The DOI matches its Crossref record; 75 of the 76 references it cites were found in a registry or an index; none of the 93 sources its claims cite is checked for support yet.
Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology
Open accessAbstract
Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.
Overview
AI snapshot
Written from the paper’s full text.
TL;DR
This conceptual paper argues that communication breakdown is a major preventable contributor to diagnostic errors and proposes a three-level framework linking diagnostic steps, communication types, and breakdown points to guide IT-based interventions. It catalogs 12 possible communication error types and discusses EMR/PHR, alerting, tracking, email, and shared decision-making strategies, while cautioning that IT alone cannot assure safer diagnosis.
Key findings
- Diagnostic errors are frequent and costly: about 40% of all malpractice payments in 2003 were diagnosis-related, with an average payment of approximately $300,000 per claim; one study of 49,345 malpractice claims from 1985–2000 found over one-third caused by diagnostic error, and 1 in 6 subjects in a National Patient Safety Foundation poll claimed personally experiencing diagnostic error.
- Communication breakdowns are common in diagnosis: over a third of women with abnormal mammograms did not receive appropriate follow-up; 68% of specialists reported receiving no information from the primary care physician before the referral visit, and 25% of primary care physicians reported still having no information from specialists 4 weeks after referral visits.
- The paper proposes a framework combining 3 diagnostic steps (data gathering, data integration, diagnosis verification), 2 communication types (interpersonal and informational), and 3 breakdown types (message transmission, reception, acknowledgement), yielding 12 possible communication error types across data gathering and diagnosis verification.
- Proposed IT interventions include EMRs, personal health records, electronic alerts, tracking of abnormal results and consultations, direct reporting of test results, secure email, and shared decision-making tools; however, the authors state IT-based interventions alone cannot assure improvement and computerized systems themselves can lead to unintended communication errors.
Methods
- Design: conceptual/review article that develops a framework and discusses potential IT-based interventions; no empirical study or trial is reported.
- Data or sample: no primary dataset or patient sample; the paper draws on cited literature and illustrative examples, including 12 examples in Table 1.
- Main analysis: narrative synthesis and conceptual framework development linking diagnostic steps, communication types, and breakdown points to proposed IT strategies.
Limitations
- Stated in the paper: the true prevalence of diagnostic error is unknown; relatively little is known about causes and prevention; a refined cognitive theory of diagnostic decision making will require years; IT-based interventions alone cannot assure improvements and may introduce unintended errors; physician adoption of email is generally low and several barriers exist.
- Evident from the text: the proposed framework and 12 communication error types are not empirically tested in this paper, and no outcome data are provided on the efficacy of the proposed IT interventions.
- Evident from the text: the examples in Table 1 are illustrative scenarios rather than validated case series or measured outcomes.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
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Cites
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Claims the paper makes
0 of 93 cited sources checked · 0 supported · 0 flagged
- Interpretationcitation§ Abstract
IT-based interventions alone cannot assure improvements in communication.
“IT-based interventions alone, however, cannot assure improvements in communication.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [25] Singh H, Arora HS, Vij MS, Rao R, Khan M, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14:459–66. source
- cites [34] Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11:104–12. source
- cites [42] Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13:547–56. source
- Premisecitation§ Abstract
Emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.
“Communication breakdowns are an increasingly recognized preventable factor in medical mishaps, and emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.21,25–32”
Quote in the paperSubstantial claim0 of 9 sources checked- cites [21] Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142:352–8. source
- cites [25] Singh H, Arora HS, Vij MS, Rao R, Khan M, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14:459–66. source
- cites [26] Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996;156:327–31. source
- cites [27] Brenner RJ, Bartholomew L. Communication errors in radiology: a liability cost analysis. J Am Coll Radiol. 2005;2:428–31. source
- cites [28] Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15:626–31. source
- cites [29] Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866–72. source
- cites [30] Poon EG, Haas JS, Louise PA, Gandhi TK, Burdick E, Bates DW, Brennan TA. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med. 2004;19:316–23. source
- cites [31] Schiff GD. Introduction: communicating critical test results. Jt Comm J Qual Patient Saf. 2005;31:63–5. source
- cites [32] Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186–94. source
- Interpretationreasoning§ Abstract
Addressing preventable communication breakdowns by using resources such as information technology offers a viable and timely opportunity to improve diagnostic quality.
“Thus, addressing preventable communication breakdowns by using resources such as information technology offers a viable and timely opportunity to improve the diagnostic quality.”
Quote in the paperSubstantial claim - Premisecitation§ Abstract
Little is known about the precise cognitive processes that physicians use to confirm and reject their diagnostic hypotheses.
“Little is known about the precise cognitive processes that physicians use to confirm and reject their diagnostic hypotheses,20”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [20] Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making. Stoneham, MA: Butterworth-Heinemann; 1988.
- Premisecitation§ Abstract
Diagnostic difficulties persist despite practitioner experience and advances in diagnostic tests.
“and diagnostic difficulties persist despite practitioner experience and advances in diagnostic tests.23,24”
Quote in the paperSubstantial claim0 of 2 sources checked
- Premisecitation§ Abstract
In a study of abnormal mammograms, over a third of the women studied did not receive appropriate follow-up.
“For example, in a study of abnormal mammograms, over a third of the women studied did not receive appropriate follow-up.30”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [30] Poon EG, Haas JS, Louise PA, Gandhi TK, Burdick E, Bates DW, Brennan TA. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med. 2004;19:316–23. source
- Premisecitation§ Abstract
Diagnostic errors are often attributed to cognitive and/or systems-related factors.
