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1.  Electronic Health Record-Based Surveillance of Diagnostic Errors in Primary Care 
BMJ quality & safety  2011;21(2):93-100.
Diagnostic errors in primary care are harmful but difficult to detect. We tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice.
We conducted a retrospective study of primary care visit records “triggered” through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalization within 14 days; and Trigger 2: A primary care index visit followed by ≥ 1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between October 1, 2006 and September 30, 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data was available at the index visit. Disagreements were resolved by an independent third reviewer.
Queries were applied to 212,165 visits. On record review, we found diagnostic errors in 141 of 674 Trigger 1-positive records (PPV=20.9%, 95% CI, 17.9%-24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI, 3.7%-7.1%). The control PPV of 2.1% (95% CI, 0.1%-3.3%) was significantly lower than that of both triggers (P ≤ .002). Inter-rater reliability was modest, though higher than in comparable previous studies (κ = 0.37 [95% CI=0.31-0.44]).
While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.
PMCID: PMC3680372  PMID: 21997348
diagnostic errors; primary care; patient safety; electronic health records; triggers; automated surveillance; error detection
2.  Characteristics and Predictors of Missed Opportunities in Lung Cancer Diagnosis: An Electronic Health Record–Based Study 
Journal of Clinical Oncology  2010;28(20):3307-3315.
Understanding delays in cancer diagnosis requires detailed information about timely recognition and follow-up of signs and symptoms. This information has been difficult to ascertain from paper-based records. We used an integrated electronic health record (EHR) to identify characteristics and predictors of missed opportunities for earlier diagnosis of lung cancer.
Using a retrospective cohort design, we evaluated 587 patients of primary lung cancer at two tertiary care facilities. Two physicians independently reviewed each case, and disagreements were resolved by consensus. Type I missed opportunities were defined as failure to recognize predefined clinical clues (ie, no documented follow-up) within 7 days. Type II missed opportunities were defined as failure to complete a requested follow-up action within 30 days.
Reviewers identified missed opportunities in 222 (37.8%) of 587 patients. Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively (P < .001). Abnormal chest x-ray was the clue most frequently associated with type I missed opportunities (62%). Follow-up on abnormal chest x-ray (odds ratio [OR], 2.07; 95% CI, 1.04 to 4.13) and completion of first needle biopsy (OR, 3.02; 95% CI, 1.76 to 5.18) were associated with type II missed opportunities. Patient adherence contributed to 44% of patients with missed opportunities.
Preventable delays in lung cancer diagnosis arose mostly from failure to recognize documented abnormal imaging results and failure to complete key diagnostic procedures in a timely manner. Potential solutions include EHR-based strategies to improve recognition of abnormal imaging and track patients with suspected cancers.
PMCID: PMC2903328  PMID: 20530272
3.  Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? 
The American journal of medicine  2010;123(3):238-244.
Follow-up of abnormal outpatient laboratory test results is a major patient safety concern. Electronic medical records can potentially address this concern through automated notification. We examined whether automated notifications of abnormal laboratory results (alerts) in an integrated electronic medical record resulted in timely follow-up actions.
We studied four alerts: hemoglobin A1c (HbA1c) ≥15%, positive hepatitis C antibody (HCV), prostate specific antigen (PSA) ≥15 ng/mL, and thyroid stimulating hormone (TSH) ≥ 15 mIU/L. An alert tracking system determined whether the alert was acknowledged (i.e. provider clicked on and opened the message) within two weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions (e.g. patient contact, treatment etc.). Multivariable logistic regression models analyzed predictors for lack of timely follow-up.
Between May 2008 and December 2008, 78,158 tests (HbA1c, HCV, TSH and PSA) were performed, of which 1163 (1.48%) were transmitted as alerts; 10.2% of these (119/1163) were unacknowledged. Timely follow-up was lacking in 79 (6.8%) and was statistically not different for acknowledged and unacknowledged alerts (6.4% vs. 10.1%; p =.13). Two-hundred two alerts (17.4% of 1163) arose from unnecessarily ordered (redundant) tests. Alerts for a new versus known diagnosis were more likely to lack timely follow-up (OR: 7.35; 95% CI: 4.16-12.97) whereas alerts related to redundant tests were less likely to lack timely follow-up (OR: 0.24; 95% CI: 0.07-0.84).
