To err is human, to correct divine: the emergence of technology-based communication systems

Development of a refill pattern method to measure polypharmacy in administrative claims databases

PURPOSE

The purposes of the study were to develop a refill pattern method to identify polypharmacy in pharmacy billing records and to compare the method with traditional days' supply overlap algorithms.

METHODS

This method is characterized by the assessment of prescription refill pattern. Concomitant therapy is assumed when two drugs are dispensed repeatedly during the active days' supply of each other. We tested the refill pattern method in a simplified scenario in which two drugs (methylphenidate/dexmethylphenidate and atomoxetine) for attention deficit/hyperactivity disorder (ADHD) were considered. Children who had at least one prescription of methylphenidate/dexmethylphenidate or atomoxetine in 2008 were included for the calculation of 2-year prevalence of ADHD treatment polypharmacy. Results were compared with traditional method that requires a minimum overlap of 30, 60 or 90 days of filled prescriptions. We compared polypharmacy prevalence estimated by the two methods and explored reasons for disagreement.

RESULTS

Among 131 385 children who had at least one prescription of methylphenidate/dexmethylphenidate or atomoxetine, the refill pattern method identified 4021 patients who had ADHD treatment polypharmacy (2-year prevalence = 3.1%). This prevalence estimate fell between those from a 30- to 60-day overlap method. The Cohen's kappa regarding determination of polypharmacy was 0.83, 0.92 and 0.80 considering 90-, 60- and 30-day overlap method, respectively.

CONCLUSIONS

The refill pattern method can be used as another way to measure polypharmacy in administrative claims databases and can be adapted to a wide variety of research questions, diseases and study populations. Copyright © 2016 John Wiley & Sons, Ltd.

Peer Review: Lessons Learned in A Pediatric Radiology Department

The purpose of this article is to illustrate types of diagnostic errors and feedback given to radiologists, using cases to support and clarify these categories. A comment-enhanced peer review system may be leveraged to generate a comprehensive feedback categorization scheme. These include errors of observation, errors of interpretation, inadequate patient data gathering, errors of communication, interobserver variability, informational feedback, and compliments. Much of this feedback is captured through comments associated with interpretative agreements.

Communication breakdowns and diagnostic errors: a radiology perspective

Timely and accurate communication is essential to safe and effective health care. Despite increased awareness over the past decade of the frequency of medical errors and greater efforts directed towards improving patient safety, patient harm due to communication breakdowns remains a significant problem. Communication problems related to diagnostic testing may account for nearly half of all errors made by typical primary care physicians in their medical practices. This article provides an overview of communication breakdowns in the context of radiology related diagnostic errors. In radiology, communication breakdowns between radiologists, referring clinicians, and patients can lead to failure of critical information to be relayed, resulting in delayed or missed diagnosis. New technologies, such electronic health records (EHRs), contribute to the increasing complexity of communication in health care, but if used correctly, they can provide several benefits to safe and effective communication. To address the complexity of communication breakdowns, a multifaceted sociotechnical approach is needed to address both technical and non-technical aspects of health care delivery. The article also provides some future directions in reducing communication breakdowns related to diagnostic testing, including proactive risk assessment of communication practices using recently released SAFER self-assessment guides.

The perils of communicating the unexpected finding

Failure to communicate is one of the greatest problems facing radiologists today. The courts have consistently held that timely communication may be as important as the diagnosis itself. One of the major driving forces that directly affects our failure to communicate is IT. Not only does IT provide patients with up-to-date information about medical conditions and diagnoses, it also allows the public to instantly communicate with one another, something they expect physicians to do as well. The paradox is that we are so advanced in imaging technology, but not in communicating imaging findings. This article addresses some of the most pressing issues in communicating unexpected findings and their possible solutions. Information technology can be a facilitator but not the substitute for direct communication with ordering physicians.

Evaluation of effectiveness of a computerized notification system for reporting critical values

Failure to adequately communicate a critical laboratory value is a potential cause of adverse events. Accreditation requirements specify that clinical laboratories must undertake assessments and appropriate measures to improve the timeliness of critical value reporting and prompt receipt by the responsible caregiver. Documentation and communication processes must be regularly monitored and implemented under ongoing systems for quality monitoring. Critical value reporting is an important phase of the clinical laboratory testing process, and notifications of results outside the target time can indicate ineffectiveness of the process. In the present study, we report data obtained in a 12-month period of critical values analysis and describe a computerized communication system conducive to improving the quality of critical value reporting at a university hospital. Automated communication improves the timeliness of notification and avoids the potential errors for which accreditation programs require read-back of the result. The communication also improves the likelihood of reaching the physician on call and may provide important decision support.

Reducing diagnostic errors through effective communication: harnessing the power of information technology

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.

Communication outcomes of critical imaging results in a computerized notification system

OBJECTIVE

Communication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardized processes and procedures in a computerized test result notification system and examined their effectiveness to reduce errors in communication of abnormal imaging results.

DESIGN

We prospectively analyzed outcomes of computerized notification of abnormal test results (alerts) that providers did not explicitly acknowledge receiving in the electronic medical record of an ambulatory multispecialty clinic.

MEASUREMENTS

In the study period, 190,799 outpatient visits occurred and 20,680 outpatient imaging tests were performed. We tracked 1,017 transmitted alerts electronically. Using a taxonomy of communication errors, we focused on alerts in which errors in acknowledgment and reception occurred. Unacknowledged alerts were identified through electronic tracking. Among these, we performed chart reviews to determine any evidence of documented response, such as ordering a follow-up test or consultation. If no response was documented, we contacted providers by telephone to determine their awareness of the test results and any follow-up action they had taken. These processes confirmed the presence or absence of alert reception.

RESULTS

Providers failed to acknowledge receipt of over one-third (368 of 1,017) of transmitted alerts. In 45 of these cases (4% of abnormal results), the imaging study was completely lost to follow-up 4 weeks after the date of study. Overall, 0.2% of outpatient imaging was lost to follow-up. The rate of lost to follow-up imaging was 0.02% per outpatient visit.

CONCLUSION

Imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.