A survey of clinicians indicates that missing clinical information for patients is common and may adversely affect patients, according to a study in the February 2 issue of JAMA.
Effectively managing clinical information (patient information such as demographics, medical history, medications, test results, and family structure) is an essential part of all medical care, according to background information in the article. Unfortunately, multiple barriers complicate the collecting, synthesizing, recording, and sharing of clinical information, including privacy regulations, decentralized medical systems, inadequate interprofessional communication, the transfer of patients' care within and across care settings, and the rapid turnover of patients' insurance plans. Accordingly, physicians may not have clinical information available when it is important for a patient's care. Missing clinical information has been implicated in injurious adverse events, but has not yet been explicitly investigated in the primary care setting.
Peter C. Smith, M.D., and colleagues with the University of Colorado Health Sciences Center at Fitzsimons, Aurora, Colo., surveyed primary care clinicians about clinical information reported as missing during patient care visits. The survey was conducted at 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1,614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing.
The researchers found that clinicians reported missing clinical information in 13.6 percent of visits (nearly 1 in 7 visits); missing information included laboratory results (6.1 percent of all visits), letters/dictation (5.4 percent), radiology results (3.8 percent), history and physical examination (3.7 percent), and medications (3.2 percent). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3 percent), to be at least somewhat likely to adversely affect patients (44 percent), and to potentially result in delayed care or additional services (59.5 percent). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6 percent; greater than 10 minutes, 10.4 percent).
Reported missing clinical information was more likely when patients were recent immigrants (about 80 percent more likely), new patients (2.4 times more likely), or had multiple medical problems compared with no problems (2-5 problems: 87 percent more likely; more than 5 problems: 2.8 times more likely). Missing clinical information was less likely in rural practices (48 percent less likely) and when individual clinicians reported having full electronic records (60 percent less likely).
"If validated by future research, these results could have serious implications for the 220 million primary care visits that occur in the United States each year," the authors write.
"This is the first direct study of missing clinical information in primary care, in contrast to retrospective detection of missing information as the etiology of a medical error or adverse event. It demonstrates reports of a high frequency of missing important clinical information, with a wide array of potential impact on patient care. Additional research on missing clinical information should focus on validating clinicians' perceptions and conducting prospective studies of its actual causes and sequelae," the authors conclude.
(JAMA. 2005;293:565-571. Available post-embargo at JAMA.com)
Editor's Note: For funding and support information, please see the JAMA article.
Editorial: Missing Clinical Information - The System Is Down
In an accompanying editorial, Nancy C. Elder, M.D., M.S.P.H., of the University of Cincinnati, Ohio, and John Hickner, M.D., M.Sc., of the University of Chicago Pritzker School of Medicine, Chicago, comment on the study on missing clinical information.
"Why do current systems have such poor communication of data that are essential for sound medical decision making? Part of the reason lies in the disjointed nature of health care in the United States. Most family physicians practice in small, independent groups of 10 or fewer physicians. To complicate matters, in 2001, 75 percent of primary care offices reported having 3 or more managed care contracts, and one-third of practices had more than 10. These contracts often dictate referral patterns for consultation and testing so that primary care offices must communicate with multiple laboratories, imaging facilities, consultants, and hospitals. These communications are not standardized -- some offices may make personal telephone calls, others may correspond by letter or fax, and still others may use e-mail or have digital interfaces that allow real-time transmission of data. It is not surprising, therefore, that Smith et al found less missing clinical information reported by clinicians practicing in rural areas where health care is divided among fewer separate entities. The use of an electronic health record has potential to decrease the amount of missing clinical information but cannot solve all of the problems," they write.
"Until effective systems of health information technology are in place, some low-tech tactics can help avert some of the problems noted by clinicians in the article by Smith et al; these can be applied immediately. The first step toward improvement is awareness that a problem exists, and this study, along with the work of others, should engender a state of mindfulness about the frequent occurrence and importance of missing clinical information. With this cognizance, practice patterns can be modified. Physicians and their staff should screen charts prior to patients' arrival, looking for the presence of anticipated reports, letters, and dictations, and office staff should attempt to find missing data at that time. Systems should be set up within practices to track all tests until the results are in the patient's chart. These tracking systems do not have to be sophisticated or expensive -- a notebook and a copy of an order form have proved successful."
"Patient care is a team sport, and clinicians, patients, and family should be members of the team. Patients should be encouraged to keep their medication list with them at all times, and these lists should be updated at each office visit and a copy provided to the patients. Patients should also be given copies of their laboratory and radiology reports; their problem lists containing their diagnoses; and a synopsis of past operations, hospitalizations, and procedures. These can be taken to the emergency department, hospital, testing facility, and consultants. Patients can serve as an additional safety buffer in the constant struggle to manage the ever-increasing amount of clinical information necessary for the daily practice of medicine. Just as physicians strive to communicate effectively with patients, equal effort must be made to communicate effectively with all those involved in the care of patients," they conclude.
(JAMA. 2005;293:489-490. Available post-embargo at JAMA.com)
Source: Eurekalert & othersLast reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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