ABSTRACT
The Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia (CARE-FH) study aims to improve diagnostic evaluation rates for FH at Geisinger, an integrated health delivery system. This clinical trial relies upon implementation science to transition the initial evaluation for FH into primary care, attempting to identify individuals prior to the onset of atherosclerotic cardiovascular disease events. The protocol for the CARE-FH study of this paper is available online. The first phase of the project focuses on trial design, including the development of implementation strategies to deploy evidence-based guidelines. The second phase will study the intervention, rolled out regionally to internal medicine, community medicine, and pediatric care clinicians using a stepped-wedge design, and analyzing data on diagnostic evaluation rates, and implementation, service, and health outcomes.
ABSTRACT
BACKGROUND: Despite routine review of medication lists during patient encounters, patients' medication lists are often incomplete and not reflective of actual medication use. Contributing to this situation is the challenge of reconciling medication information from existing health records, along with external locations (eg, pharmacies, other provider/hospital records, and care facilities) and patient-reported use. Advances in the interoperability and digital collection of information provides a foundation for integration of these once disparate information sources. OBJECTIVE: We aim to evaluate the effectiveness of and satisfaction with an electronic health record (EHR)-integrated web-based medication reconciliation application, MedTrue (MT). METHODS: We conducted a cluster-randomized controlled trial of MT in 6 primary care clinics within an integrated health care delivery system. Our primary outcome was medication list accuracy, as determined by a pharmacist-collected best-possible medication history (BPMH). Patient and staff perspectives were evaluated through surveys and semistructured interviews. RESULTS: Overall, 224 patients were recruited and underwent a BPMH with the pharmacist (n=118 [52.7%] usual care [UC], n=106 [47.3%] MT). For our primary outcome of medication list accuracy, 8 (7.5%) patients in the MT arm and 9 (7.6%) in the UC arm had 0 discrepancies (odds ratio=1.01, 95% CI 0.38-2.72, P=.98). The most common discrepancy identified was patients reporting no longer taking a medication (UC mean 2.48 vs MT mean 2.58, P=.21). Patients found MT easy to use and on average would highly recommend MT (average net promoter score=8/10). Staff found MT beneficial but difficult to implement. CONCLUSIONS: The use of a web-based application integrated into the EHR which combines EHR, patient-reported data, and pharmacy-dispensed data did not improve medication list accuracy among a population of primary care patients compared to UC but was well received by patients. Future studies should address the limitations of the current application and assess whether improved implementation strategies would impact the effectiveness of the application.
ABSTRACT
PROBLEM: Reducing diagnostic errors requires improving both systems and individual clinical reasoning. One strategy to achieve diagnostic excellence is learning from feedback. However, clinicians remain uncomfortable receiving feedback on their diagnostic performance. Thus, a team of researchers and clinical leaders aimed to develop and implement a diagnostic performance feedback program for learning that mitigates potential clinician discomfort. APPROACH: The program was developed as part of a larger project to create a learning health system around diagnostic safety at Geisinger, a large, integrated health care system in rural Pennsylvania. Steps included identifying potential missed opportunities in diagnosis (MODs) from various sources (for example, risk management, clinician reports, patient complaints); confirming MODs through chart review; and having trained facilitators provide feedback to clinicians about MODs as learning opportunities. The team developed a guide for facilitators to conduct effective diagnostic feedback sessions and surveyed facilitators and recipients about their experiences and perceptions of the feedback sessions. OUTCOMES: 28 feedback sessions occurred from January 2019 to June 2020, involving MODs from emergency medicine, primary care, and hospital medicine. Most facilitators (90.6% [29/32]) reported that recipients were receptive to learning and discussing MODs. Most recipients reported that conversations were constructive and nonpunitive (83.3% [25/30]) and allowed them to take concrete steps toward improving diagnosis (76.7% [23/30]). Both groups believed discussions would improve future diagnostic safety (93.8% [30/32] and 70.0% [21/30], respectively). KEY INSIGHTS AND NEXT STEPS: An institutional program was developed and implemented to deliver diagnostic performance feedback. Such a program may facilitate learning and improvement to reduce MODs. Future efforts should assess long-term effects on diagnostic performance and patient outcomes.
