timely follow-up/rechecking of patient
What
Went Wrong
Preventing/Mitigating Diagnosis Errors
Fertile Fields to Plow
•
More reliable test result f/up
•
Improving patient follow-up & feedback
•
Re-engineered clinical documentation, EMR
•
Learning from mistakes, recalibration
•
Diagnosis time out
•
Just-in-time knowledge, consultations
•
Enhanced role for the patient
El-Kareh
Schiff
BMJ QS 2013
Priority to
“rapidly improve
EHR usability
and functionality
Residents, rushing to complete numerous tasks for large numbers of patients, have
sometimes pasted in the medical history and the history of the present illness from
someone else’s note even before the patient arrives at the clinic. Efficient? Yes. Useful?
No.
This capacity to manipulate the electronic record makes it far too easy for trainees to
avoid taking their own histories and coming to their own conclusions about what might
be wrong. Senior physicians also cut and paste from their own notes, filling each note
with the identical medical history, family history, social history, and review of systems.
Writing in a personal and independent way forces us to think and formulate our ideas.
Notes that are meant to be focused and selective have become voluminous and
templated, distracting from the key cognitive work of providing care.
Such charts may satisfy the demands of third-party payers, but they are the product of a
word processor, not of physicians’ thoughtful review and analysis. They may be
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Although the intent may be to ensure thoroughness, in the new electronic sea of results,
it becomes difficult to find those that are truly relevant. A colleague at a major cancer
center that recently switched to electronic medical records said that chart review during
rounds has become nearly worthless. He bemoaned the vain search through
meaningless repetition in multiple notes for the single line that represented a new
development. “It’s like ‘Where’s Waldo?’ ” he said bitterly.
Ironically, he has started to handwrite a list of new developments on index cards so that
he can refer to them at the bedside.
...we have observed the electronic medical record become a powerful
vehicle for perpetuating erroneous information, leading to diagnostic errors that gain
momentum when passed on electronically
These problems, we believe, will only worsen, for even as
we are pressed to see more patients per hour and to work
with greater “efficiency,” we must respond to demands for
detailed documentation to justify our billing and protect
ourselves from lawsuits. Though the electronic medical
record serves these exigencies, it simultaneously risks
compromising care by fostering a generic approach to
diagnosis and treatment.
The worst kind of electronic medical record requires
filling in boxes with little room for free text. Although
completing such templates may help physicians survive
a report-card review, it directs them to ask restrictive
questions rather than engaging in a narrative-based,
open-ended dialogue. Such dialogue can be key to
making the correct diagnosis and to understanding which
treatment best fits a patient’s beliefs and needs.
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Perhaps most important, we should be cautious in using
templates that constrain creative clinical thinking and promote
automaticity. We must be attentive to the shift in focus
demanded by electronic medical records, which can lead
clinicians to suspend thinking, blindly accept diagnoses, and fail
to talk to patients in a way that allows deep, independent
probing.
The computer should not become a barrier between physician
and patient; as medicine incorporates new technology, its
focus should remain on interaction between the sick and the
healer. Practicing “thinking” medicine takes time, and
electronic records will not change that. We need to make this
technology work for us, rather than allowing ourselves to work
for it.
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Role for Electronic
Documentation
Goals and Features of Redesigned Systems
Providing access toinformation
Ensure ease, speed, and selectivity of information searches; aid cognition through aggregation, trending, contextual relevance, and minimizing of superfluous data.
Recording and sharing assessments
Provide a space for recording thoughtful, succinct assessments, differential diagnoses, contingencies, and unanswered questions; facilitate sharing and review of assessments by both patient and other clinicians.
Maintaining dynamic patient history
Carry forward information for recall, avoiding repetitive pt
querying and recording while minimizing erroneous copying and pasting
Maintaining problem lists Ensure that problem lists are integrated into workflow to allow for continuous updating.
Tracking medications Record medications patient is actually taking, patient responses to medications, and adverse effects to avert misdiagnoses and ensure timely recognition of medication problems.
Tracking tests Integrate management of diagnostic test results into note
workflow to facilitate review, assessment, and responsive action as well as documentation of these steps.
Role for Electronic
Documentation
Goals and Features of Redesigned Systems
Ensuring coordination andcontinuity
Aggregate and integrate data from all care episodes and fragmented encounters to permit thoughtful synthesis.
Enabling follow-up Facilitate patient education about potential red-flag symptoms; track follow-up.
Providing feedback Automatically provide feedback to clinicians upstream, facilitating learning from outcomes of diagnostic decisions.
Providing prompts Provide checklists to minimize reliance on memory and directed questioning to aid in diagnostic thoroughness and problem solving.
Providing placeholder for resumption of work
Delineate clearly in the record where clinician should resume work after interruption, preventing lapses in data collection and thought process.
33
Schiff A J Med 2008
Open Loop System
•
•
Water goes on the same
time each day, regardless
of whether it is raining or
lawn is flooded
35
Diagnosis Essentials Checklist
1. Essential Data Elements
- Elements of Hx, P.exam, tests data that
should be reliably obtained for
every
pt presenting with given sx. In
many situations can reliably be done w/ computer questionnaire.
