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. 2023 May 10;6(2):ooad031.
doi: 10.1093/jamiaopen/ooad031. eCollection 2023 Jul.

Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach

Alison Garber  1 , Pamela Garabedian  1 , Lindsey Wu  1 , Alyssa Lam  1 , Maria Malik  1 , Hannah Fraser  1 , Kerrin Bersani  1 , Nicholas Piniella  1 , Daniel Motta-Calderon  1 , Ronen Rozenblum  1   2 , Kumiko Schnock  1   2 , Jacqueline Griffin  3 , Jeffrey L Schnipper  1   2 , David W Bates  1   2   4 , Anuj K Dalal  1   2
Affiliations

Developing, pilot testing, and refining requirements for 3 EHR-integrated interventions to improve diagnostic safety in acute care: a user-centered approach

Alison Garber et al. JAMIA Open. .

Abstract

Objective: To describe a user-centered approach to develop, pilot test, and refine requirements for 3 electronic health record (EHR)-integrated interventions that target key diagnostic process failures in hospitalized patients.

Materials and methods: Three interventions were prioritized for development: a Diagnostic Safety Column (DSC) within an EHR-integrated dashboard to identify at-risk patients; a Diagnostic Time-Out (DTO) for clinicians to reassess the working diagnosis; and a Patient Diagnosis Questionnaire (PDQ) to gather patient concerns about the diagnostic process. Initial requirements were refined from analysis of test cases with elevated risk predicted by DSC logic compared to risk perceived by a clinician working group; DTO testing sessions with clinicians; PDQ responses from patients; and focus groups with clinicians and patient advisors using storyboarding to model the integrated interventions. Mixed methods analysis of participant responses was used to identify final requirements and potential implementation barriers.

Results: Final requirements from analysis of 10 test cases predicted by the DSC, 18 clinician DTO participants, and 39 PDQ responses included the following: DSC configurable parameters (variables, weights) to adjust baseline risk estimates in real-time based on new clinical data collected during hospitalization; more concise DTO wording and flexibility for clinicians to conduct the DTO with or without the patient present; and integration of PDQ responses into the DSC to ensure closed-looped communication with clinicians. Analysis of focus groups confirmed that tight integration of the interventions with the EHR would be necessary to prompt clinicians to reconsider the working diagnosis in cases with elevated diagnostic error (DE) risk or uncertainty. Potential implementation barriers included alert fatigue and distrust of the risk algorithm (DSC); time constraints, redundancies, and concerns about disclosing uncertainty to patients (DTO); and patient disagreement with the care team's diagnosis (PDQ).

Discussion: A user-centered approach led to evolution of requirements for 3 interventions targeting key diagnostic process failures in hospitalized patients at risk for DE.

Conclusions: We identify challenges and offer lessons from our user-centered design process.

Keywords: acute care; diagnostic errors; diagnostic safety; electronic health records; user-centered intervention design.

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Conflict of interest statement

Dr. Dalal reports consulting fees from MayaMD, which makes AI software for patient engagement and decision support. Dr. Rozenblum reports having an equity in Hospitech Respiration Ltd., which makes Airway Management Solutions. Dr. Bates reports grants and personal fees from EarlySense, personal fees from CDI Negev, equity from ValeraHealth, equity from Clew, equity from MDClone, personal fees and equity from AESOP, and grants from IBM Watson Health, outside the submitted work. Authors otherwise report no conflicts of interest.

Figures

Figure 1.
Figure 1.
User-centered approach for developing, testing, and refining diagnostic safety interventions.
Figure 2.
Figure 2.
Prioritized interventions across Safer Dx process dimensions.
Figure 3.
Figure 3.
Three interventions functioning as an EHR-integrated system to improve diagnostic safety.
Figure 4.
Figure 4.
Diagnostic time-out.
See this image and copyright information in PMC

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References

    1. Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine. The national academies of sciences, engineering, and medicine. In: Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. Washington (DC: ): National Academies Press; 2015. Summary available from: https://www.ncbi.nlm.nih.gov/books/NBK338596/. doi: 10.17226/21794. - DOI - PubMed
    1. Bishop TF, Ryan AM, Casalino LP.. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA 2011; 305 (23): 2427–31. - PubMed
    1. Gupta A, Snyder A, Kachalia A, Flanders S, Saint S, Chopra V.. Malpractice claims related to diagnostic errors in the hospital. BMJ Qual Saf 2018; 27 (1): 53–60. - PubMed
    1. Raffel KE, Kantor MA, Barish P, et al.Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. BMJ Qual Saf 2020; 29 (12): 971–9. - PubMed
    1. Bergl PA, Taneja A, El-Kareh R, Singh H, Nanchal RS.. Frequency, risk factors, causes, and consequences of diagnostic errors in critically ill medical patients: a retrospective cohort study. Crit Care Med 2019; 47 (11): e902–10. - PubMed

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