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Black GB, Moreland J, Fulop NJ, Lyratzopoulos G, Nicholson BD, Whitaker KL. Personal and organisational health literacy in the non-specific symptom pathway for cancer: An ethnographic study. Health Expect 2024; 27:e14062. [PMID: 38704822 PMCID: PMC11070181 DOI: 10.1111/hex.14062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024] Open
Abstract
INTRODUCTION People being investigated for cancer face a wealth of complex information. Non-specific symptom pathways (NSS) were implemented in the United Kingdom in 2017 to address the needs of patients experiencing symptoms such as weight loss, fatigue or general practitioner 'gut feeling', who did not have streamlined pathways for cancer investigation. This study aimed to explore the health literacy skills needed by patients being investigated for cancer in NSS pathways. METHODS This study employed ethnographic methods across four hospitals in England, including interviews, patient shadowing and clinical care observations, to examine NSS pathways for cancer diagnosis. We recruited 27 patients who were shadowed and interviewed during their care. We also interviewed 27 professionals. The analysis focused on patient communication and understanding, drawing on the concepts of personal and organisational health literacy. RESULTS Our analysis derived six themes highlighting the considerable informational demands of the NSS pathway. Patients were required to understand complex blood tests and investigations in primary care and often did not understand why they were referred. The NSS pathway itself was difficult to understand with only a minority of patients appreciating that multiple organs were being investigated for cancer. The process of progressing through the pathway was also difficult to understand, particularly around who was making decisions and what would happen next. The results of investigations were complex, often including incidental findings. Patients whose persistent symptoms were not explained were often unsure of what to do following discharge. CONCLUSION We have identified several potential missed opportunities for organisations to support patient understanding of NSS pathways which could lead to inappropriate help-seeking post-discharge. Patients' difficulties in comprehending previous investigations and findings could result in delays, overtesting or inadequately targeted investigations, hindering the effective use of their medical history. Third, patients' limited understanding of their investigations and results may impede their ability to engage in patient safety by reporting potential care errors. PATIENT OR PUBLIC CONTRIBUTION Patient, public, clinical and policy representatives contributed to developing the research objectives through a series of meetings and individual conversations in preparation for the study. We have held several events in which patients and the public have had an opportunity to give feedback about our results, such as local interest groups in North London and academic conferences. A clinical contributor (J.-A. M.) was involved in data analysis and writing the manuscript.
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Affiliation(s)
- Georgia B. Black
- Centre for Cancer Screening, Prevention and Early Diagnosis, Wolfson Institute of Population HealthQueen Mary University of LondonLondonUK
- Department of Applied Health ResearchUniversity College LondonLondonUK
| | - Julie‐Ann Moreland
- Department of RadiologyOxford University Hospitals NHS Foundation TrustOxfordUK
| | - Naomi J. Fulop
- Department of Applied Health ResearchUniversity College LondonLondonUK
| | | | - Brian D. Nicholson
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Katriina L. Whitaker
- Department of Cancer Care, School of Health SciencesUniversity of SurreyGuildfordUK
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Liu SK, Bourgeois F, Dong J, Harcourt K, Lowe E, Salmi L, Thomas EJ, Riblet N, Bell SK. What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process. Diagnosis (Berl) 2024; 11:63-72. [PMID: 38114888 PMCID: PMC10875277 DOI: 10.1515/dx-2023-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/18/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES Accurate and timely diagnosis relies on close collaboration between patients/families and clinicians. Just as patients have unique insights into diagnostic breakdowns, positive patient feedback may also generate broader perspectives on what constitutes a "good" diagnostic process (DxP). METHODS We evaluated patient/family feedback on "what's going well" as part of an online pre-visit survey designed to engage patients/families in the DxP. Patients/families living with chronic conditions with visits in three urban pediatric subspecialty clinics (site 1) and one rural adult primary care clinic (site 2) were invited to complete the survey between December 2020 and March 2022. We adapted the Healthcare Complaints Analysis Tool (HCAT) to conduct a qualitative analysis on a subset of patient/family responses with ≥20 words. RESULTS In total, 7,075 surveys were completed before 18,129 visits (39 %) at site 1, and 460 surveys were completed prior to 706 (65 %) visits at site 2. Of all participants, 1,578 volunteered positive feedback, ranging from 1-79 words. Qualitative analysis of 272 comments with ≥20 words described: Relationships (60 %), Clinical Care (36 %), and Environment (4 %). Compared to primary care, subspecialty comments showed the same overall rankings. Within Relationships, patients/families most commonly noted: thorough and competent attention (46 %), clear communication and listening (41 %) and emotional support and human connection (39 %). Within Clinical Care, patients highlighted: timeliness (31 %), effective clinical management (30 %), and coordination of care (25 %). CONCLUSIONS Patients/families valued relationships with clinicians above all else in the DxP, emphasizing the importance of supporting clinicians to nurture effective relationships and relationship-centered care in the DxP.