“Although diagnostic errors may occur when signs of a disease are atypical or absent, diagnostic errors are often attributed to cognitive (e.g., faulty clinical reasoning) and/or systems-related factors (e.g., inefficient processes and poor communication7,9–21).”
Quote in the paperSubstantial claim0 of 10 sources checked- cites [7] Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–9. source
- cites [9] Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488–96. source
- cites [10] Croskerry P. Diagnostic failure: a cognitive and affective approach. AHRQ . 2005. Available at Available at: http://www.ahrq.gov/downloads/pub/advances/vol2/Croskerry.pdf . Accessed 7-2-2007. source
- cites [11] Elstein AS. Heuristics and biases: selected errors in clinical reasoning. Acad Med. 1999;74:791–4. source
- cites [12] Hodder RJ, Ballal M, Selvachandran SN, Cade D. Variations in the evaluation of colorectal cancer risk. Colorectal Dis. 2005;7:254–62. source
- cites [13] Kahneman D, Slovic P, Tversky A. Judgment Under Uncertainty: Heuristics and Biases. Cambridge UK: Cambridge University Press; 1982. source
- cites [14] Klein G. Sources of Power: How People Make Decisions. Cambridge, Massachusetts: The MIT Press; 1998.
- cites [15] McDonald CJ. Medical heuristics: the silent adjudicators of clinical practice. Ann Intern Med. 1996;124:56–62. source
- cites [16] Tanenbaum SJ. What physicians know. N Engl J Med. 1993;329:1268–71. source
- cites [17] Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981;211:453–8. source
- Interpretationreasoning§ Abstract
This framework posits that many diagnostic errors can be traced to 1 or more communication errors during data gathering and diagnosis verification.
“This framework posits that many diagnostic errors can be traced to 1 or more communication errors during data gathering and diagnosis verification.”
Quote in the paperNot a substantial claim - Premisecitation§ Abstract
Communication breakdowns are an increasingly recognized preventable factor in medical mishaps.
“Communication breakdowns are an increasingly recognized preventable factor in medical mishaps, and emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.21,25–32”
Quote in the paperSubstantial claim0 of 9 sources checked- cites [21] Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142:352–8. source
- cites [25] Singh H, Arora HS, Vij MS, Rao R, Khan M, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14:459–66. source
- cites [26] Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996;156:327–31. source
- cites [27] Brenner RJ, Bartholomew L. Communication errors in radiology: a liability cost analysis. J Am Coll Radiol. 2005;2:428–31. source
- cites [28] Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15:626–31. source
- cites [29] Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866–72. source
- cites [30] Poon EG, Haas JS, Louise PA, Gandhi TK, Burdick E, Bates DW, Brennan TA. Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med. 2004;19:316–23. source
- cites [31] Schiff GD. Introduction: communicating critical test results. Jt Comm J Qual Patient Saf. 2005;31:63–5. source
- cites [32] Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186–94. source
- Interpretationreasoning§ Abstract
An acknowledgement breakdown can still lead to a poor outcome because the sender may not be able to verify whether the message was received and the action took place.
“Thus, an acknowledgement breakdown can still lead to a poor outcome because the sender may not be able to verify whether the message was received and the action took place.”
Quote in the paperSubstantial claim - Interpretationreasoning§ Abstract
Inadequate data collection would lead to errors in clinical reasoning and therefore in data integration.
“Inadequate data collection would lead to errors in clinical reasoning and therefore in data integration as well.”
Quote in the paperSubstantial claim - Premisecitation§ Abstract
In another study, 68% of specialists reported not receiving any information from the primary care physician before the referral visit.
“In another study, 68% of specialists reported not receiving any information from the primary care physician before the referral visit, and 25% of primary care physicians reported that they still had not received any information from specialists 4 weeks after referral visits.28”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [28] Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15:626–31. source
- Premisecitation§ Abstract
Relatively little is known about the causes and prevention of diagnostic errors.
“Despite the importance of diagnostic errors, relatively little is known about their causes and prevention.22”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [22] Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care. 2006;15:159–64. source
- Premisecitation§ Abstract
Computerized information systems themselves can lead to unintended errors including those that involve communication processes.
“For instance, computerized information systems themselves can lead to unintended errors including those that involve communication processes.25,34,42”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [25] Singh H, Arora HS, Vij MS, Rao R, Khan M, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14:459–66. source
- cites [34] Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11:104–12. source
- cites [42] Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13:547–56. source
- Premisecitation§ Abstract
In our recent work on informational communication related to diagnosis verification, we have validated a 3-point taxonomy of communication breakdowns proposed by Weinger in which communication errors are classified as breakdowns in message transmission, message reception, and message acknowledgement.
“In our recent work on informational communication related to diagnosis verification, we have validated a 3-point taxonomy of communication breakdowns proposed by Weinger in which communication errors are classified as breakdowns in message transmission, message reception, and message acknowledgement.35”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [35] Weinger MB, Blike G. Intubation Mishap. Agency for Health Care Research and Quality Web M & M Rounds. 2003.
- Premisecitation§ Abstract
In another study, 25% of primary care physicians reported that they still had not received any information from specialists 4 weeks after referral visits.
“In another study, 68% of specialists reported not receiving any information from the primary care physician before the referral visit, and 25% of primary care physicians reported that they still had not received any information from specialists 4 weeks after referral visits.28”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [28] Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15:626–31. source
- Interpretationreasoning§ Abstract
In the near term, communication processes are a more feasible target for improving the timeliness and accuracy of diagnoses than a refined cognitive theory of diagnostic decision making.
“Although a refined cognitive theory of diagnostic decision making will require years of development, in the near term communication processes are a more feasible target for improving the timeliness and accuracy of diagnoses.”
