It is important that both patients and clinicians fully understand the telemedicine process and its associated limitations and risks, including the scope of the diagnostic health care services that can be delivered safely through this medium. http://healthaffairs.org/blog/2014/11/03/oncs-10-year-roadmap-towards-interoperability-requires-changes-to-the-meaningful-use-program (accessed March 27, 2015). For example, if clinicians are tired or distracted by elements in the work system, they may fail to recognize when a decison provided by system 1 processing needs to be reconsidered (Croskerry, 2009b). The potential benefits of health IT for improving diagnosis cannot be realized without usable, useful health IT systems. For example, in the absence of a prior patient–clinician relationship, a clinician may not know enough details about the patient’s history to ask pertinent questions, which may lead clinicians to overutilize diagnostic testing (Huff, 2014). An official American thoracic society workshop report: Developing performance measures from clinical practice guidelines. Dwoskin, E., and J. Walker. The fusiform face area: A cortical region specialized for the perception of faces. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/default.htm (accessed May 15, 2015). Although clinicians have reported a high level of use and satisfaction with certain health IT features, such as electronic prescribing (Makam et al., 2013), a number of challenges with usability remain, and the National Institute of Standards and Technology has indicated that usability is often overlooked in the adoption of EHR systems (NIST, 2015). 2011. This should be done in a way easily accessible to customers and to potential customers. In addition, it provides facilities with data on diagnostic performance that can be used for benchmarking, self-monitoring, and improvement. diagnostic verification step is particularly important so that a patient is not exposed to these risks without a reasonable chance that the testing or treatment options will be informative and will likely improve patient outcomes. For instance, one version of a patient’s EHR may exist on the primary clinical information system while a variety of outdated or partial versions of the record are present in other places. A unified attentional bottleneck in the human brain. Journal of Evaluation in Clinical Practice 20(6):748–758. The problem list derives from the problem-oriented medical record, developed by. 2009. Second opinions. Can computerized clinical decision support systems improve practitioners’ diagnostic test ordering behavior? 2013. Identifying diagnostic errors in primary care using an electronic screening algorithm. Journal of the American College of Radiology 6(3):194–200. Paper presented at HIT Policy Meaningful Use and Certification/Adoption Workgroups Clinical Documentation Hearing. Clinicians need to be able to complete a task without having to undergo extra steps, such as clicking, scrolling, or switching between a keyboard and mouse; however, many health IT tools are cumbersome to navigate. www.rsna.org/QI_Tools.aspx (accessed May 22, 2015). 2010. Croskerry, P. 2009a. Johnson, P. T., S. L. Zimmerman, D. Heath, J. Eng, K. M. Horton, W. W. Scott, and E. K. Fishman. Safety issues related to the electronic medical record (EMR): Synthesis of the literature from the last decade, 2000–2009. 2008. ACMG (American College of Medical Genetics and Genomics) Board of Directors. Design of a study on suboptimal cognitive acts in the diagnostic process, the effect on patient outcomes and the influence of workload, fatigue and experience of physician. 2014. Commentary: How can we make diagnosis safer? Telepathology: Guidance from The Royal College of Pathologists. Weed, L. L., and L. Weed. The IOM report Health IT and Patient Safety: Building a Safer Health System recognized interoperability as a key feature of safely functioning health IT and noted that interoperability needs to be in place across the entire health care continuum: “Currently, laboratory data have been relatively easy to exchange because good standards exist such as Logical Observation Identifiers Names and Codes (LOINC) and are widely accepted. Boston: Butterworths. Clinical Laboratory Improvement Amendments (CLIA). Do emotions help or hurt decision making? As the diagnostic process proceeds, a fairly broad list of potential diagnoses may be narrowed into fewer potential options, a process referred to as diagnostic modification and refinement (Kassirer et al., 2010). An example of the former would be cases of patients with newly diagnosed pulmonary embolism who were seen in the 2 weeks preceding diagnosis by an outpatient or emergency department clinician with symptoms that may have indicated pulmonary embolism (e.g., cough, shortness of breath, chest pain). The executive override pathway shows that system 2 surveillance has the potential to overrule system 1 decision making. For many conditions (e.g., brain tumors), imaging is the only noninvasive diagnostic method available. Usability tools. However, it is important to note. 2010. Furthermore, the use of structured reporting templates tailored to specific examinations can help to increase the clarity, thoroughness, and clinical relevance of image interpretation (Schwartz et al., 2011). Boca Raton, FL: Taylor & Francis. Govern, P. 2013. Insufficient clinical information can be problematic as radiologists and pathologists often use this information to inform their interpretations of diagnostic testing results and suggestions for next steps (Alkasab et al., 2009; Obara et al., 2015). Elementary, my dear