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. 2012 Jul-Aug;19(4):591-6.
doi: 10.1136/amiajnl-2011-000375. Epub 2012 Mar 19.

Presence of key findings in the medical record prior to a documented high-risk diagnosis

Mitchell J Feldman  1 , Edward P Hoffer, G Octo Barnett, Richard J Kim, Kathleen T Famiglietti, Henry Chueh
Affiliations

Presence of key findings in the medical record prior to a documented high-risk diagnosis

Mitchell J Feldman et al. J Am Med Inform Assoc. 2012 Jul-Aug.

Abstract

Background: Failure or delay in diagnosis is a common preventable source of error. The authors sought to determine the frequency with which high-information clinical findings (HIFs) suggestive of a high-risk diagnosis (HRD) appear in the medical record before HRD documentation.

Methods: A knowledge base from a diagnostic decision support system was used to identify HIFs for selected HRDs: lumbar disc disease, myocardial infarction, appendicitis, and colon, breast, lung, ovarian and bladder carcinomas. Two physicians reviewed at least 20 patient records retrieved from a research patient data registry for each of these eight HRDs and for age- and gender-compatible controls. Records were searched for HIFs in visit notes that were created before the HRD was established in the electronic record and in general medical visit notes for controls.

Results: 25% of records reviewed (61/243) contained HIFs in notes before the HRD was established. The mean duration between HIFs first occurring in the record and time of diagnosis ranged from 19 days for breast cancer to 2 years for bladder cancer. In three of the eight HRDs, HIFs were much less likely in control patients without the HRD.

Conclusions: In many records of patients with an HRD, HIFs were present before the HRD was established. Reasons for delay include non-compliance with recommended follow-up, unusual presentation of a disease, and system errors (eg, lack of laboratory follow-up). The presence of HIFs in clinical records suggests a potential role for the integration of diagnostic decision support into the clinical workflow to provide reminder alerts to improve the diagnostic focus.

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Conflict of interest statement

Competing interests: MJF, EPH, GOB, RJK, KTF and HCC are employed by the Laboratory of Computer Science at Massachusetts General Hospital, the developers of the DXplain diagnostic decision support system. During the previous 3 year period, the Laboratory of Computer Science has received licensing royalties related to the DXplain system from approximately 40 hospitals and medical schools, and from Merck & Co, Inc and Epocrates, Inc.

Figures

Figure 1
Figure 1
Flow diagram.
Figure 2
Figure 2
Number of high information clinical findings (HIFs) in each record for high-risk diagnoses (HRDs) and controls. For each HRD, the data referring to patients with a known HRD are shown to the left (black), and the data for the control group without the HRD are shown to the right (gray). CA, cancer; Dz, disease; MI, myocardial infarction.
See this image and copyright information in PMC

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