Safety concerns related to timely patient follow-up remain despite automated notification of non-life threatening abnormal laboratory results in the outpatient setting.
PMCID: PMC2878665  PMID: 20193832
diagnostic errors; abnormal diagnostic test results; electronic medical records; patient follow-up; patient safety; health information technology; communication; primary care
4.  Timely Follow-Up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting: Are Electronic Medical Records Achieving Their Potential? 
Archives of internal medicine  2009;169(17):1578-1586.
Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic test results remains a challenge. We hypothesized that an EMR that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem.
We studied critical imaging alert notifications in the outpatient setting of a tertiary care VA facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (i.e. provider opened the message for viewing) within two weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted providers to determine timely follow-up actions (e.g. ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by providers analyzed predictors for two outcomes; lack of acknowledgment and lack of timely follow-up.
Of 123,638 studies (including X-rays, CT scans, ultrasounds, MRI and mammography), 1196 (0.97%) images generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when ordering providers were trainees (OR, 5.58;95%CI, 2.86-10.89) and when dual (more than one provider alerted) as opposed to single communication was used (OR, 2.02;95%CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs. 9.7%;p=0.2). Risk for lack of timely follow-up was higher with dual communication (OR,1.99;95%CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12;95%CI: 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment.
Critical imaging results may not receive timely follow-up actions even when providers receive and read results in an advanced, integrated EMR system. A multidisciplinary approach is needed to improve patient safety in this area.
PMCID: PMC2919821  PMID: 19786677
diagnostic errors; abnormal diagnostic test results; electronic medical records; patient follow-up; patient safety; health information technology; communication; primary care
5.  Communication Outcomes of Critical Imaging Results in a Computerized Notification System 
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.
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.
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.
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.
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.
PMCID: PMC2244901  PMID: 17460135
6.  A quasi-experimental test of an intervention to increase the use of thiazide-based treatment regimens for people with hypertension 
Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens.
This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital. The intervention group consisted of the practitioners (13 staff and 215 trainees), nurses, and patients (3,502) of the teaching practice; non-randomized concurrent controls were the practitioners (31 providers) and patients (18,292) of the non-teaching practices. Design of the implementation intervention was based on Rogers' Diffusion of Innovations model. Over 10.5 months, intervention teams met weekly or biweekly and developed and disseminated informational materials among themselves and to trainees, patients, and administrators. These teams also reviewed summary electronic-medical-record data on thiazide use and blood pressure (BP) goal attainment. Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen, and the proportion of hypertensive patients attaining BP goals regardless of regimen. Thirty-three months of time-series data were available; statistical process control charts, change point analyses, and before-after analyses were used to estimate the intervention's effects.
Baseline use of thiazides and rates of BP control were higher in the intervention group than controls. During the intervention, thiazide use and BP control increased in both groups, but changes occurred earlier in the intervention group, and primary change points were observed only in the intervention group. Overall, the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients (0.091 vs. 0.058; p = 0.0092), as was the proportion achieving BP goals (0.092 vs. 0.044; p = 0.0005). At the end of the implementation period, 41.4% of intervention patients were prescribed thiazides vs. 30.6% of controls (p < 0.001); 51.6% of intervention patients had achieved BP goals vs. 44.3% of controls (p < 0.001).
This multi-faceted intervention appears to have resulted in modest improvements in thiazide prescribing and BP control. The study also demonstrates the value of electronic medical records for implementation research, how Rogers' model can be used to design and launch an implementation strategy, and how all members of a clinical microsystem can be involved in an implementation effort.
PMCID: PMC1803001  PMID: 17298669

Results 1-6 (6)