Quote in the paperSubstantial claim - Premisecitation§ Abstract
Physicians currently tend to favor direct reporting of test results to patients only when results are normal, have less diagnostic severity, or have less potential for emotional impact.
“Although direct reporting to patients may prevent loss of follow-up, physicians currently tend to favor direct reporting only when test results are normal, have less diagnostic severity, or have less potential for emotional impact.55”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [55] Sung S, Forman-Hoffman V, Wilson MC, Cram P. Direct reporting of laboratory test results to patients by mail to enhance patient safety. J Gen Intern Med. 2006;21:1075–8. source
- Premisecitation§ Abstract
Electronic alerts have been shown to improve critical lab results communication in the inpatient setting.
“Electronic “alerts” have been shown to improve critical lab results communication in the inpatient setting, and they show promise in improving the safety of outpatient test result follow-up.45,52,53”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [45] Kuperman GJ, Teich JM, Tanasijevic MJ, et al. Improving response to critical laboratory results with automation: results of a randomized controlled trial. J Am Med Inform Assoc. 1999;6:512–22. source
- cites [52] Rind DM, Safran C, Phillips RS, et al. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med. 1994;154:1511–7. source
- cites [53] Choksi V, Marn C, Piotrowski M, Bell Y, Carlos R. Illustrating the root cause analysis process: creation of safety net with a semi-automated process for notification of critical findings in diagnostic imaging. J Am Coll Radiol. 2005;2:768–76. source
- Interpretationreasoning§ Abstract
Electronic alerting could help prevent the communication breakdown in Example 10, where the abnormal report would be sent to the provider's EMR screen automatically.
“Electronic alerting could help prevent the communication breakdown in Example 10, where the abnormal report would be sent to the provider’s EMR screen automatically.”
Quote in the paperNot a substantial claim- Rests on an assumption: Several EMRs use a notification system (for instance, the VA’s View Alert system) that immediately alerts clinicians about clinically significant events such as abnormal test results.
- Premisecitation§ Abstract
Adoption of electronic communication by physicians is generally low.
“adoption by physicians is generally low61–63”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [61] Baker LP, Wagner THP, Singer SM, Bundorf MK. Use of the internet and e-mail for health care information: results from a national survey. (Article). JAMA. 2003;289:2400–6. source
- cites [62] Brooks GR, Menachemi N. Physicians’ use of email with patients: factors influencing electronic communication and adherence to best practices. J Med Internet Res. 2006;8:e2. source
- cites [63] Moyer CA, Stern DT, Dobias KS, Cox DT, Katz SJ. Bridging the electronic divide: patient and provider perspectives on e-mail communication in primary care. Am J Manag Care. 2002;8:427–33.
- Premisecitation§ Abstract
In a recent study, the internet proved to be a remarkably effective and accurate mechanism for enhancing peer communication.
“In a recent study, the internet proved to be a remarkably effective and accurate mechanism for enhancing peer communication.67”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [67] Esquivel A, Meric-Bernstam F, Bernstam EV. Accuracy and self correction of information received from an internet breast cancer list: content analysis. BMJ. 2006;332:939–42. source
- Premisecitation§ Abstract
Overall patient desire to communicate with their physicians electronically is high.
“Although overall patient desire to communicate with their physicians electronically is high,60”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [60] Sittig DF, King S, Hazlehurst BL. A survey of patient–provider e-mail communication: what do patients think? International Journal of Medical Informatics. 2001;61:71–80. source
- Premisecitation§ Abstract
Future physicians tend to over-rely on expensive and unnecessary diagnostic tests.
“Clearly, the training curriculum needs to further emphasize traditional history and physical examination to our future physicians, who tend to over-rely on expensive and unnecessary diagnostic tests.48”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [48] Bordage G. Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad Med. 1999;74:S138–43. source
- Premisecitation§ Abstract
Electronic alerts show promise in improving the safety of outpatient test result follow-up.
“Electronic “alerts” have been shown to improve critical lab results communication in the inpatient setting, and they show promise in improving the safety of outpatient test result follow-up.45,52,53”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [45] Kuperman GJ, Teich JM, Tanasijevic MJ, et al. Improving response to critical laboratory results with automation: results of a randomized controlled trial. J Am Med Inform Assoc. 1999;6:512–22. source
- cites [52] Rind DM, Safran C, Phillips RS, et al. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med. 1994;154:1511–7. source
- cites [53] Choksi V, Marn C, Piotrowski M, Bell Y, Carlos R. Illustrating the root cause analysis process: creation of safety net with a semi-automated process for notification of critical findings in diagnostic imaging. J Am Coll Radiol. 2005;2:768–76. source
- Premisecitation§ Abstract
Studies including our own have reported communication breakdowns among providers even in systems that use advanced IT.
“Studies including our own have reported communication breakdowns among providers even in systems that use advanced IT.25”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [25] Singh H, Arora HS, Vij MS, Rao R, Khan M, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14:459–66. source
- Premisecitation§ Abstract
"Smart monitors" could reduce the total number of alerts by filtering information through algorithms so that providers are alerted only when immediate action is necessary.
“In addition, “smart monitors” could reduce the total number of alerts by filtering information through algorithms so that providers are alerted only when immediate action is necessary.54”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [54] Wahls T, Haugen T, Cowell K, Becker B. Assessing diagnostic test result managment in a VA health care network. Fed Pract. 2006;23:23–42.
- Premisecitation§ Abstract
Email has potential to enhance patient-physician interaction, particularly when face-to-face communication is limited.
