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Kennedy EE, Bowles KH. Human Factors Considerations in Transitions in Care Clinical Decision Support System Implementation Studies. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:621-630. [PMID: 35308926 PMCID: PMC8861703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Objective: Review transitions in care clinical decision support system (CDSS) implementation studies and describe human factors considerations in users, design, alert types, intervention timing, and implementation outcomes. Methods: Literature review in PubMed guided by subject matter experts. Results: Twelve articles were included. Targeted users included physicians, nurses, pharmacists, or interdisciplinary teams. Alerts were deployed via email, cloud-based software, or the EHR in inpatient and/or outpatient settings. Outcome measures varied across articles, with mixed performance. There were six readmissions-focused, two prescribing, one laboratory, two prescribing and laboratory, and one discharge disposition CDSS. Few articles reported statistically significant differences in outcomes, and many reported alert fatigue. Discussion and Conclusion: Despite the increasing prevalence of CDSS for transitions in care, few articles describe implementation processes and outcomes, and evidence of clinical practice improvement is mixed. Future studies should utilize implementation science frameworks and incorporate appropriate implementation outcomes in addition to traditional clinical outcomes like readmission rates.
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Affiliation(s)
- Erin E Kennedy
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health Philadelphia, PA
| | - Kathryn H Bowles
- University of Pennsylvania School of Nursing, NewCourtland Center for Transitions and Health Philadelphia, PA
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Shriner AR, Baker RM, Ellis A, Dixon R, Saysana M. Improving Follow-Up of Tests Pending at Discharge. Hosp Pediatr 2021; 11:1363-1369. [PMID: 34849927 DOI: 10.1542/hpeds.2021-006000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Follow-up on results of inpatient tests pending at discharge (TPAD) must occur to ensure patient safety and high-quality care continue after discharge. We identified a need to improve follow-up of TPAD and began a quality improvement initiative with an aim of reducing the rate of missed follow-up of TPAD to ≤20% within 12 months. METHODS The team used the Plan-Do-Study-Act method of quality improvement and implemented a process using reminder messages in the electronic health record. We collected data via retrospective chart review for the 6 months before the intervention and monthly thereafter. The primary outcome measure was the percentage of patients with missed follow-up of TPAD, defined as no documented follow-up within 72 hours of a result being available. The use of a reminder message was monitored as a process measure. RESULTS We reviewed charts of 764 discharged patients, and 216 (28%) were noted to have TPAD. At baseline, the average percentage of patients with missed follow-up was 80%. The use of reminder messages was quickly adopted. The average percentage of patients with missed follow-up of TPAD after beginning the quality improvement interventions was 35%. CONCLUSIONS We had significant improvement in follow-up after our interventions. Additional work is needed to ensure continued and sustained improvement, focused on reducing variability in performance between providers and investing in technology to allow for automation of the follow-up process.
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Affiliation(s)
- Andrew R Shriner
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
| | - Richelle M Baker
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
| | - Andrew Ellis
- Mercy Children's Hospital, St Louis, Missouri.,Department of Child Health School of Medicine, University of Missouri, Columbia, Missouri
| | - Rebecca Dixon
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
| | - Michele Saysana
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana.,Department of Pediatrics, Section of Hospital Medicine School of Medicine, Indiana University, Indianapolis, Indiana
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Mikhaeil JS, Jalali H, Orchanian-Cheff A, Chartier LB. Quality Assurance Processes Ensuring Appropriate Follow-up of Test Results Pending at Discharge in Emergency Departments: A Systematic Review. Ann Emerg Med 2020; 76:659-674. [DOI: 10.1016/j.annemergmed.2020.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/20/2020] [Accepted: 04/28/2020] [Indexed: 11/16/2022]
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Thomas J, Dahm MR, Li J, Smith P, Irvine J, Westbrook JI, Georgiou A. Variation in electronic test results management and its implications for patient safety: A multisite investigation. J Am Med Inform Assoc 2020; 27:1214-1224. [PMID: 32719839 PMCID: PMC7481032 DOI: 10.1093/jamia/ocaa093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 05/06/2020] [Indexed: 11/15/2022] Open
Abstract