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Affiliation(s)
- Stephen K. Liu
- White River Junction VA Medical Center, White River Junction, VT, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Fabienne Bourgeois
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Joe Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kendall Harcourt
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Elizabeth Lowe
- Patient and Family Advisory Council, Department of Social Work, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Liz Salmi
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric J. Thomas
- Department of Medicine, University of Texas McGovern Medical School, Houston, TX, USA
- Center for Healthcare Quality and Safety, Memorial Hermann Texas Medical Center, Houston, TX, USA
| | - Natalie Riblet
- White River Junction VA Medical Center, White River Junction, VT, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sigall K. Bell
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Lowe JT, Leonard J, Dominguez F, Widmer K, Deakyne Davies SJ, Wiersma AJ, Mendenhall M, Grubenhoff JA. Preferred language and diagnostic errors in the pediatric emergency department. Diagnosis (Berl) 2024; 11:49-53. [PMID: 37795819 DOI: 10.1515/dx-2023-0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES To investigate the relationship between language and diagnostic errors (DxE) in the pediatric emergency department (ED). METHODS Electronic trigger identified ED encounters resulting in unplanned hospital admission that occurred within 10 days of an index visit from January 2018 through February 2022. Manual screening of each triggered encounter identified cases where the index visit diagnosis and hospitalization discharge diagnosis differed, and these were screened in for review using the Revised Safer Dx instrument to determine if a diagnostic error (DxE) occurred. Non-English primary language (NEPL) and English-proficient (EP) groups were established based on caregiver language. The primary outcome was the proportion of DxE each group. Data were analyzed using univariate analysis and multivariable logistic regression to identify independent predictors of DxE. RESULTS Electronic trigger identified 3,551 patients, of which 806 (22.7 %) screened in for Safer Dx review. 172 (21.3 %) experienced DxE. The proportion of DxE was similar between EP and NEPL groups (21.5 vs. 21.7 %; p=0.97). Age≥12 years and fewer prior admissions in the preceding 6 months predicted higher odds of DxE. NEPL did not predict higher odds of DxE. CONCLUSIONS NEPL was not associated with increased odds DxE resulting in unplanned admission.
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Affiliation(s)
| | - Jan Leonard
- Children's Hospital of Philadelphia, Philadelphia, PN, USA
| | | | - Kaitlin Widmer
- University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | | | - Alexandria J Wiersma
- University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Marcela Mendenhall
- University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Joseph A Grubenhoff
- University of Colorado School of Medicine, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
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Liu X, Shen M, Lie M, Zhang Z, Liu C, Li D, Mark RG, Zhang Z, Celi LA. Evaluating Prognostic Bias of Critical Illness Severity Scores Based on Age, Sex, and Primary Language in the United States: A Retrospective Multicenter Study. Crit Care Explor 2024; 6:e1033. [PMID: 38239408 PMCID: PMC10796141 DOI: 10.1097/cce.0000000000001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES Although illness severity scoring systems are widely used to support clinical decision-making and assess ICU performance, their potential bias across different age, sex, and primary language groups has not been well-studied. DESIGN SETTING AND PATIENTS We aimed to identify potential bias of Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores via large ICU databases. SETTING/PATIENTS This multicenter, retrospective study was conducted using data from the Medical Information Mart for Intensive Care (MIMIC) and eICU Collaborative Research Database. SOFA and APACHE IVa scores were obtained from ICU admission. Hospital mortality was the primary outcome. Discrimination (area under receiver operating characteristic [AUROC] curve) and calibration (standardized mortality ratio [SMR]) were assessed for all subgroups. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS A total of 196,310 patient encounters were studied. Discrimination for both scores was worse in older patients compared with younger patients and female patients rather than male patients. In MIMIC, discrimination of SOFA in non-English primary language speakers patients was worse than that of English speakers (AUROC 0.726 vs. 0.783, p < 0.0001). Evaluating calibration via SMR showed statistically significant underestimations of mortality when compared with overall cohort in the oldest patients for both SOFA and APACHE IVa, female patients (1.09) for SOFA, and non-English primary language patients (1.38) for SOFA in MIMIC. CONCLUSIONS Differences in discrimination and calibration of two scores across varying age, sex, and primary language groups suggest illness severity scores are prone to bias in mortality predictions. Caution must be taken when using them for quality benchmarking and decision-making among diverse real-world populations.