“Email also has potential to enhance patient–physician interaction, particularly when face-to-face communication is limited,57”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [57] Weiner M, Biondich P. The influence of information technology on patient–physician relationships. J Gen Intern Med. 2006;21(Suppl 1):S35–9. source
- Premisecitation§ Abstract
Direct reporting of test results to patients may prevent loss of follow-up.
“Although direct reporting to patients may prevent loss of follow-up”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [55] Sung S, Forman-Hoffman V, Wilson MC, Cram P. Direct reporting of laboratory test results to patients by mail to enhance patient safety. J Gen Intern Med. 2006;21:1075–8. source
- Premisecitation§ Abstract
An EMR can reduce the problem of missing clinical information that is frequently encountered in paper-based records.
“An EMR can reduce the problem of missing clinical information that is frequently encountered in paper-based records.49”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [49] Smith PC, Raya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;293:565–71. source
- Premisecitation§ Abstract
Email provides opportunities to improve the efficiency of clinical time use.
“and provides opportunities to improve the efficiency of clinical time use.58,59”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [58] Leong SL, Gingrich D, Lewis PR, Mauger DT, George JH. Enhancing doctor–patient communication using email: a pilot study. J Am Board Fam Pract. 2005;18:180–8. source
- cites [59] Mandl KD, Kohane IS, Brandt AM. Electronic patient–physician communication: problems and promise. Ann Intern Med. 1998;129:495–500. source
- Premisecitation§ Abstract
Several barriers to physician adoption of electronic communication exist.
“and several barriers exist.64”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [64] Slack WV. A 67-year-old man who e-mails his physician. JAMA. 2004;292:2255–61. source
- Premisecitation§ Abstract
Data gathering problems may be the most common reasons for diagnostic errors, at least among trainees.
“Data gathering problems may be the most common reasons for diagnostic errors, at least among trainees.4”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] Singh H, Thomas EJ, Khan M, Petersen LA. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med. 2007;167(3):302–8. source
- Interpretationreasoning§ Abstract
Provider-to-provider communication through electronic progress notes could reduce communication breakdowns between health providers.
“Provider-to-provider communication through electronic progress notes could reduce communication breakdowns between health providers as in Examples 4 and 5.”
Quote in the paperNot a substantial claim - Interpretationreasoning§ Abstract
Achieving high standards of patient safety through the use of IT also entails system redesign to include formal policies and procedures regarding the use of IT.
“Thus, achieving high standards of patient safety through the use of IT also entails system redesign to include formal policies and procedures regarding the use of IT.43–47”
Quote in the paperNot a substantial claim0 of 5 sources checked- cites [43] Brantley SD, Brantley RD. Reporting significant unexpected findings: the emergence of information technology solutions. J Am Coll Radiol. 2005;2:304–7. source
- cites [44] Brenner RJ. To err is human, to correct divine: the emergence of technology-based communication systems. J Am Coll Radiol. 2006;3:340–5. source
- cites [45] Kuperman GJ, Teich JM, Tanasijevic MJ, et al. Improving response to critical laboratory results with automation: results of a randomized controlled trial. J Am Med Inform Assoc. 1999;6:512–22. source
- cites [46] Poon EG, Wang SJ, Gandhi TK, Bates DW, Kuperman GJ. Design and implementation of a comprehensive outpatient Results Manager. J Biomed Inform. 2003;36:80–91. source
- cites [47] Berlin L. Using an automated coding and review process to communicate critical radiologic findings: one way to skin a cat. AJR Am J Roentgenol. 2005;185:840–3. source
- It may state two separate claims as one. 9
- Probably not a substantial claim. 15
It may state two separate claims as one.
Premisecitation§ AbstractThe Situation-Background-Assessment-Recommendation (SBAR) technique implemented widely at health systems such as Kaiser Permanente standardizes communication and reduces breakdowns related to data gathering.
“For example, the Situation-Background-Assessment-Recommendation (SBAR) technique implemented widely at health systems such as Kaiser Permanente standardizes communication and reduces breakdowns related to data gathering.40”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [40] Kaiser Permanente of Colorado. SBAR Technique for Communication: A Situational Briefing Model. The Institute for Healthcare Improvement . 2006. Available at http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm . Accessed 7-2-2007.
Probably not a substantial claim.
Premisecitation§ AbstractOften communication in the health care setting is not only intended to transfer information, but also to generate a response from the recipient, such as taking an action and acknowledging receipt of the information.
“In this paper, it is worthwhile to consider the goals of communication in the health care setting: often communication is not only intended to transfer information, but also to generate a response from the recipient of the information, such as taking an action and acknowledging receipt of the information.34”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [34] Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11:104–12. source
It may state two separate claims as one.
Interpretationreasoning§ AbstractAll 3 steps of the diagnostic process, but particularly data gathering and diagnosis verification, rely on good communication and may be targeted for interventions to improve the process of making a correct diagnosis.
“Thus, all 3 of the above steps, but particularly data gathering and diagnosis verification, rely on good communication and may be targeted for interventions to improve the process of making a correct diagnosis.”
Quote in the paperSubstantial claimProbably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractTo improve communication and patient safety, the Institute of Medicine has called for redesigning and error-proofing health care delivery systems.
“To improve communication and patient safety, the Institute of Medicine has called for redesigning and error-proofing health care delivery systems.36”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [36] Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractIn a study of 49,345 malpractice claims between 1985 and 2000, over one-third of the claims were caused by diagnostic error.