Objective The management and follow-up of diagnostic test results is a major patient safety concern. The aim of this qualitative study was to explore how clinicians manage test results on an everyday basis (work-as-done) in a health information technology–enabled emergency department setting. The objectives were to identify (1) variations in work-as-done in test results management and (2) the strategies clinicians use to ensure optimal management of diagnostic test results. Materials and Methods Qualitative interviews (n = 26) and field observations were conducted across 3 Australian emergency departments. Interview data coded for results management (ie, tracking, acknowledgment, and follow-up), and artifacts, were reviewed to identify variations in descriptions of work-as-done. Thematic analysis was performed to identify common themes. Results Despite using the same test result management application, there were variations in how the system was used. We identified 5 themes relating to electronic test results management: (1) tracking test results, (2) use and understanding of system functionality, (3) visibility of result actions and acknowledgment, (4) results inbox use, and (5) challenges associated with the absence of an inbox for results notifications for advanced practice nurses. Discussion Our findings highlight that variations in work-as-done can function to overcome perceived impediments to managing test results in a HIT-enabled environment and thus identify potential risks in the process. By illuminating work-as-done, we identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality. Conclusions Test results tracking and follow-up is a priority area in need of health information technology development and training to improve team-based collaboration/communication of results follow-up and diagnostic safety.
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Affiliation(s)
- Judith Thomas
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Maria R Dahm
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Julie Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Peter Smith
- Emergency Medicine, Illawarra Shoalhaven Local Health District, New South Wales, Australia.,Graduate School of Medicine, University of Wollongong, New South Wales, Australia
| | - Jacqui Irvine
- Emergency Medicine, Illawarra Shoalhaven Local Health District, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
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5
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De Gagne JC, Yang Y, Rushton S, Koppel PD, Hall K. Email Use Reconsidered in Health Professions Education: Viewpoint. JMIR MEDICAL EDUCATION 2020; 6:e19300. [PMID: 32478659 PMCID: PMC7296417 DOI: 10.2196/19300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 05/06/2023]
Abstract
Email has become a popular means of communication in the past 40 years, with more than 200 billion emails sent each day worldwide. When used appropriately, email can be an effective and useful form of correspondence, although improper practices, such as email incivility, can present challenges. Email is ubiquitous in education and health care, where it is used for student-to-teacher, provider-to-provider, and patient-to-provider communications, but not all students, faculty members, and health professionals are skilled in its use. This paper examines the challenges and opportunities posed by email communication in health professions education and reveals important deficiencies in training, as well as steps that can be taken by health professions educators to address them. Recommendations are offered to help health professions educators develop approaches for teaching email professionalism.
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Affiliation(s)
| | - Yesol Yang
- Duke University School of Nursing, Durham, NC, United States
| | - Sharron Rushton
- Duke University School of Nursing, Durham, NC, United States
| | - Paula D Koppel
- Duke University School of Nursing, Durham, NC, United States
| | - Katherine Hall
- West Virginia University School of Nursing, Morgantown, WV, United States
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Whitehead NS, Williams L, Meleth S, Kennedy S, Epner P, Singh H, Wooldridge K, Dalal AK, Walz SE, Lorey T, Graber ML. Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review. J Hosp Med 2018; 13:631-636. [PMID: 29489926 PMCID: PMC9491200 DOI: 10.12788/jhm.2944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/29/2017] [Accepted: 12/17/2017] [Indexed: 01/25/2023]
Abstract
Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, eight met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published Laboratory Medicine Best Practices (LMBP™) A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.
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Affiliation(s)
| | - Laurina Williams
- Centers for Disease Control and Prevention, Atlanta, Georgia
- Author for correspondence: Laurina Williams, PhD, MPH, Centers for Disease Control and Prevention, Center for Surveillance, Epidemiology, and Laboratory Services, Division of Laboratory Systems,1600 Clifton Road, NE, MS G25, Atlanta, GA 30329; Telephone: 404-498-2267; Fax: 404-498-2215,
| | | | - Sara Kennedy
- RTI International, Research Triangle Park, North Carolina
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas
| | | | - Anuj K. Dalal
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Tom Lorey
- Kaiser Permanente Northern California, Berkeley, California
| | - Mark L. Graber
- RTI International, Research Triangle Park, North Carolina
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Dalal AK, Schaffer A, Gershanik EF, Papanna R, Eibensteiner K, Nolido NV, Yoon CS, Williams D, Lipsitz SR, Roy CL, Schnipper JL. The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial. J Gen Intern Med 2018; 33:1043-1051. [PMID: 29532297 PMCID: PMC6025668 DOI: 10.1007/s11606-018-4393-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/03/2018] [Accepted: 02/01/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up. KEY RESULTS Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03). CONCLUSIONS Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern. CLINICAL TRIALS IDENTIFIER NCT01153451.
