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5 Technology and Tools in the Diagnostic Process
Pages 217-262

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From page 217...
... , clinical decision support, patient engagement tools, computerized provider order entry, laboratory and medical imaging information systems, health information exchanges, and medical devices. Health IT plays key roles in various aspects of the diagnostic process: capturing information about a patient that informs the diagnostic process, including the clinical history and interview, physical exam, and diagnostic testing results; shaping a clinician's workflow and decision making in the diagnostic process; and facilitating information exchange.
From page 218...
... This content builds on earlier Institute of Medicine (IOM) work, including the report Health IT and Patient Safety: Building a Safer Health System ­ (IOM, 2012a)
From page 219...
... naided clinicians often make diagnostic errors" because they are "[v] ulnerable to fallible human memory, variable disease presentation, clinical disease processes plagued by communication lapses, and a series of well-documented ‘heuristics,' biases and disease-specific pitfalls." It is widely recognized that health IT has the potential to help health care professionals address or mitigate these human limitations.
From page 220...
... for high-prevalence, high-impact EHR-related patient safety risks.
From page 221...
... to exercise all available authorities to regulate EHRs, health information exchanges, and personal health records. Recommendation 9b: The Secretary should immediately direct FDA to begin developing the necessary framework for regulation.
From page 222...
... Providing Automatically provide feedback to clinicians upstream, facilitating feedback learning from outcomes of diagnostic decisions. Providing Provide checklists to minimize reliance on memory and directed prompts questioning to aid in diagnostic thoroughness and problem solving.
From page 223...
... Can electronic clinical documentation help prevent diagnostic errors?
From page 224...
... . In line with these recommendations, the committee recommends that health IT vendors and ONC should work together with users to ensure that health IT used in the diagnostic process demonstrates usability, incorporates human factors knowledge, integrates measurement capability, fits well within clinical workflow, provides clinical decision support, and facilitates the timely flow of information among patients and health care professionals involved in the diagnostic process.
From page 225...
... . Health IT that is not designed and implemented to support the diagnostic process can increase vulnerability to diagnostic errors.
From page 226...
... •  romote data liquidity. EHRs should facilitate connected health care -- ­ P interoperability across different venues such as hospitals, ambulatory care settings, laboratories, pharmacies and post-acute and long-term-care settings.
From page 227...
... 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. The problem list derives from the problem-oriented medical record, developed by
From page 228...
... . For example, one EHR system graphed diagnostic testing results in reverse chronological order; none of the EHRs in the analysis had graphs with y-axis labels that displayed both the name of the variable and the units of measurement.
From page 229...
... . Inefficient health IT tools may impede diagnosis by adding to clinicians' work burdens, leaving them with less time for the cognitive work involved in diagnosis and communicating with patients and the other health care professionals who are involved in the patients' care.
From page 230...
... . A critical element of workflow is health IT: Effective integration of health IT into the clinical workflow is essential for preventing diagnostic errors.
From page 231...
... . Clinical documentation has been defined as "the process of recording historical data, observations, assessments, interventions, and care plans in an indi­ idual's v health record.
From page 232...
... Chapter 7 further elaborates on how documentation guidelines for billing interfere with the diagnostic process and presents the committee's recommendation for how to better align documentation guidelines with clinical reasoning activities. A major goal of using data collected within EHRs for legal, billing, and population-wide health management has led to a profusion of structured clinical documentation formats within health IT tools.
From page 233...
... In its input to the committee, the American College of Radiology stated that structured decision support for image ordering and reporting is critical for reducing diagnostic errors (Allen and Thorwarth, 2014)
From page 234...
... (2003) have developed scores to measure the impact of diagnostic decision support on the quality of clinical decision making.
From page 235...
... . Though relatively early in its development, the application of new computational methods, such as artificial intelligence and natural language processing, has the potential to improve clinical decision support (Arnaout, 2012)
From page 236...
