What causes diagnostic errors? This was the question asked by researchers at the Michael E. DeBakey VA Medical Center (EDVA) in Houston. It is also a question of great interest to pathologists and clinical laboratory scientists, since the failure of physicians to properly order and interpret medical laboratory tests can be a cause of diagnostic errors.
Researchers were investigating how access to patient data embedded in hospital electronic health records (EHRs) affects patient safety. The results of their study—and the challenges they encountered accessing the data during the research—led to some startling conclusions about accessibility to patient data, and the nature of the data itself.
The researchers published their findings online in “Challenges in Patient Safety Improvement Research in the Era of Electronic Health Records.” Their paper examines ways in which EHRs can assist healthcare professionals in improving patient safety and guaranteeing proper follow-up care.
The researchers included Daniel R. Murphy, MD, MBA; Elise Russo, research coordinator; and Hardeep Singh, MD, MPH. All three are staff members of the EDVA hospital. They were joined by Dean F. Sittig, PhD, Professor, Biomedical Informatics, from University of Texas Health Science Center in San Antonio.
The researchers studied potential diagnostic errors by examining patients who visited a primary care physician and then were admitted unexpectedly to hospital within 10 days. They also scrutinized the records of patients who had received abnormal tests results, but for whom no follow-ups were initiated.
Privacy Policies Bar Researchers from Accessing Data
The majority of healthcare organizations in the US have implemented EHRs. There appears, however, to be major obstacles to utilizing the data contained within these EHRs. During the study, the researchers attempted to perform patient inquiries in three health systems outside the VA. But they were blocked by healthcare administrators who were reluctant to provide them with access to the organization’s EHR data due to increased fear of data breaches. Even though the researchers had approval to access the information, there were policies in place that barred outsiders from reviewing the data.
The lack of structured data also proved to be an issue in examining three other organizations. Even after EHR data had been placed into the computer systems, a lack of methodology for accessing the data prevented the identification of abnormal radiology, pathology, microbiology, and clinical laboratory results. Therefore, the researchers had to manually sort and organize data to ascertain which medical records to evaluate for further analysis.
The researchers also found it difficult to work with the Information Technology Departments (IT) at the institutions studied. The IT personnel, the researchers stated, were “resource-constrained” and often dealt with several competing priorities. The researchers found that the IT staffs lacked the necessary resources to extract and examine EHR data, and did not understand the specific needs of healthcare professionals.
The researchers concluded their paper with suggestions for ways to combat the problem of patients falling through the cracks due to the inaccessibility of EHR data. They recommended that healthcare organizations:
• Implement policies that allow authentication for remote access to EHRs;
• Ensure that clinicians are properly trained to use the EHRs;
• That key IT personnel receive basic clinical training; and
• That dedicated IT personnel be added to ensure adequate coverage for quality improvement and patient safety research support.
Missed Test Results Due to Inadequate EHR Notification Systems
The researchers performed similar studies in the past within the VA system and found that EHR-based patient follow-ups also can be negatively affected by user behaviors, workload, and organizational traits. Singh and Sittig participated in one such study that found “over half (55.6%) reported that the EHR notification system as currently implemented made it possible for practitioners to miss test results. Almost a third (29.8%) reported having personally missed results that led to care delays.”
According to The Society to Improve Diagnosis in Medicine, one in 10 medical diagnoses are incorrect. In addition, studies have shown that it is highly likely each of us will experience at least one diagnostic error in our lifetime, and that these errors account for 40,000 to 80,000 deaths or more annually in the United States.
The primary reasons for incorrect medical diagnoses are:
• Cognitive errors on the part of clinicians;
• Poor teamwork and communications between healthcare professionals;
• Lack of dependable systems for common outpatient situations; and
• Improper follow-up on test results.
Pathologists serve a critical role in reducing diagnostic errors by helping physicians correctly interpret lab test results so they can make an accurate diagnosis and select the most appropriate therapy. Pathologists can also assist physicians in ordering the right test for the patient at the right time. Exchanging EHR information freely among different medical organizations can be a useful tool in patient safety and proper treatment.