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Affiliation(s)
- Anuj K Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Adam Schaffer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, MA, USA
| | - Esteban F Gershanik
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ranganath Papanna
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katyuska Eibensteiner
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Nyryan V Nolido
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy S Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah Williams
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Partners HealthCare, Inc., Boston, MA, USA
| | - Stuart R Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christopher L Roy
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Hospital Medicine Unit, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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8
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Capsule Commentary on Dalal et al., The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial. J Gen Intern Med 2018; 33:1139. [PMID: 29667087 PMCID: PMC6025648 DOI: 10.1007/s11606-018-4438-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Barr NG, Randall GE, Archer NP, Musson DM. Physician communication via Internet-enabled technology: A systematic review. Health Informatics J 2017; 25:919-934. [PMID: 28992744 DOI: 10.1177/1460458217733122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The use of Internet-enabled technology (information and communication technology such as smartphone applications) may enrich information exchange among providers and, consequently, improve health care delivery. The purpose of this systematic review was to gain a greater understanding of the role that Internet-enabled technology plays in enhancing communication among physicians. Studies were identified through a search in three electronic platforms: the Association for Computing Machinery Digital Library, ProQuest, and Web of Science. The search identified 5140 articles; of these, 21 met all inclusion criteria. In general, physicians were satisfied with Internet-enabled technology, but consensus was lacking regarding whether Internet-enabled technology improved efficiency or made a difference to clinical decision-making. Internet-enabled technology can play an important role in enhancing communication among physicians, but the extent of that benefit is influenced by (1) the impact of Internet-enabled technology on existing work practices, (2) the availability of adequate resources, and (3) the nature of institutional elements, such as privacy legislation.
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Clarity C, Sarkar U, Lee J, Handley MA, Goldman LE. Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health Care System. Jt Comm J Qual Patient Saf 2017; 43:517-523. [PMID: 28942776 DOI: 10.1016/j.jcjq.2017.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Missed or delayed follow-up of abnormal subcritical tests (tests that do not require immediate medical attention) can lead to poor patient outcomes. Safety-net health systems with limited resources and socially complex patients are vulnerable to safety gaps resulting from delayed management. Clinician perspectives to identify system challenges, vulnerable situations, and potential solutions were sought in focus groups. METHODS Five semistructured focus groups were conducted in 2015 with purposefully sampled clinicians from radiology, hospital medicine, emergency medicine, risk management, and ambulatory care from an urban, academic, integrated, safety-net health system. Thematic analysis identified challenges of current management of abnormal subcritical tests, vulnerable situations, and solution characteristics. A total of 43 clinicians participated. RESULTS Clinicians cited challenges in assigning responsibility for follow-up and identified tests pending at discharge and tests requiring delayed follow-up as vulnerable situations. The lack of tracking systems and missing contact information for patients and providers exacerbated these challenges. Proposed solution characteristics involved protocols to aid in assigning responsibility, reliable paths of communication, and systems to track the status of tests. Clinicians noted a strong desire for integration of the work flow and technology solutions into existing structures. CONCLUSION In an urban safety-net setting, clinicians recommended outlining clear chains of responsibility and communication in the management of subcritical test results, and employing simple, integrated technological solutions that allow for tracking and management of tests. Existing test management solutions should be adapted to work within safety-net systems, which often have fewer resources and more complex patients and may function in the absence of integrated technology systems.
