The problem of diagnostic discordance, which occurs when a patient is diagnosed with a different problem after being transferred, is gaining more attention as a quality and patient safety issue, and it occurs more often than one might think.
Diagnostic discordance is a fairly new term for a problem that has been around for a long time, occurring in about 85% of hospital transfers, says Michael Usher, MD, PhD, assistant professor of medicine in the Division of General Internal Medicine at the University of Minnesota Medical School in Minneapolis. He recently authored a study that found the high rate of discrepancy in diagnoses before and after transfer. (An abstract is available online at: https://bit.ly/2CPYJ9P.)
His earlier research looked at the rate at which documentation arrived with a transferred patient, and that rate was “exceedingly bad,” Usher says. That prompted him to look further into the diagnoses associated with patients before and after treatment.
“If you have a critically ill patient who may not be conscious or can’t speak, and they arrive without documentation and the person sending them is not available to talk to, you cannot care for that patient properly,” Usher says. “Missing documentation was associated with higher rates of mortality, so this study was the next step in determining what happens to patients when they are transferred and their diagnoses at the receiving facility are not the same. When information is not provided accurately, that puts patients at risk.”
Higher LOS, Risk of Death
The association of patient risk and transfers has been known for some time, he notes. A patient who is transferred is more likely to be the victim of a medical error and has a greater risk of longer length of stay and death. In his recent study, Usher and his colleagues reviewed billing records for 180,000 transferred patients with chronic diseases.
The reasoning was that such diseases should always be found in the medical record of a transferred patient, and the absence would suggest that the patient was exposed to more risk after transfer because the receiving facility did not have that information, he explains.
The problem was found in 85% of the transfers, though the rate was lower when the two hospitals used the same health information exchange (HIE) system to share data. Mortality also was reduced in those instances.
“Seventy-three percent of patients gained a new diagnosis following transfer, while 47% of patients lost a diagnosis,” the study says. Researchers at the university also are studying whether transferring patients between different types of facilities has any effect on diagnostic discordance, as well as any potential effect from the patient having insurance coverage.
“Transfers are understudied. More than a million patients are transferred between hospitals on a yearly basis, and that number is increasing. The cost is very high — in the billions of dollars per year,” Usher says. “It’s certainly a risky transition of care where information can get lost or errors can be missed, or near-misses become misses because of potential delays in care.”
Common Data Systems Help
Disparities among HIEs appear to worsen the problem of diagnostic discordance, Usher says. Minnesota hospitals overwhelmingly use one HIE, and that helps improve the transfer of data for transferred patients, he says, but even then, moving that data into the actual workflow of another facility can be challenging.
“Outside of Minnesota where there is a lot more variability, a lot of times hospitals rely on fax machines or even paper records sent with the patient. That can introduce a lot of variability into the quality of care,” Usher says.
These issues are not unknown at tertiary hospitals, where the patients often are received without adequate information.
“At referring hospitals, I think this issue may be less understood because they don’t receive feedback,” Usher says. “It’s a lot of work to do a good job transferring a patient to another hospital, and a lot of times they don’t hear anything back from the receiving facility. We struggle sometimes with determining how much feedback we should give the transferring hospital, whether we should give them any feedback at all, and if so, how we provide it.”
Part of that hesitancy comes from recognizing that smaller community hospitals often are working with limited resources, sometimes relying on a doctor simply telling a nurse to put the patient’s records in a folder to send along in the ambulance, he explains.
“These breakdowns are systematic, not just occurring at the provider level. We don’t have a standardized system for providing feedback that might lead to more team-based care,” Usher says.
More Structured Transfer Process
The University of Minnesota is working to improve that by mandating that documentation be provided as part of the handoff procedure. That is mostly accomplished by obtaining informed consent for access through the HIE shared by most Minnesota hospitals, but when that is not possible, the University of Minnesota Medical Center requires that patient records be electronically faxed.
Doctors must review the records before a handoff is accepted, Usher says.
“That is just so we are certain of all the information as we are accepting the patient, as opposed to trying to find it afterward,” he says. “It slows things down a little bit, but we’ve found that our providers are more confident with the information they’ve received, and we know there is nothing about the patient’s condition that is going to be lost once the patient arrives.”
That process is being implemented in a randomized fashion across the hospital to help gauge its effectiveness over the more traditional method of accepting transfers, Usher says.
“We’re going from ‘Oh, yeah, just send us the patient, and we’ll see them when they get here,’ to a very regimented process in which we expect them to send us the documents, let us review them, and then we’ll do a detailed, structured handoff as the patient arrives,” Usher says.
“We’re using a clinical trial design to see if there is an actual impact on clinical quality measures.”
Know Your Own System
The proper use of electronic medical records and HIEs can facilitate better transfers and help reduce some of the associated risks, Usher says.
When the electronic systems are not the same, hospitals may need to investigate IT solutions that will facilitate the effective exchange of information, he says.
The first step in addressing diagnostic discordance and improving transfer between hospitals is to understand what happens in your own facility, whether you are transferring or receiving a patient, Usher says.
“The goal is to create a more collaborative environment between the referring and receiving providers,” Usher says. “A more structured environment will help everyone feel comfortable that nothing is missed.”
- Michael Usher, MD, PhD, Assistant Professor of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis. Phone: (612) 301-1409. Email: [email protected].