“One such study analyzed 49,345 malpractice claims between 1985 and 2000 and found over one-third of the claims to be caused by diagnostic error.2”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [2] Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004;13:121–6. source
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
Premisecitation§ AbstractOut of all liability claims, those related to diagnoses are the most frequent and expensive, about 40% of all malpractice payments in 2003, with an average payment of approximately $300,000 per claim.
“Large risk-management database studies have shown that out of all liability claims, those related to diagnoses are the most frequent and expensive (about 40% of all malpractice payments in 2003, with an average payment of approximately $300,000 per claim1).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [1] Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5. source
It may state two separate claims as one.
Premisecitation§ AbstractUsing information technology (IT) and adopting electronic medical records (EMR) can significantly improve the quality of information transfer and reduce failures in several of the pathways we have described.
“Using information technology (IT) and adopting electronic medical records (EMR) can significantly improve the quality of information transfer38,39 and reduce failures in several of the pathways we have described.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [38] Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003;348:2526–34. source
- cites [39] Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77–87.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractRead-back verification requires the clinician to repeat the information back to the person who transmitted it, completing the loop of reception and acknowledgement in a verifiable manner.
“Another intervention known as “read-back verification” requires the clinician to repeat the information back to the person who transmitted it, completing the loop of reception and acknowledgement in a verifiable manner.41”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [41] Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (Read-Back) telephone reports of critical information. Am J Clin Pathol. 2004;121:801–3. source
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
Interpretationreasoning§ AbstractAlthough message acknowledgement is not strictly necessary for data synthesis and follow-up action in all cases, acknowledgement facilitates concordance among parties and typically implies that some action will follow.
“Although message acknowledgement is not strictly necessary for data synthesis and follow-up action in all cases, acknowledgement facilitates concordance among parties and typically implies that some action will follow.”
Quote in the paperNot a substantial claimProbably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractIn a National Patient Safety Foundation poll, 1 in 6 subjects interviewed claimed to have personally experienced diagnostic error.
“Although the true prevalence of diagnostic error is unknown, 1 in 6 subjects interviewed in a National Patient Safety Foundation poll claimed to have personally experienced diagnostic error.3”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [3] Golodner L. How the public perceives patient safety. Newsletter of the National Safety Foundation. 2004;1997:1–6.
Probably not a substantial claim.
Premisecitation§ AbstractOne method for achieving this goal is to develop electronic information systems for the delivery of health care data.
“One method for achieving this goal is to develop electronic information systems for the delivery of health care data.36,37”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [36] Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.
- cites [37] Institute of Medicine of the National Academies. Patient Safety: Achieving a New Standard for Care. Washington, D.C.: National Academy Press; 2004.
Probably not a substantial claim.
Premisecitation§ AbstractAccording to Kuhn, the process of making a diagnosis involves 3 sequential, overlapping steps: data gathering, data integration, and verification of diagnosis.
“According to Kuhn, the process of making a diagnosis involves 3 sequential, overlapping steps: data gathering, data integration, and verification of diagnosis.23”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [23] Kuhn GJ. Diagnostic errors. Acad Emerg Med. 2002;9:740–50. source
Probably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractDiagnostic errors are a frequent cause of medical errors in the United States.
“Diagnostic errors are a frequent cause of medical errors in the United States.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [1] Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5. source
- cites [2] Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care. 2004;13:121–6. source
Probably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractDiagnostic errors appear to be burdensome in the training environment.
“Such errors also appear to be burdensome in the training environment.4–6”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [4] Singh H, Thomas EJ, Khan M, Petersen LA. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med. 2007;167(3):302–8. source
- cites [5] Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007 Oct 22;167(19):2030–6. source
- cites [6] Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089–94. source
Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
Interpretationnone given§ CONCLUSIONSFocusing interventions on diagnostic steps that are prone to communication breakdowns could achieve a significant reduction in diagnostic errors.
“Focusing interventions on diagnostic steps that are prone to communication breakdowns could achieve a significant reduction in diagnostic errors.”
Quote in the paperNot a substantial claim- Rests on an assumption: Communication breakdowns lead to diagnostic errors.
It may state two separate claims as one.
Premisecitation§ AbstractPatients can use personal health records (PHRs) to generate their own medical histories before their visits and integrate selected information with the physician's EMR at their discretion.
“Patients can use personal health records (PHRs; secure electronic repositories of health information50) to generate their own medical histories before their visits and integrate selected information with the physician’s EMR at their discretion.51”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [50] Gearon CJ. Perspectives on the Future of Personal Health Records. Health Records . 2007. 7-17-2007. Available at http://www.chcf.org/documents/chronicdisease/PHRPerspectives.pdf . Accessed 7-12-2007.
- cites [51] Medical Net Systems, Inc. Medical Net Systems EMR PHR Integration and Other Advance Features; Executive Summary. Medical Net Systems, Inc. 2007. Available at http://www.medicalnetsystems.com/index/EMR_PHR_Integration . Accessed 7-12-2007.
Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
Interpretationreasoning§ CONCLUSIONSMultidisciplinary IT-based strategies that integrate the science of physician-patient communication and health informatics can offer a pragmatic approach to reduce diagnostic errors in health care.
“Multidisciplinary IT-based strategies that integrate the science of physician–patient communication and health informatics can offer a pragmatic approach to reduce diagnostic errors in health care.”
Quote in the paperNot a substantial claim- Rests on an assumption: Communication breakdowns lead to diagnostic errors.
It may state two separate claims as one.
Premisecitation§ AbstractThese studies use an interactive voice response tool to enhance self-care and improve the diagnosis of disease decompensation.