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Dalal AK, Pesterev BM, Eibensteiner K, Newmark LP, Samal L, Rothschild JM. Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. J Am Med Inform Assoc 2015; 22:905-8. [PMID: 25796594 PMCID: PMC6283058 DOI: 10.1093/jamia/ocv007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 12/15/2014] [Accepted: 01/19/2015] [Indexed: 12/13/2022] Open
Abstract
Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment functionality to ensure follow-up of nonurgent CSTRs.
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Affiliation(s)
- Anuj K Dalal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital
| | - Bailey M Pesterev
- Division of General Medicine and Primary Care, Brigham and Women's Hospital
| | | | - Lisa P Newmark
- Division of General Medicine and Primary Care, Brigham and Women's Hospital Partners HealthCare, Inc
| | - Lipika Samal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital
| | - Jeffrey M Rothschild
- Division of General Medicine and Primary Care, Brigham and Women's Hospital Partners HealthCare, Inc
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Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. J Gen Intern Med 2015; 30:312-8. [PMID: 25416599 PMCID: PMC4351274 DOI: 10.1007/s11606-014-3064-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 08/18/2014] [Accepted: 09/25/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge. OBJECTIVE To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies. DESIGN Pre-post analysis. PATIENTS 260 consecutive patients discharged from inpatient general medicine services from July to August 2013. INTERVENTION Development of an EMR-based tool that automatically generates a list of studies pending at discharge. MAIN MEASURES The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies. KEY RESULTS Pre-intervention, 70% of patients had at least one pending study at discharge, but only 18% of these were communicated in the discharge summary. Most studies were microbiology cultures (68%), laboratory studies (16%), or microbiology serologies (10%). The majority of study results were ultimately normal (83%), but 9% were newly abnormal. Post-intervention, communication of studies pending increased to 43% (p < 0.001). CONCLUSIONS Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.
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Affiliation(s)
- Molly A Kantor
- Stanford University School of Medicine, 300 Pasteur Drive, Lane 154, Stanford, CA, 94305, USA,
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Goyder C, Atherton H, Car M, Heneghan CJ, Car J. Email for clinical communication between healthcare professionals. Cochrane Database Syst Rev 2015; 2015:CD007979. [PMID: 25698124 PMCID: PMC10685995 DOI: 10.1002/14651858.cd007979.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Email is one of the most widely used methods of communication, but its use in healthcare is still uncommon. Where email communication has been utilised in health care, its purposes have included clinical communication between healthcare professionals, but the effects of using email in this way are not well known. We updated a 2012 review of the use of email for two-way clinical communication between healthcare professionals. OBJECTIVES To assess the effects of email for clinical communication between healthcare professionals on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information. SEARCH METHODS We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9 2013), MEDLINE (OvidSP) (1946 to August 2013), EMBASE (OvidSP) (1974 to August 2013), PsycINFO (1967 to August 2013), CINAHL (EbscoHOST) (1982 to August 2013), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched November 2013). We used additional search methods: examining reference lists and contacting authors. SELECTION CRITERIA Randomised controlled trials, quasi-randomised trials, controlled before and after studies, and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information in the form of: 1) unsecured email, 2) secure email, or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information and have reported all measures as per the study report. MAIN RESULTS The previous version of this review included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment versus usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement or osteoporosis medication, or both) when compared with usual care. The evidence for its impact on patient behaviours or actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively (patients had a higher calcium intake), and two found no difference between the two groups. The study did not assess health service outcomes or harms.No new studies were identified for this update. AUTHORS' CONCLUSIONS Only one study was identified for inclusion, providing insufficient evidence for guiding clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research should aim to utilise high-quality study designs that use the most recent developments in information technology, with consideration of the complexity of email as an intervention.
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Affiliation(s)
- Clare Goyder
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK, OX2 6GG.
