Variation in electronic test results management and its implications for patient safety: A multisite investigation

Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies' Report Improving Diagnosis in Health Care

BACKGROUND

Standards for accurate and timely diagnosis are ill-defined. In 2015, the National Academies of Science, Engineering, and Medicine (NASEM) committee published a landmark report, Improving Diagnosis in Health Care , and proposed a new definition of diagnostic error, "the failure to ( a ) establish an accurate and timely explanation of the patient's health problem(s) or ( b ) communicate that explanation to the patient."

OBJECTIVE

This study aimed to explore how researchers operationalize the NASEM's definition of diagnostic error with relevance to accuracy, timeliness, and/or communication in peer-reviewed published literature.

METHODS

Using the Arskey and O'Malley's framework framework, we identified published literature from October 2015 to February 2021 using Medline and Google Scholar. We also conducted subject matter expert interviews with researchers.

RESULTS

Of 34 studies identified, 16 were analyzed and abstracted to determine how diagnostic error was operationalized and measured. Studies were grouped by theme: epidemiology, patient focus, measurement/surveillance, and clinician focus. Nine studies indicated using the NASEM definition. Of those, 5 studies also operationalized with existing definitions proposed before the NASEM report. Four studies operationalized the components of the NASEM definition and did not cite existing definitions. Three studies operationalized error using existing definitions only. Subject matter experts indicated that the NASEM definition functions as foundation for researchers to conceptualize diagnostic error.

CONCLUSIONS

The NASEM report produced a common understanding of diagnostic error that includes accuracy, timeliness, and communication. In recent peer-reviewed literature, most researchers continue to use pre-NASEM report definitions to operationalize accuracy and timeliness. The report catalyzed the use of patient-centered concepts in the definition, resulting in emerging studies focused on examining errors related to communicating diagnosis to patients.

Improving Results Management Processes in an Acute Hospital Using a Multi-Faceted Approach

BACKGROUND

Radiological examinations and laboratory tests are routinely ordered by hospital physicians as part of the care plan to diagnose and treat patients. However, the failure to actively review and follow-up on these results pose a significant problem to patient safety. A study team was formed to mitigate the clinical risks of poor results management, which was identified as a top clinical risk in our organisation, in order to make improvements to the results management process and to ensure the timely review, acknowledgement, and follow-up of test results.

METHODS

The institutional expectations of results management were set and published as a hospital policy, which was communicated to all clinical departments for compliance. Improvements to the electronic medical records system were made to facilitate the results acknowledgement process, and physicians were engaged to educate them on the importance of results management.

RESULTS

The study team observed a decrease in unacknowledged results from approximately 16,000 in March 2017 to 2673 in December 2020. The compliance rate for acknowledgement results increased from a monthly average of 83.7% (from March to December 2017) to a monthly average of 99.3% (in 2020). The risk score for results management decreased from 16 to 6.5, and was excluded from the organisation's top clinical risks.

CONCLUSION

This study showed the importance of both system improvements and culture changes that are required to improve the process of results management, and provides a step forward for the hospital to safeguard patient safety and mitigate clinical risk.

Identifying the mechanisms that contribute to safe and effective electronic test result management systems- a multisite qualitative study

OBJECTIVE

Suboptimal design of health information technology (IT) systems can lead to the introduction of errors in the diagnostic process. We aimed to identify mechanisms that can affect the safety and effectiveness of these systems in hospital settings thus contributing to the building of an explicit and replicable understanding of the variables that can affect the functioning of IT systems.

MATERIALS AND METHODS

This qualitative study drew from observations and semistructured interviews from a purposive sample of 46 participants (26 emergency department and 20 laboratory and medical imaging staff) across 3 Australian hospitals. Iterative, inductive coding of the data led to the development of higher-level themes based on relationships between codes.