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Affiliation(s)
- Xiaoli Liu
- Center for Artificial Intelligence in Medicine, The General Hospital of PLA, Beijing, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Max Shen
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Margaret Lie
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Zhongheng Zhang
- Department of Emergency Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Liu
- Department of Critical Care Medicine, The First Medical Center, The General Hospital of PLA, Beijing, China
| | - Deyu Li
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Roger G Mark
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Zhengbo Zhang
- Center for Artificial Intelligence in Medicine, The General Hospital of PLA, Beijing, China
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
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Bourgeois FC, Hart NJ, Dong Z, Ngo LH, DesRoches CM, Thomas EJ, Bell SK. Partnering with Patients and Families to Improve Diagnostic Safety through the OurDX Tool: Effects of Race, Ethnicity, and Language Preference. Appl Clin Inform 2023; 14:903-912. [PMID: 37967936 PMCID: PMC10651368 DOI: 10.1055/s-0043-1776055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/24/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Patients and families at risk for health disparities may also be at higher risk for diagnostic errors but less likely to report them. OBJECTIVES This study aimed to explore differences in race, ethnicity, and language preference associated with patient and family contributions and concerns using an electronic previsit tool designed to engage patients and families in the diagnostic process (DxP). METHODS Cross-sectional study of 5,731 patients and families presenting to three subspecialty clinics at an urban pediatric hospital May to December 2021 who completed a previsit tool, codeveloped and tested with patients and families. Prior to each visit, patients/families were invited to share visit priorities, recent histories, and potential diagnostic concerns. We used logistic regression to determine factors associated with patient-reported diagnostic concerns. We conducted chart review on a random subset of visits to review concerns and determine whether patient/family contributions were included in the visit note. RESULTS Participants provided a similar mean number of contributions regardless of patient race, ethnicity, or language preference. Compared with patients self-identifying as White, those self-identifying as Black (odds ratio [OR]: 1.70; 95% confidence interval [CI]: [1.18, 2.43]) or "other" race (OR: 1.48; 95% CI: [1.08, 2.03]) were more likely to report a diagnostic concern. Participants who preferred a language other than English were more likely to report a diagnostic concern than English-preferring patients (OR: 2.53; 95% CI: [1.78, 3.59]. There were no significant differences in physician-verified diagnostic concerns or in integration of patient contributions into the note based on race, ethnicity, or language preference. CONCLUSION Participants self-identifying as Black or "other" race, or those who prefer a language other than English were 1.5 to 2.5 times more likely than their counterparts to report potential diagnostic concerns when proactively asked to provide this information prior to a visit. Actively engaging patients and families in the DxP may uncover opportunities to reduce the risk of diagnostic errors and potential safety disparities.