“These studies use an interactive voice response tool to enhance self-care and improve the diagnosis of disease decompensation.68,69”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [68] Heisler M, Piette JD. "I help you, and you help me": facilitated telephone peer support among patients with diabetes. Diabetes Educ. 2005;31:869–79. source
- cites [69] Heisler M, Halasyamani L, Resnicow K, et al. “I am not alone”: the feasibility and acceptability of interactive voice response-facilitated telephone peer support among older adults with heart failure. Congest Heart Fail. 2007;13:149–57. source
Probably not a substantial claim. The paper’s conclusions may not depend on it.
Premisecitation§ AbstractTo improve the design of any IT-based system, the IOM proposes the application of engineering concepts and methods, especially in the area of human factors.
“To improve the design of any IT-based system, the IOM proposes the application of engineering concepts and methods, especially in the area of human factors.36,37”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [36] Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.
- cites [37] Institute of Medicine of the National Academies. Patient Safety: Achieving a New Standard for Care. Washington, D.C.: National Academy Press; 2004.
It may state two separate claims as one.
Premisecitation§ AbstractThe VA's View Alert system tracks acknowledgement of abnormal test results, and results that go unacknowledged receive a higher degree of oversight to reduce the chance that the report would be lost in the system.
“For instance, the VA’s View Alert system tracks acknowledgement of abnormal test results, and results that go unacknowledged receive a higher degree of oversight to reduce the chance that the report would be lost in the system (e.g., Example 12).25”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [25] Singh H, Arora HS, Vij MS, Rao R, Khan M, Petersen LA. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14:459–66. source
It may state two separate claims as one.
Interpretationreasoning§ AbstractCustomizing EMR screens to receive only critical alerts and using special alert management software to track them can avoid problems when providers fail to take action or acknowledge alerts or ignore alerts because they receive too many.
“Customizing EMR screens to receive only critical alerts and using special alert management software to track them can avoid such problems.”
Quote in the paperSubstantial claim- Rests on an assumption: Several EMRs use a notification system (for instance, the VA’s View Alert system) that immediately alerts clinicians about clinically significant events such as abnormal test results.
Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
Interpretationreasoning§ CONCLUSIONSThis framework can inform the design and testing of IT-based interventions to improve the effectiveness of communication.
“This framework can inform the design and testing of IT-based interventions to improve the effectiveness of communication.”
Quote in the paperNot a substantial claim- Rests on an assumption: Communication breakdowns lead to diagnostic errors.
The paper relies on this without support.
EMRs can provide effective decision support, clinical reminders, and other diagnostic aids so that the diagnostic workup can be automatically prompted based on complaints and findings.
“EMRs can provide effective decision support, clinical reminders, and other diagnostic aids so that the diagnostic workup can be automatically prompted based on complaints and findings.”
The paper relies on this without support.
EMR linkages can make available a “distributed” electronic health record to several providers across multiple health care systems and thereby centralize patient information to facilitate diagnosis.
“EMR linkages can make available a “distributed” electronic health record to several providers across multiple health care systems and thereby centralize patient information to facilitate diagnosis.”
The paper relies on this without support.
Several EMRs use a notification system (for instance, the VA’s View Alert system) that immediately alerts clinicians about clinically significant events such as abnormal test results.
“Alerting for Diagnostic Test Result Management Several EMRs use a notification system (for instance, the VA’s View Alert system) that immediately alerts clinicians about clinically significant events such as abnormal test results.”
The paper relies on this without support.
Secure email can serve as an adjunct to interpersonal communication and facilitate data gathering and diagnosis verification.
“Secure email can be an adjunct to interpersonal communication and facilitates both data gathering and diagnosis verification.”
The paper relies on this without support.
EMRs can track patient appointments for tests and consultations and hence can facilitate interpersonal communication during diagnosis verification.
“EMRs can track patient appointments for tests and consultations and hence can facilitate interpersonal communication during diagnosis verification.”
The paper relies on this without support.
PHRs can be used to provide patient reminders for tests and appointments.
“PHRs can also be used to provide patient reminders for tests and appointments.”
The paper relies on this without support.
Closer monitoring of patients with increased health care needs in their homes via devices and applications connected to an electronic network can facilitate earlier diagnosis when problems arise.
“Closer monitoring of patients with increased health care needs in their homes via devices and applications connected to an electronic network can also facilitate earlier diagnosis when problems arise.”
The paper relies on this without support.
Communication breakdowns lead to diagnostic errors.
“communication breakdowns that lead to diagnostic errors”
The paper relies on this without support.
Many patient engagement processes are prone to the same errors that contribute to communication breakdowns.
“many of these processes are prone to the same errors that contribute to communication breakdowns.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Missed laboratory results or delayed recognition of results creates a significant potential for outpatient diagnostic errors, adverse events, and liability claims.
“missed laboratory results or delayed recognition of results leads to a significant potential for outpatient diagnostic errors, adverse events and liability claims.”
From Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain? (2010) · cites this paper as [16]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Example 3 is assigned to two different diagnostic steps
MinorTable 1 places Example 3 among data-gathering-related errors, but the later discussion uses the same example to illustrate communication during diagnosis verification.
“Examples of communication breakdowns that may result in data gathering-related diagnostic errors 1. Interpersonal transmission errors:”
“EMRs can track patient appointments for tests and consultations and hence can facilitate interpersonal communication during diagnosis verification. For instance, in Example 3 the interpersonal acknowledgement problem could be overcome using an EMR-generated reminder letter to the patient followed by a reminder notification to the physician.”