RESULTS

Two overarching themes emerged: (1) usability and safety of the electronic test result management system; and (2) system redesign considerations about who is meant to follow up, when and how. The usability and safety of digital systems and the way these systems deal with accountability processes are triggered by mechanisms that are contextually dependent.

DISCUSSION

Our findings highlighted the multitransactional nature of the test result management process involving numerous healthcare professionals across different settings. This communication requires integration of the systems utilized by different departments and transparency of the test result follow-up process to facilitate clear lines of responsibility and accountability.

CONCLUSION

Identifying mechanisms that shape the functionality and sustainability of electronic result management can offer a valuable appreciation of key elements that need to be accounted for, and the circumstances in which they need to operate effectively.

The Role of Electronic Medical Records in Reducing Unwarranted Clinical Variation in Acute Health Care: Systematic Review

BACKGROUND

The use of electronic medical records (EMRs)/electronic health records (EHRs) provides potential to reduce unwarranted clinical variation and thereby improve patient health care outcomes. Minimization of unwarranted clinical variation may raise and refine the standard of patient care provided and satisfy the quadruple aim of health care.

OBJECTIVE

A systematic review of the impact of EMRs and specific subcomponents (PowerPlans/SmartSets) on variation in clinical care processes in hospital settings was undertaken to summarize the existing literature on the effects of EMRs on clinical variation and patient outcomes.

METHODS

Articles from January 2000 to November 2020 were identified through a comprehensive search that examined EMRs/EHRs and clinical variation or PowerPlans/SmartSets. Thirty-six articles met the inclusion criteria. Articles were examined for evidence for EMR-induced changes in variation and effects on health care outcomes and mapped to the quadruple aim of health care.

RESULTS

Most of the studies reported positive effects of EMR-related interventions (30/36, 83%). All of the 36 included studies discussed clinical variation, but only half measured it (18/36, 50%). Those studies that measured variation generally examined how changes to variation affected individual patient care (11/36, 31%) or costs (9/36, 25%), while other outcomes (population health and clinician experience) were seldom studied. High-quality study designs were rare.

CONCLUSIONS

The literature provides some evidence that EMRs can help reduce unwarranted clinical variation and thereby improve health care outcomes. However, the evidence is surprisingly thin because of insufficient attention to the measurement of clinical variation, and to the chain of evidence from EMRs to variation in clinical practices to health care outcomes.

Why is there variation in test ordering practices for patients presenting to the emergency department with undifferentiated chest pain? A qualitative study

INTRODUCTION

Up to one-third of laboratory tests ordered in the ED for adults presenting with undifferentiated chest pain are generally not indicated by current Australian guidelines. This study set out to undertake a qualitative investigation of clinician perceptions to identify the reasons for variations in pathology requesting.

METHODS

For this study, we draw on data from semistructured interviews (n=38) conducted in the EDs and laboratories across three hospitals as part of a larger study on the test result management process from test request to result follow-up. Thematic analysis was conducted to determine what aspects of the clinical routines and environment might contribute to variations in pathology requesting. Informed by the findings from the analysis, targeted questions were developed and further focus groups (n=5) were held with clinicians, hospital management and electronic medical record (eMR) analysts to investigate in more detail the reasons for requesting outside of guidelines.

RESULTS

Participants cited four main reasons for ordering outside of guidelines. Clinicians requested tests outside of guidelines and the ED scope of practice to facilitate the patient journey along the broader continuum of care, including admission to hospital or transfer to another site. Clinicians were also faced with multiple and inconsistent guidelines regarding appropriate test selection. Limited access to in-house specialty and diagnostic services also influenced ordering patterns in smaller non-referral hospitals. Finally, certain features of the current electronic ordering framework within the eMR facilitated overordering and failed to impose any real restrictions on ordering inappropriately or outside of scope of practice.

CONCLUSION

Beyond the standardisation of pathology requesting advice across electronic decision support, order sets and guidelines, attempts to address issues related to the appropriateness and variation of laboratory test ordering should consider local and systemic factors which also shape the ordering process.