2. Don’t miss diagnoses
- critical dx can present w/ sx that are fatal or
have serious consequences if not recognized and rx promptly. These
dx should be considered in every patient with that symptom.
3. Red flag symptoms -
sx or findings (e.g. back pain with new urinary
incontinence in cancer patient) that may indicate serious condition &
should lead to heightened suspicion/evaluation for don’t miss dx.
Schiff & Leape Acad Med 2012 Schiff BMJ Safety & Qual 2012
Diagnosis Essentials Checklist
4. Potential drug causes
- meds that can cause the symptom. High %
sx med side effects, yet infrequently considered.
5. Required referrals
- When is specialist expertise or technology
needed to adequately and safely evaluate the patient? Includes
possible rare conditions that only specialists have sufficient
experience or where required testing (biopsy or endoscopy)
6. Patient follow-up instructions and plan
- Warnings that patients
should receive regarding specific symptoms that should lead them to
return or call. These should be in writing and include a time frame.
(e.g. call if you develop rash or fever, or if you are not improved in 48
hours)
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Fatigue Checklist (27 diagnoses)
♠
Don’t miss
*
Often missed
Pr
ev
alenc
e
Ely Acad Med 2010
Obstructive sleep apnea
♠Depression, anxiety Deconditioning
*Drugs (beta blocker, clonidine, alcohol) Chronic fatigue syndrome, fibromyalgia
♠*Infections, infectious mononucleosis, hepatitis, pneumonia, mastitis
♠Pregnancy ♠*Anemia Vitamin D deficiency ♠Hypothyroidism, hyperthyroidism ♠Hypokalemia, hyponatremia ♠*Myocardial infarction ♠Celiac disease
♠Disturbance of calcium, phosphorus, magnesium
♠Polymyalgia rheumatica/Temporal arteritis Parkinson disease
Hypogonadism Myasthenia gravis
♠*Heart failure, myocarditis Pulmonary, hepatic, renal failure Restless legs syndrome
Multiple sclerosis
♠Carbon monoxide
♠Adrenal insufficiency, Addison’s disease B12 deficiency
♠Botulism
Role for Electronic
Documentation
Goals and Features of Redesigned Systems
Calculating Bayesianprobabilities
Embed calculator into notes to reduce errors and minimize biases in subjective estimation of diagnostic probabilities.
Providing access to information sources
Provide instant access to knowledge resources through context-specific “info buttons” triggered by keywords in notes that link user to relevant textbooks and guidelines.
Offering second opinion or consultation
Integrate immediate online or telephone access to consultants to answer questions related to referral triage, testing strategies, or definitive diagnostic assessments.
Increasing efficiency More thoughtful design, workflow integration, easing and
distribution of documentation burden could speed up charting, freeing time for communication and cognition.
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Summary – Areas for Improvement Where EMR
Could Help
•
Tighten gaps so less likely to fall through cracks; safety
nets for those that do.
•
Operationalize, create safety around dx uncertainty
•
Redesign follow-up; feedback
–
Open door, pull systems for patients
–
e-curbside just-in-time consults for clinicians
•
Improve info access; decrease cognitive burden w/
smarter display.
•
Learn from and share mistakes/pitfalls
•
Engage the patient in all of above
Diagnostic Safety in EHR-based
Healthcare: “Missed Test Results”
Hardeep Singh, MD MPH
Chief Health Policy Quality and Informatics Program,
Houston Veterans Affairs Health Services Research &
Development Center of Excellence
Michael E. DeBakey VA Medical Center & BCM
Director, Houston VA Patient Safety Center of Inquiry
PATIENT SAFETY AWARENESS WEEK
DIAGNOSTIC ERROR WEBCAST SERIES
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Doctors sometimes miss electronic test results
By Julie Steenhuysen
CHICAGO | Mon Sep 28, 2009 5:51pm EDT
(Reuters) - Part of the appeal of electronic medical records is that they can help doctors keep track of test results and avoid medical errors, but a study released on Monday suggests that doctors
sometimes ignore electronic warnings about abnormal test results. Researchers found doctors failed to follow up on nearly 8
percent of electronic alerts that a patient had something abnormal on an X-ray, mammogram, computed tomography or CT or magnetic resonance imaging or MRI scan that needed quick attention.
"Just the fact that you can use technology to deliver a piece of information from the radiologist to a doctor doesn't mean it will be taken care of," said Dr. Hardeep Singh of the Baylor College of Medicine in Houston, whose study appears in the Archives of Internal Medicine.
"The electronic health record system is a huge improvement from previous paper-based systems," but it is not perfect, Singh said in a telephone interview.
President Barack Obama has made electronic medical records a centerpiece of his health reform efforts, promising nearly $1.2 billion to help doctors and hospitals make the switch from paper-based records.