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Cited by
Sorted by citations
Missed and Delayed Diagnosis of Dementia in Primary Care: Prevalence and Contributing Factors
Bradford, A., Kunik, M. E., Schulz, P., Williams, S. P., & Singh, H. (2009) · Alzheimer Disease & Associated Disorders · doi:10.1097/wad.0b013e3181a6bebc · Cited by 969
“The use of information technology, including electronic health records with integrated reminders for patient communication and follow-up, may also augment patient-provider communication and improve the diagnostic process.(22) Among providers, studies citing a lack of relevant training suggest that many primary care ph…”
BackgroundSelf-citationThe Global Burden of Diagnostic Errors in Primary Care
Singh, H., Schiff, G. D., Graber, M. L., Onakpoya, I., & Thompson, M. J. (2017) · BMJ Quality & Safety · doi:10.1136/bmjqs-2016-005401 · Cited by 395
Self-citationMining Electronic Health Records (EHRs): A Survey
Yadav, P., Steinbach, M., Kumar, V., & Simon, G. (2018) · ACM Computing Surveys · doi:10.1145/3127881 · Cited by 299
“Multiple studies have observed that EHRs have reduced clinical errors [1–5], improved chronic illness care [6–10] and improved the completeness, accuracy and timeliness of case reporting to public health.”
Backgrounde-Health Cloud: Opportunities and Challenges
AbuKhousa, E., Mohamed, N., & Al-Jaroodi, J. (2012) · Future Internet · doi:10.3390/fi4030621 · Cited by 230
Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review
Callen, J. L., Westbrook, J. I., Georgiou, A., & Li, J. (2012) · Journal of General Internal Medicine · doi:10.1007/s11606-011-1949-5 · Cited by 229
Singh, H., Thomas, E. J., Mani, S., Sittig, D., Arora, H., Espadas, D., Khan, M. M., & Petersen, L. A. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2009.263 · Cited by 212
“The volume of outpatient care and nature of high-risk transitions between health care practitioners/ providers (HCPs), settings, and systems of care makes timely communication particularly challenging.(13) For example, a patient referred for diagnostic workup for respiratory symptoms by a primary care provider (PCP) m…”
BackgroundSelf-citationPatient portals and health apps: Pitfalls, promises, and what one might learn from the other
Baldwin, J. L., Singh, H., Sittig, D. F., & Giardina, T. D. (2016) · Healthcare · doi:10.1016/j.hjdsi.2016.08.004 · Cited by 179
“For example, health IT can be used to facilitate information exchange with clinicians and instruct patients when to act upon clinical issues, such as out of range physiologic parameters, followup of test results, and complications of medication use.(2) Tools such as personal health records, patient portals, and variou…”
BackgroundSelf-citationQudah, B., & Luetsch, K. (2019) · Patient Education and Counseling · doi:10.1016/j.pec.2019.01.021 · Cited by 200
Reducing Hospital Errors: Interventions that Build Safety Culture
Singer, S. J., & Vogus, T. J. (2013) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-031912-114439 · Cited by 219
Callen, J. L., Georgiou, A., Li, J., & Westbrook, J. I. (2011) · BMJ Quality & Safety · doi:10.1136/bmjqs.2010.044339 · Cited by 168
Singh, H., Thomas, E. J., Sittig, D. F., Wilson, L., Espadas, D., Khan, M. M., & Petersen, L. A. (2010) · The American Journal of Medicine · doi:10.1016/j.amjmed.2009.07.027 · Cited by 160
Self-citationSystem-related interventions to reduce diagnostic errors: a narrative review
Singh, H., Graber, M. L., KISSAM, S. M., Sorensen, A. V., Lenfestey, N. F., Tant, E. M., Henriksen, K., & LaBresh, K. A. (2011) · BMJ Quality & Safety · doi:10.1136/bmjqs-2011-000150 · Cited by 134
Self-citationSingh, H., Hirani, K., Kadiyala, H., Rudomiotov, O., Giardina, T. D., Khan, M. M., & Wahls, T. L. (2010) · Journal of Clinical Oncology · doi:10.1200/jco.2009.25.6636 · Cited by 136
“so on) among front-line primary care providers, consultants, and other diagnostic specialists.(34) We hypothesized that using an EHR”
BackgroundSelf-citationQuinn, M., Forman, J. H., Harrod, M., Winter, S. M., Fowler, K. E., Krein, S. L., Gupta, A. B., Saint, S. K., Singh, H., & Chopra, V. (2018) · Diagnosis · doi:10.1515/dx-2018-0036 · Cited by 130
Self-citationHaluza, D., Naszay, M., Stockinger, A., & Jungwirth, D. (2017) · Health Communication · doi:10.1080/10410236.2016.1220044 · Cited by 116
Medical Malpractice Liability in the Age of Electronic Health Records
Mangalmurti, S. S., Murtagh, L., & Mello, M. M. (2010) · New England Journal of Medicine · doi:10.1056/nejmhle1005210 · Cited by 101
Singh, H., Spitzmueller, C., Petersen, N. J., Sawhney, M. K., Smith, M. W., Murphy, D. R., Espadas, D., Laxmisan, A., & Sittig, D. F. (2013) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2012-001267 · Cited by 92
Self-citationEight Recommendations for Policies for Communicating Abnormal Test Results
Singh, H., & Vij, M. S. (2010) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(10)36037-5 · Cited by 83
Self-citationImproving the Healthcare Effectiveness: The Possible Role of EHR, IoMT and Blockchain
Girardi, F., Gennaro, G. D., Colizzi, L., & Convertini, V. N. (2020) · Electronics · doi:10.3390/electronics9060884 · Cited by 78
“Inadequate data collection and low rates of communication lead to errors in clinical reasoning which decrease the quality of care, so it is likely that many of these errors are due to the reduced availability of the information necessary to make the correct decisions in organizing a patient’s therapeutic diagnostic pa…”
BackgroundMcCoy, A. B., Wright, A. T., Kahn, M. G., Shapiro, J. S., Bernstam, E. V., & Sittig, D. F. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2012-001419 · Cited by 72
Primary care and communication in shared cancer care: a qualitative study.
