Missing Clinical Information During Primary Care Visits

Missing Clinical Information During Primary Care Visits A 2005 report by the Journal of the American Medical Association (293:565-571) describes primary care clinicians’ reports of missing clinical information and their perception of patient harm resulting from these events. This survey only confirms the importance of properly capturing, tagging and centralizing medical data collected at the point of care. If you think about it, probably as much as 95% of all medical records are handled through the dictation-transcription process. As the survey outlines, it is not so much about the mere presence of an EMR, but more about the clinician’s involvement / familiarity with the EMR, which, once again, isn’t worth much without the dictated data that feeds it.

Here is an overview of the survey’s findings:

“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; it is particularly crucial for primary care to be able to fulfill what the Institute of Medicine and others consider to be its defining task of coordinating comprehensive care across the health care system. 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. Elder et al reported that missing clinical information was associated with 15.6% of all reported errors in primary care, most of which were perceived by clinicians as likely to be harmful, and was implicated in every major category of medical error. In the only research studying missing clinical information directly, Canadian emergency department physicians reported that 15.3% of visits had important information missing at the time of the encounter that was very likely to result in patient harm. Such harm could include otherwise avoidable drug interactions or duplications, missed or delayed diagnoses, missed immunizations, unnecessary testing and procedures, and the downstream effects of such events.

…In nearly 1 in 7 visits, (clinicians) reported that clinical information important for the patient’s care was missing. Although laboratory reports and dictations or letters predominated, clinicians reported that the missing information originated from a variety of sources and often included more than 1 type. In 44% of the visits with missing information, clinicians believed the patient would be at least somewhat likely to be adversely affected. 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.

…Clinicians believed that missing information would likely result in either delayed care or at least 1 duplicative medical service in 59.5% of visits with missing information…

…Clinicians reporting a full EMR in their practice were significantly less likely to report missing clinical information, but this did not eliminate the problem. Missing information was believed more likely to be outside the clinical system than within it and therefore may be beyond the reach of an EMR. The lack of impact of partial EMRs and electronic access to hospital data on adverse events has been found in other settings. We found no difference in reports of missing information when we used the concurrence among clinicians within a practice to determine the EMR variable. This difference from individual report may indicate that familiarity with or actual use of an EMR is a better predictor of effective information management than the mere presence of an EMR.”

Full report is available from the JAMA web site.

See also this thread: Speech Recognition Prototype for EMR Interoperability

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