doctor watson. The CDC performs research on laboratory testing processes, including quality improvement studies, and develops technical standards and laboratory practice guidelines (CDC, 2014). At the outset, it can be very difficult to determine which particular diagnosis is indicated by a particular combination of symptoms, especially if symptoms are nonspecific, such as fatigue. This can help refine and narrow the differential diagnosis. New England Journal of Medicine 363(21):2060–2067. Snow, V., C. Mottur-Pilson, R. J. Cooper, and J. R. Hoffman. Thomas Eric Duncan traveled from Liberia to the United States in September 2014. Unfortunately, poorly designed health IT systems, such as those with confusing user interfaces and disorganized patient information, may contribute to cognitive overload rather than easing the cognitive burden on clinicians. of what should or should not happen in particular situations, in order to test possible actions or to explore alternative causes of events (Stanovich, 2009). Almost half of the clinicians they surveyed reported that completing EHR documentation for each scheduled half-day clinic session required 1 or more extra hours of work, and 30 percent reported that they spent at least 1 extra hour communicating electronically with patients, even though they may not get paid for this time. B., E. Cagliero, A. Dubey, P. Murphy-Sheehy, C. Gildesgame, H. Chueh, M. J. Barry, D. E. Singer, and D. M. Nathan. New England Journal of Medicine 283(21):1139–1142. Language barriers to health care in the United States. Step 5: Plan and execute improvement actions • Review the assessment findings • Types of changes: • Curriculum Tombu, M. N., C. L. Asplund, P. E. Dux, D. Godwin, J. W. Martin, and R. Marois. Medical Decision Making. 1970. How widely is computer-aided detection used in screening and diagnostic mammography? IEEE Transactions on Systems, Man and Cybernetics—Part A: Systems and Humans 30(3):286–297. Santa Monica, CA: RAND. This process is repeated for each condition in the differential diagnosis and may be augmented by additional sources of information, such as diagnostic testing, further history gathering or physical examination, or referral or consultation. 2010. BMC Medical Informatics and Decision Making 13:86. Journal of Patient Safety 6(4):199–205. For health IT systems that are used by multiple health care organizations or across multiple settings (inpatient and outpatient), common platforms for measuring diagnostic errors will permit comparisons of diagnostic error rates across organizations and settings. There is a move to standardize the structure and content of problem lists in EHRs through the use of diagnostic and problem codes (AHIMA, 2011). Ramnarayan, P., G. C. Roberts, M. Coren, V. Nanduri, A. Tomlinson, P. M. Taylor, J. C. Wyatt, and J. F. Britto. 2011. The information-gathering approaches can be employed at different times, and diagnostic information can be obtained in different orders. Adequate performance in this phase depends on the correct execution of a chemical analysis or morphological examination (Hollensead et al., 2004), and the contribution to diagnostic errors at this step is small. Although the definitions vary, telemedicine and telehealth generally refer to the delivery of care, consultations, and information using communications technology (American Telemedicine Association, 2015). 4. In addition to these efforts involving generalized decision support tools, there are also ongoing efforts to use decision support in radiology. An example of the latter may be patients who are hospitalized or seen in the emergency department within 2 weeks of an unscheduled outpatient visit, which may be suggestive of a failure to correctly diagnosis the patient at the first visit (Singh et al., 2007b, 2012; Sittig and Singh, 2012). 1999. DSM. Cognitive debiasing 1: Origins of bias and theory of debiasing. JAMA 258(18):2543–2547. 2008. Hypotheticodeductivism is an analytical reasoning model that describes clinical reasoning as hypothesis testing (Elstein et al., 1978, 1990). profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance. Panels of biomarkers are being developed into molecular diagnostic tests (omics-based tests) that are used to assess risk and inform treatment decisions, such as Oncotype DX and MammaPrint in breast cancer (IOM, 2012). The process of ruling in or ruling out a diagnosis involves probabilistic reasoning as findings are integrated and interpreted. Patient safety goals for the proposed Federal Health Information Technology Safety Center. Pincus, H. 2014. 2015. The risks associated with diagnostic testing are important considerations when conducting information-gathering activities in the diagnostic process. 2015. Rockville, MD: Agency for Healthcare Research and Quality. Journal of the American Medical Informatics Association 22(2):426–434. New England Journal of Medicine 359(26):2748–2751. BMJ Quality and Safety 22(Suppl 2):ii1–ii5. Presentation to the Committee on Diagnostic Error in Health Care, August, 7, 2014, Washington, DC. The effect of race and sex on physicians’ recommendations for cardiac catheterization. Journal of the American Medical Informatics Association. About the AAFP proficiency testing program. Journal of General Internal Medicine 25(8):756–757. Clinical problem solving and diagnostic decision making: Selective review of the cognitive literature. Wachter, R. M. 2015. Taking stock of naturalistic decision making. MyNAP members SAVE 10% off online. 