Objective
•
Discuss why we need a multi-faceted “socio-technical”
approach to reduce “missed” tests results in EHRs
•
Discuss examples of strategies to address missed test
results in EHR-based health care
43
Objective
•
Discuss why we need a multi-faceted “socio-technical”
approach to reduce “missed” tests results in EHRs
•
Discuss examples of strategies to address missed test
Errors of Test Results Follow-up
•
Failure to follow-up abnormal test results: up to 36%
•
Communication breakdowns prevalent but also a
problem IT can solve!
•
Will technology eliminate failures to follow-up test
results?
45
Alert in “View
Alert” window
Case Study
“View Alert” Window
Example of an abnormal imaging alert
47
Case Study Background
•
Hypothesized that unacknowledged alerts are indicators
for missed test results (vs. acknowledged results that
can serve as “read receipts”)
•
Queried an alert repository of abnormal imaging results
•
Outcomes determined with assumption:
–
Acknowledged
took action
Quantitative Data Assessment
•
Outcomes: documented response /follow-up action on
record review and phone calls
•
Findings:
–
Providers did not acknowledge receipt of 368 of 1,017
of transmitted alerts
–
45/368 unacknowledged alerts lost to follow-up at 4
weeks
•
Next study hypothesis: Timely follow-up higher when
providers acknowledge the alert
49
Findings…
•
Evaluation of 1,163 outpatient abnormal lab & 1,196
abnormal imaging result alerts
–
7% abnormal labs lacked timely follow-up
–
8% abnormal imaging lacked timely follow-up
•
Follow-up in acknowledged vs. unacknowledged alerts?
51
Digging Deeper Qualitatively…
“One of the issues is just the
sheer volume of alerts, and
there’s a number of alerts that
in all honesty [you] really don’t
have any business seeing.”
53
Multiple “Socio-Technical” Issues
Issue
Examples
Software
no functionality for saving, tracking, and
retrieving alerts
Content
too many unnecessary alerts
Usability
poor signal to noise ratio on screen
Workflow
“surrogate feature” to forward alerts when
providers out of office not used properly
Providers
lack of knowledge/training
Organizational
policies for follow-up ambiguous
Lessons from Research
•
EHR-based systems better than paper
•
Not achieving full potential mostly due to
non-technological reasons!
•
Need a sociotechnical model to improve safety
55
Hardware & Software
Personnel Content
Workflow & Communication
Ex ter na l Rules & R egul at ions Measurement & Monitoring Organizational Policies,
Procedures, & Culture
8-Dimensional Socio-Technical Model of Safe &
Effective EHR Use
Objective
•
Discuss why we need a multi-faceted “socio-technical”
approach to reduce “missed” tests results in EHRs
•
Discuss examples of strategies to address missed test
results in EHR-based health care
Experiences with National VA Policy Development
•
Align with team-based model of care
•
Leverage IT including for patient communication
•
Standardize when possible especially in high-risk
situations
•
Give more hands-on guidance on workflow and
processes
59
“SAFER Guides”
•
ONC-sponsored “Safety Assurance Factors for EHR
Resilience (SAFER) project”
•
Proactive risk assessment and guidance
•
Self-assessment; not meant to be regulatory
•
Focused on high-risk areas
•
Nine guides including
Test Results Reporting and
Follow-up
Singh et al BMC Med Inf 2013
The Checklist is structured as a quick way to enter and print your self-assessment. Your selections on the checklist will
automatically update the related section of the corresponding recommended practice worksheet. The Worksheet provides guidance on implementing the Practice.
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Can EHR “Triggers” Help Us?
•
Finding Needles in a Haystack and Creating Safety Nets!
•
On a daily basis, thousands of patients have abnormal
test results
•
Can we electronically identify those likely to be
experiencing diagnostic delays and intervene?
63
Clinical laboratories must give patients access to their own lab-test results upon request, without going through the physician who ordered them, according to a new federal rule announced Monday by the Department of Health and Human Services.
The rule, first proposed in 2011, is part of an Obama administration effort to give patients more control over their own health information.
"Information like lab results can empower patients to track their health progress, make decisions with their health-care professionals and adhere to important treatment plans," said HHS Secretary Kathleen Sebelius.
The final rule amends two existing federal laws, the Health Insurance Portability and Accountability Act, known as HIPAA, and the Clinical Laboratory Improvement Amendments, or CLIA, which regulates most of the clinical testing labs in the U.S. Patient advocacy groups had also pushed for the change.
In Closing…
•
Missed test results in EHRs related to both technical
and non-technical reasons
•
A sociotechnical approach is needed to improve safety
& effectiveness of EHR-based test result follow-up
•
Proactive risk-assessment, EHR-based triggers and
patient engagement additional strategies to consider
for reducing test result follow-up errors
65
Thank You
•
Acknowledgements of Funding Support
–
Veterans Affairs Health Services Research &
Development
–
Veterans Affairs National Center for Patient Safety
–
National Institutes of Health/Agency for Healthcare
Research and Quality
–
Office of the National Coordinator for Health
Information Technology
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