Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes

Abstract

Background The 21st Century Cures Act mandates patients’ access to their electronic health record (EHR) notes. To our knowledge, no previous work has systematically invited patients to proactively report diagnostic concerns while documenting and tracking their diagnostic experiences through EHR-based clinician note review. Objective To test if patients can identify concerns about their diagnosis through structured evaluation of their online visit notes. Methods In a large integrated health system, patients aged 18–85 years actively using the patient portal and seen between October 2019 and February 2020 were invited to respond to an online questionnaire if an EHR algorithm detected any recent unexpected return visit following an initial primary care consultation (“at-risk” visit). We developed and tested an instrument (Safer Dx Patient Instrument) to help patients identify concerns related to several dimensions of the diagnostic process based on notes review and recall of recent “at-risk” visits. Additional questions assessed patients’ trust in their providers and their general feelings about the visit. The primary outcome was a self-reported diagnostic concern. Multivariate logistic regression tested whether the primary outcome was predicted by instrument variables. Results Of 293 566 visits, the algorithm identified 1282 eligible patients, of whom 486 responded. After applying exclusion criteria, 418 patients were included in the analysis. Fifty-one patients (12.2%) identified a diagnostic concern. Patients were more likely to report a concern if they disagreed with statements “the care plan the provider developed for me addressed all my medical concerns” [odds ratio (OR), 2.65; 95% confidence interval [CI], 1.45–4.87) and “I trust the provider that I saw during my visit” (OR, 2.10; 95% CI, 1.19–3.71) and agreed with the statement “I did not have a good feeling about my visit” (OR, 1.48; 95% CI, 1.09–2.01). Conclusion Patients can identify diagnostic concerns based on a proactive online structured evaluation of visit notes. This surveillance strategy could potentially improve transparency in the diagnostic process.

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

“…We are not aware of other reported attempts at refining user requirements for EHR-based preventative interventions targeting common and impactful diagnostic process failures during the hospital encounter. 8 , 12 , 14 , 15 While prior studies have evaluated the potential for clinical decision support tools, quality improvement collaboratives, diagnostic pauses, and diagnostic questionnaires administered to patients, 13 , 16 , 21 , 58 , 62 these studies have generally been conducted in ambulatory settings and do not include a mechanism to target interventions to specific patients through use of real-time prediction algorithms that leverage EHR data obtained via APIs. 26 , 30 , 31 , 33 As a preliminary attempt, we recognize that how the 3 interventions are ultimately implemented and sustained in the EHR and clinical workflow will determine its success at preventing DEs from occurring in hospitalized patients.…”

A National Leadership Incubator to Promote Equity in Diagnostic Excellence

“…9 Another scholar engaged underrepresented patients to cocreate medical notes of their diagnostic journeys in order to overcome barriers to diagnostic safety. 10…”

“…One scholar focused on optimally engaging racial and ethnic minority patients in the often prolonged diagnostic journeys of rare and underrecognized diseases . Another scholar engaged underrepresented patients to cocreate medical notes of their diagnostic journeys in order to overcome barriers to diagnostic safety …”

Patient Reasoning: Patients’ and Care Partners’ Perceptions of Diagnostic Accuracy in Emergency Care

“…Whether the patient follows up with a treatment, pursues further diagnostic steps, visits another emergency or urgent care facility, or disengages from seeking care for this and future health problems, all options rely on patient assessing of the explanation they were given and is mediated via trust. 2,14,15 The patient's perception of an explanation of a health problem is proximal to a co-produced, shared, meaningful diagnosis. [16][17][18] There is a gap in the understanding of patients' perception of the diagnostic care they receive, especially the accuracy of explanations of health problems they are given.…”

“…Diagnostic excellence encompasses both an accurate and timely explanation of a health problem that was communicated well and used the optimal process. 1 Assessing diagnostic excellence from the patient perspective is undeniably valuable, 2 – 5 particularly in an emergency or urgent care setting. Patient report of diagnostic excellence overcomes informational gaps in emergency and urgent care with their one-time visits, lack of established patient-clinician relationships, and limited time and resources to triage patients and educate patients on next steps.…”