... . Timely Flow of Information The timely and effective exchange of information among health care professionals and patients is critical to improving diagnosis, and breakdowns in that communication are a major contributor to adverse events, including diagnostic errors (Gandhi et al., 2000; Poon et al., 2004; Schiff, 2005; Singh et al., 2007a)
From page 237...
... A free flow of information is critical to ensuring accurate and timely diagnoses because in order for health care professionals to develop a complete picture of a patient's health problem, all relevant health information needs to be available and accessible. A lack of interoperability can impede the
From page 238...
... . Discussion Current evidence suggests that patients seen in the emergency department are at high risk of experiencing diagnostic errors because of the range of conditions seen, the time pressures involved, and complexity of the work system environment (Campbell et al., 2007)
From page 239...
... 3.  reakdowns in information flow and communication are some of the most B common factors identified in cases of diagnostic error, just as they are in other major patient safety adverse events.
From page 240...
... However, the progress toward achieving health information exchange and interoperability has been slow (CHCF, 2014)
From page 241...
... . They recommended that laboratory health care professionals collaborate with other stakeholders to "develop effective solutions to reduce identified patient safety risks in and improve the safety of EHR systems" regarding laboratory data (CDC, 2014, p.
From page 242...
... i Current market conditions create business incentives for information blocking, that is, "when persons or entities knowingly and unreasonably interfere with the exchange or use of electronic health information" (ONC, 2015, p.
From page 243...
... . A number of health IT–related patient safety risks may affect the diagnostic process and the occurrence of diagnostic errors.
From page 244...
... . BOX 5-5 Recommendations from an American Medical Informatics Association Special Task Force on Health Information Technology Contracts 1.
From page 245...
... Winkelstein, Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: A report of an AMIA special task force, Journal of the American Medical Informatics Association, 2011,18(1) :77–81, by permission of the American Medical Informatics Association.
From page 246...
... . Because the safety of health IT is critical for improvements to the diagnostic process, health IT vendors need to proactively monitor their products in order to identify potential adverse events, which could contribute to diagnostic errors and challenges in the diagnostic process ­Carayon( et al., 2011)
From page 247...
... 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)
From page 248...
... Addi­ionally, health care professionals may need to document t their findings differently in the absence of face-to-face interactions, given the absence of a comprehensive physical exam. Clinicians participating in telemedicine need to be attuned to care continuity and coordination ­issues and to effectively convey to their patients who has accountability over their care and whom they should contact for follow-up.
From page 249...
... mHealth and Wearable Technologies mHealth applications7 and wearable technologies8 are transforming health care delivery for both health care professionals and patients, and 7  Mobile applications are software programs that have been developed to run on a com puter or mobile device to accomplish a specific purpose. 8 Electronics embedded in watchbands, clothing, contact lenses, or other wearable equipment.
From page 250...
... mHealth applications are often designed to assist clinicians at the point of care and include drug reference guides, medical calculators, clinical practice guidelines, textbooks, literature search portals, and other decision support aids. Other mHealth applications are designed specifically for patients and facilitate the gathering of diagnostic data or assist patients in coordinating care by keeping track of their medical conditions, diagnostic tests, and treatments.
From page 251...
... . RECOMMENDATION Goal 3: Ensure that health information technologies support patients and health care professionals in the diagnostic process Recommendation 3a: Health information technology (health IT)
From page 252...
... 2014. Appropriate use of the copy and paste functionality in electronic health records.
From page 253...
... 2007. Some un intended consequences of clinical decision support systems.
From page 254...
... 2015. Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine.
From page 255...
... 2013. Use of health information technology to reduce diagnostic error.
From page 256...
... 2013. Clinical decision support (CDS)
From page 257...
... Journal of the American Medical Informatics Association 15(4)
From page 258...
... 2014. An analysis of electronic health record-related patient safety concerns.
From page 259...
... 2003. Measuring the impact of diagnostic decision support on the qual ity of clinical decision making: Development of a reliable and valid composite score.
From page 260...
... 2012. Electronic health record-based surveillance of diagnostic errors in primary care.
From page 261...
... 2014a. Patient safety goals for the proposed Federal Health Information Technology Safety Center.


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