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Sloan CE, Chadalavada SC, Cook TS, Langlotz CP, Schnall MD, Zafar HM. Assessment of follow-up completeness and notification preferences for imaging findings of possible cancer: what happens after radiologists submit their reports? Acad Radiol 2014; 21:1579-86. [PMID: 25179562 DOI: 10.1016/j.acra.2014.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 02/07/2023]
Abstract
RATIONALE AND OBJECTIVES To understand the reasons leading to potentially inappropriate management of imaging findings concerning for malignancy and identify optimal methods for communicating these findings to providers. MATERIALS AND METHODS We identified all abdominal imaging examinations with findings of possible cancer performed on six randomly selected days in August to December 2013. Electronic medical records (EMR) of one patient group were reviewed 3 months after the index examination to determine whether management was appropriate (completed follow-up or documented reason for no follow-up) or potentially inappropriate (no follow-up or no documented reason). Providers of a second patient group were contacted 5-6 days after imaging examinations to determine notification preferences. RESULTS Among 43 patients in the first group, five (12%) received potentially inappropriate management. Reasons included patient loss to follow-up and provider failure to review imaging results, document known imaging findings, or communicate findings to providers outside the health system. Among 16 providers caring for patients in the second group, 33% were unaware of the findings, 75% preferred to be notified of abnormal findings via e-mail or EMR, 56% wanted an embedded hyperlink enabling immediate follow-up order entry, and only 25% had a system to monitor whether patients had completed ordered testing. CONCLUSIONS One in eight patients did not receive potentially necessary follow-up care within 3 months of imaging findings of possible cancer. Automated notification of imaging findings and follow-up monitoring not only is desired by providers but can also address many of the reasons we found for inappropriate management.
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Affiliation(s)
- Caroline E Sloan
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Seetharam C Chadalavada
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tessa S Cook
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Curtis P Langlotz
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mitchell D Schnall
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanna M Zafar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Liao JM, Roy CL, Eibensteiner K, Nolido N, Schnipper JL, Dalal AK. Lost in transition: discrepancies in how physicians perceive the actionability of the results of tests pending at discharge. J Hosp Med 2014; 9:407-9. [PMID: 24585757 DOI: 10.1002/jhm.2177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/20/2014] [Accepted: 01/24/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Joshua M Liao
- Department of Internal Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
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16
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Roy CL, Rothschild JM, Dighe AS, Schiff GD, Graydon-Baker E, Lenoci-Edwards J, Dwyer C, Khorasani R, Gandhi TK. An initiative to improve the management of clinically significant test results in a large health care network. Jt Comm J Qual Patient Saf 2014; 39:517-27. [PMID: 24294680 DOI: 10.1016/s1553-7250(13)39068-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged. METHODS In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action. RESULTS The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics. CONCLUSIONS This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.
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17
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Dalal AK, Roy CL, Poon EG, Williams DH, Nolido N, Yoon C, Budris J, Gandhi T, Bates DW, Schnipper JL. Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. J Am Med Inform Assoc 2013; 21:473-80. [PMID: 24154834 DOI: 10.1136/amiajnl-2013-002030] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results. METHODS We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction. RESULTS We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention. CONCLUSIONS Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT01153451).
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Affiliation(s)
- Anuj K Dalal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
Across the globe, the ways in which patients' test results are managed are as varied as the many different types of healthcare systems that manage these data. The outcomes, however, are often not too dissimilar: too many clinically significant test results fall through the cracks. The consequences of not following up test results in a timely manner are serious and often devastating to patients: diagnoses are delayed, treatments are not initiated or altered in time, and diseases progress. In resource-poor settings, test results too commonly get filed away within the paper chart in ways that isolate them and prevent passage to future providers caring for a patient. To make matters worse, the onus to act upon these test results often rests on patients who need to return to the clinic within a specified timeframe in order to obtain their results but who may not have the means or are too ill to do so. Even in more developed healthcare settings that use electronic records, clinical data residing in the electronic medical record (EMR) are often stubbornly "static"-key pieces of clinical information are frequently not recognized, retrieved, or shared easily. In this way, EMRs are not unlike paper record systems, and therefore, EMRs alone will not solve this problem. To illustrate this problem, consider the case of a patient newly diagnosed with HIV in 3 different healthcare delivery settings.
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Affiliation(s)
- Daniel Palazuelos
- Daniel Palazuelos, MD, MPH, is an associate physician on the BWH Hospitalist Service, Division of General Medicine, Brigham and Women's Hospital; an assistant program director for the Global Health Equity (GHE) Residency in the Division of GHE, Brigham and Women's Hospital; the director of the Community Health Worker Quality Improvement Task Force at Partners in Health; and an instructor at Harvard Medical School, Boston, Massachusetts
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