Health systems have more communications tools than ever before. Yet communication problems are still a leading contributor to diagnostic errors. What can be done to improve this perennial issue?
Experts acknowledge that there’s no magic answer. But, they suggest, a combination of high tech and high touch strategies—and some deliberate self-care—can help.
1. Put systems in place—and follow through
Medical offices must have systems in place to track, record, and disseminate diagnostic testing orders and results. Electronic medical records (EMRs) can help with this, but the process depends on humans following through and ensuring that information is received and acknowledged by all critical parties.
“It’s not enough to just push out there that there is a concerning result,” says Calvin Chou, MD, PhD, FACE, vice president of external education with the Academy for Communication in Healthcare (ACH) and an internist in practice in the San Francisco VA Health System. Chou recommends setting up a system requiring a clinician to confirm that results were received. He compares it to the read-back/hear-back protocol in aviation, where a pilot and air traffic controller repeat information back and forth to ensure understanding.
A variety of models and workflows are available to help manage test results. One to consider: the Agency for Healthcare Research and Quality (AHRQ)’s Improving Your Laboratory Testing Process toolkit.
2. Document, document, document—but do it thoughtfully
Specific, detailed, and timely documentation is essential to the diagnostic process. Not only does it ensure that all members of the healthcare team have access to the most complete and current information, but it is also a critical component of risk management.
That being said, documentation is only useful if other members of the healthcare team read it. Daniel O’Connell, PhD, a clinical psychologist on the faculty at University of Washington Medical School and a consultant for the Institute for Healthcare Communication, encourages students to use the medical record more thoughtfully. “A progress note is a monologue,” he says. “There’s this asynchronous back and forth of information, but never a sense of ‘what are we going to do?’”
Many EMR users only scratch the surface of the system’s functionality. Often, the systems include a variety of tools that can facilitate better communication: secure messaging functionality, paging capability, and routing reminders are a few examples. In many cases, these features can be turned on and off at the user level, so clinicians can pick and choose tools without a system-level mandate.
3. Don’t be afraid to pick up the phone
Despite its usefulness, O’Connell warns physicians not to rely too heavily on an EMR. “What we often see [in cases of diagnostic error] is there was never real-time coordinated decision making in the face of uncertainty,” he says. Although the medical record reflects that uncertainty, there is no resolution. “In any other industry [in a situation like this], there’d be a conference call,” O’Connell says.
Physicians often claim that they do not have time for calls. But both O’Connell and Chou agree that telephone calls can actually save physicians time. “People are under the illusion that by pushing an email to someone, it’s simpler,” says Chou. “In actuality, a conversation is higher yield because there are nuances that are best addressed in person.”
Consider establishing a workflow that triggers a phone call or other real-time communication with other clinicians when certain conditions are met, such as a specified length of time without a diagnosis or after the exchange of a certain number of inconclusive emails or progress notes.
4. Practice self-care
We know that exhaustion and stress can lead to errors in any profession. Diagnosis-related errors in clinical care are no exception. Chou says that physician burnout contributes to this reality specifically, by impeding healthy communication among members of the healthcare team.
“It’s about the way we interact with each other,” says Chou. “If [you] create an environment where team members don’t feel safe sharing information [with you], errors happen.” Chou says the ACH has seen an increase in requests for seminars on provider-to-provider communication in recent years, as health systems recognize the importance of clinical collegiality and physicians’ personal resilience.
The National Academy of Medicine has established the Action Collaborative on Clinician Well-Being and Resilience to address this issue. The Collaborative’s Resource Center provides tools for organizations and individuals to assess and address clinician burnout.
5. Involve patients
The Shared Decision Making model is all about communication between clinicians and patients. This model has great relevance to the diagnostic process, perhaps even more so when the diagnosis is uncertain.
“Pay attention when [patients] say ‘I’m not getting better,’” says O’Connell. “Read their body language, listen for uncertainly and anxiety.” O’Connell says that failing to pick up on a patient’s cues can lead to a misdiagnosis or delayed diagnosis, leading to a more serious situation that is harder to reverse.
And again, don’t be afraid to pick up the phone to check in with a patient that you’re struggling to diagnose. A five-minute phone call between appointments can often save a healthcare team time in the long run if it reveals that the patient’s condition is deteriorating or that a treatment is not being well tolerated.