Delayed diagnosis: Poor communication is factor
Poor communication among care team members is one of the primary factors resulting in delayed diagnosis and treatment, according to an analysis of 111 root cause analysis reports submitted to the Veterans Affairs (VA) National Center for Patient Safety in Ann Arbor, MI, from 2005 to 2012.1
The researchers took advantage of the comprehensive data available from the VA, which is a very large and integrated health system, says Hardeep Singh, MD, MPH, one of the study’s authors. Singh is chief of the health policy, quality, and informatics program at the Houston VA Center for Innovations in Quality, Effectiveness, and Safety and associate professor of medicine at Baylor College of Medicine in Houston, TX.
Other healthcare systems might not have access to the same data points, because patients often are traversing through multiple care settings. "We have a much better understanding of the longitudinal care patterns that patients experience," says Singh.
Because the VA uses a comprehensive, integrated electronic health record (EHR), the researchers had access to all patient care progress notes including consultant reports, laboratory, imaging and pathology reports, procedures, and emergency department visits. "When you have access to all that information, you can figure out a lot about what’s going on with patient care," says Singh. "This data can really shed light on communication and coordination issues."
Not many systems perform outpatient root cause analyses, which is another reason the data was unique, says Singh. "We are a fairly team-based outpatient care model, but there were still several breakdowns in team level decision-making that were prominent," he says. For example, researchers noted miscommunications related to the degree of urgency of a patient’s situation. At times, providers lacked awareness of specific patient information, such as their abnormal test results.
As the U.S. health system moves to a more team-based model of care, "we will continue to see such breakdowns unless specific factors are addressed," adds Singh. Here are some of the findings in the analysis:
• The organization’s EHR, though more sophisticated than many other commonly used systems, still needs enhancements.
"The EHRs of today probably don’t support the level of teamwork that we need in order to prevent delays in care," says Singh.
• Better policies and procedures are needed to clarify roles and to address the diffusion of responsibility.
"When patients travel between different people and different systems of care, it’s often not clear who is responsible for following up abnormal test results or ensuring patients are following up or returning for important appointments," says Singh.
• Teamwork principles need to be better integrated.
This is becoming more important, says Singh, as the "doctor-centric" model of care moves to accountable care organizations (ACOs) and medical homes. "We will need to learn much more about teamwork principles," he says. Singh says that while they are doing teamwork training in the inpatient and operating room settings, "these programs need to be adapted and exported to the outpatient setting as well."
Physicians Insurance in Seattle is seeing more claims involving handoffs of patients from provider to provider, in the hospital to out of the hospital, and from primary care physicians to specialists, reports Dennis R. Olson, vice president of risk management."The complexity of medical care is a major factor in our malpractice cases," Olson says.
Singh says that to address the contributors of delays in diagnosis and treatment, "we need multiple solutions."
- Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff 2013; 32(8):1368-1375.