2015. Avoiding premature closure in sequential diagnosis. Frommer, D., J. Morris, S. Sherlock, J. Abrams, and S. Newman. Vargas, B. mHealth applications may augment traditional health care professional education by providing opportunities for interactive teaching and more personalized educational experiences for students. Obtaining a history can be chal-. Emergency Radiology 19(2):127–133. 2015b. Disclosure of information should not create legal liability for good-faith reporting. Evidence-informed person-centered healthcare (part I): Do “cognitive biases plus” at organizational levels influence quality of evidence? The rel-. Best care at lower cost: The path to continuously learning health care in America. Box 2-6 works through two examples of probabilistic reasoning. The emergency department clinician seeing a patient with recent onset of low back pain immediately settles on a diagnosis of lumbar disc disease without considering other possibilities in the differential diagnosis. 1977. CHCF (California HealthCare Foundation). The plan should specify: Recommendation 2: The Secretary of HHS should ensure insofar as possible that health IT vendors support the free exchange of information about health IT experiences and issues and not prohibit sharing of such information, including details (e.g., screenshots) relating to patient safety. Schulman, K. A., J. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years. MQSA has decreased the variability in mammography performed across the United States and improved the quality of care (Allen and Thorwarth, 2014). 2014. Grading quality of evidence and strength of recommendations in clinical practice guidelines: Part 2 of 3. For example, in 2005 the Centers for Disease Control and Prevention and the Food and Drug Administration issued a warning about potential diagnostic errors related to false positives caused by contamination in a Lyme disease test (Nelson et al., 2014). Rational actors or rational fools: Implications of the affect heuristic for behavioral economics. NIST (National Institute of Standards and Technology). www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf (accessed February 9, 2015). According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. Publications have increased steadily over 40 years. In addition, systematic reviews and clinical practice guidelines (CPGs) help synthesize available information in order to inform clinical practice decision making (IOM, 2011a,b). Recommendation 1: The Secretary of Health and Human Services (HHS) should publish an action and surveillance plan within 12 months that includes a schedule for working with the private sector to assess the impact of health IT [health information technology] on patient safety and minimizing the risk of its implementation and use. BMJ 347:f5151. Reproduced from Use of health information technology to reduce diagnostic error. The quality of health care delivered to adults in the United States. Cue interpretation (diagnostic modification and refinement): Clinicians interpret the consistency of the information with each of the alternative hypotheses under consideration. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errors—has been largely unappreciated in efforts to improve the quality and safety of health care. Such forums include the forthcoming ONC Patient Safety Center or patient safety organizations (see Chapter 7) (RTI International, 2014; Sittig et al., 2014a). jamia.oxfordjournals.org/content/jaminfo/early/2015/03/18/jamia.ocv013.full.pdf (accessed December 8, 2015). At the end of this string, it possesses a nozzle in order have an injection at a higher velocity. IMPORTANT CONSIDERATIONS IN THE DIAGNOSTIC PROCESS, The committee elaborated on several aspects of the diagnostic process which are discussed below, including. Health Affairs (Millwood) 34(5):727–731. Ash, J. S., M. Berg, and E. Coiera. ASCP also manages a CMS-approved PT program for gynecologic cytology (ASCP, 2014). If the diagnostic team members are not satisfied that the necessary information has been collected to explain the patient’s health problem or that the information available is not consistent with a diagnosis, then the process of information gathering, information integration and interpretation, and develop-. 2015. In particular, the problem list feature of EHRs can help clinicians to quickly see a patient’s most important health problem; it is a way of organizing a patient’s health information within the health record. When to use: to give all details (inputs and outputs) related to a process step Clinical & Investigative Medicine 5(1):49–55. American Journal of Geriatric Cardiology 15(1):7–11; quiz 12. A careful physical exam can help a clinician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic testing, and can aid in building trust with the patient (Verghese, 2011). 2015. However, when system 1 overrides system 2 processing, this can also result in irrational decision making. 2015. Human Factors 57(1):61–100. Usability has been defined as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use” (ISO, 1998). 2013. iPhone ECG application for community screening to detect silent atrial fibrillation: A novel technology to prevent stroke. 2011. 2006. 2014. 2013. National hospital ambulatory medical care survey. Typically, clinicians will consider more than one diagnostic hypothesis or possibility as an explanation of the patient’s symptoms and will refine this list as further information is obtained in the diagnostic process. Of major importance in the diagnostic process is the element of time. As described above, the diagnostic process involves initial information gathering that leads to a working diagnosis.
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