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Affiliation(s)
- Fabienne C. Bourgeois
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Nicholas J. Hart
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Zhiyong Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Long H. Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Catherine M. DesRoches
- Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Eric J. Thomas
- Department of Medicine, University of Texas at Houston Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, United States
- McGovern Medical School at the University of Texas Health Science Center Houston, Houston, Texas, United States
| | - Sigall K. Bell
- Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
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Bell SK, Harcourt K, Dong J, DesRoches C, Hart NJ, Liu SK, Ngo L, Thomas EJ, Bourgeois FC. Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis. BMJ Qual Saf 2023:bmjqs-2022-015793. [PMID: 37604678 PMCID: PMC10879445 DOI: 10.1136/bmjqs-2022-015793] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 07/19/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Accurate and timely diagnosis relies on sharing perspectives among team members and avoiding information asymmetries. Patients/Families hold unique diagnostic process (DxP) information, including knowledge of diagnostic safety blindspots-information that patients/families know, but may be invisible to clinicians. To improve information sharing, we co-developed with patients/families an online tool called 'Our Diagnosis (OurDX)'. We aimed to characterise patient/family contributions in OurDX and how they differed between individuals with and without diagnostic concerns. METHOD We implemented OurDX in two academic organisations serving patients/families living with chronic conditions in three subspecialty clinics and one primary care clinic. Prior to each visit, patients/families were invited to contribute visit priorities, recent histories and potential diagnostic concerns. Responses were available in the electronic health record and could be incorporated by clinicians into visit notes. We randomly sampled OurDX reports with and without diagnostic concerns for chart review and used inductive and deductive qualitative analysis to assess patient/family contributions. RESULTS 7075 (39%) OurDX reports were submitted at 18 129 paediatric subspecialty clinic visits and 460 (65%) reports were submitted among 706 eligible adult primary care visits. Qualitative analysis of OurDX reports in the chart review sample (n=450) revealed that participants contributed DxP information across 10 categories, most commonly: clinical symptoms/medical history (82%), tests/referrals (54%) and diagnosis/next steps (51%). Participants with diagnostic concerns were more likely to contribute information on DxP risks including access barriers, recent visits for the same problem, problems with tests/referrals or care coordination and communication breakdowns, some of which may represent diagnostic blindspots. CONCLUSION Partnering with patients and families living with chronic conditions through OurDX may help clinicians gain a broader perspective of the DxP, including unique information to coproduce diagnostic safety.
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Affiliation(s)
- Sigall K Bell
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kendall Harcourt
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joe Dong
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Catherine DesRoches
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas J Hart
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stephen K Liu
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Long Ngo
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Eric J Thomas
- Department of Internal Medicine, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
- UT Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, USA
| | - Fabienne C Bourgeois
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Bell SK, Dong ZJ, Desroches CM, Hart N, Liu S, Mahon B, Ngo LH, Thomas EJ, Bourgeois F. Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool. J Am Med Inform Assoc 2023; 30:692-702. [PMID: 36692204 PMCID: PMC10018262 DOI: 10.1093/jamia/ocad003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/27/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Patients and families are key partners in diagnosis, but methods to routinely engage them in diagnostic safety are lacking. Policy mandating patient access to electronic health information presents new opportunities. We tested a new online tool ("OurDX") that was codesigned with patients and families, to determine the types and frequencies of potential safety issues identified by patients/families with chronic health conditions and whether their contributions were integrated into the visit note. METHODS Patients/families at 2 US healthcare sites were invited to contribute, through an online previsit survey: (1) visit priorities, (2) recent medical history/symptoms, and (3) potential diagnostic concerns. Two physicians reviewed patient-reported diagnostic concerns to verify and categorize diagnostic safety opportunities (DSOs). We conducted a chart review to determine whether patient contributions were integrated into the note. We used descriptive statistics to report implementation outcomes, verification of DSOs, and chart review findings. RESULTS Participants completed OurDX reports in 7075 of 18 129 (39%) eligible pediatric subspecialty visits (site 1), and 460 of 706 (65%) eligible adult primary care visits (site 2). Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. In total, probable DSOs were identified by 7.5% of pediatric and adult patients/families with underlying health conditions, respectively. The most common types of DSOs were patients/families not feeling heard; problems/delays with tests or referrals; and problems/delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. CONCLUSIONS OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients/families identified DSOs and most of their OurDX contributions were included in the visit note.
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Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Zhiyong J Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine M Desroches
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Hart
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Liu
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Brianna Mahon
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Eric J Thomas
- Department of Medicine, UT Houston—Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, USA
- McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Fabienne Bourgeois
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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