Sada, Y. H., Street, R. L., Singh, H., Shada, R. E., & Naik, A. D. (2011) · PubMed · Cited by 70
Self-citationSingh, H., Wilson, L., Petersen, L. A., Sawhney, M. K., Reis, B., Espadas, D., & Sittig, D. F. (2009) · BMC Medical Informatics and Decision Making · doi:10.1186/1472-6947-9-49 · Cited by 64
Self-citationUsing a Multifaceted Approach to Improve the Follow-Up of Positive Fecal Occult Blood Test Results
Singh, H., Kadiyala, H., Bhagwath, G., Shethia, A., El‐Serag, H. B., Walder, A. M., Velez, M. E., & Petersen, L. A. (2009) · The American Journal of Gastroenterology · doi:10.1038/ajg.2009.55 · Cited by 63
“We believe that use of information technology and case managers with dedicated time could facilitate tracking procedures (”
Self-citationBell, S. K., Folcarelli, P. H., Fossa, A. J., Gerard, M., Harper, M. B., Leveille, S. G., Moore, C., Sands, K., Lee, B. S., Walker, J., et al. (2021) · PubMed · doi:10.1097/pts.0000000000000494 · Cited by 53
Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records
Bhise, V., Meyer, A. N. D., Singh, H., Wei, L., Russo, E. M., Al-Mutairi, A., & Murphy, D. R. (2017) · The American Journal of Medicine · doi:10.1016/j.amjmed.2017.03.009 · Cited by 54
“Unlike previous studies, which used paper-based medical records, where there is often missing diagnostic information, we used an integrated EHR, which provides comprehensive access to diagnostic information (eg, documentation of abnormal findings, reports, information about multiple provider visits) and facilitates in…”
MethodSelf-citationISBAR for clear communication: one hospital’s experience spreading the message
Finnigan, M., Marshall, S. D., & Flanagan, B. (2010) · Australian Health Review · doi:10.1071/ah09823 · Cited by 53
ICT AND THE FUTURE OF HEALTH CARE: ASPECTS OF DOCTOR-PATIENT COMMUNICATION
Haluza, D., & Jungwirth, D. (2014) · International Journal of Technology Assessment in Health Care · doi:10.1017/s0266462314000294 · Cited by 49
“As a consequence, valuable communication leads to several improved physical and psychological outcomes including reduction of duplicative testing, hospital (re)admission, and mortality rates due to enhancement of patients ´ knowledge (2).”
BackgroundGopalan, A., Mishra, P., Alexeeff, S., Blatchins, M. A., Kim, E., Man, A. H., & Grant, R. W. (2018) · Diabetic Medicine · doi:10.1111/dme.13808 · Cited by 52
Communication breakdowns and diagnostic errors: a radiology perspective
Murphy, D. R., Singh, H., & Berlin, L. (2014) · Diagnosis · doi:10.1515/dx-2014-0035 · Cited by 52
“Directing solutions towards the root causes of communication breakdowns could lead to reductions in missed and delayed diagnoses and care [4].”
BackgroundSelf-citationDiagnostic errors in ambulatory care: dimensions and preventive strategies
Singh, H., & Weingart, S. N. (2009) · Advances in Health Sciences Education · doi:10.1007/s10459-009-9177-z · Cited by 51
“Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors (Singh et al. 2008).”
BackgroundSelf-citationSabih, D., Sabih, A., Sabih, Q., & Khan, A. N. (2010) · Insights into Imaging · doi:10.1007/s13244-010-0048-1 · Cited by 48
“The recent voice recognition tools come with their own vulnerabilities [50], but newer information technology tools can be used to ensure a timely delivery, emphasising important information in the report with follow-ups [51] and confirming acknowledgement of receipt.”
BackgroundTeamwork Errors in Trauma Resuscitation
Sarcevic, A., Marsic, I., & Burd, R. S. (2012) · ACM Transactions on Computer-Human Interaction · doi:10.1145/2240156.2240161 · Cited by 49
Barwise, A., Leppin, A., Dong, Y., Huang, C., Pinevich, Y., Herasevich, S., Soleimani, J., Gajic, O., Pickering, B., & Kumbamu, A. (2021) · Journal of Patient Safety · doi:10.1097/pts.0000000000000817 · Cited by 43
Older Adults' Needs for Home Health Care and the Potential for Human Factors Interventions
Mitzner, T. L., Beer, J. M., McBride, S. E., Rogers, W. A., & Fisk, A. D. (2009) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/154193120905301118 · Cited by 47
Ten Strategies to Improve Management of Abnormal Test Result Alerts in the Electronic Health Record
Singh, H., Wilson, L., Reis, B., Sawhney, M. K., Espadas, D., & Sittig, D. F. (2010) · Journal of Patient Safety · doi:10.1097/pts.0b013e3181ddf652 · Cited by 43
“Automated alert notification systems integrated within electronic health records (EHRs) offer a potential solution.(5,6) For instance, communication of abnormal clinical information through Balerts[ (computerized notifications of significantly abnormal or critical test results) can potentially facilitate rapid review…”
BackgroundSelf-citationChallenges for Home Health Care Providers: A Needs Assessment
McBride, S. E., Beer, J. M., Mitzner, T. L., & Rogers, W. A. (2011) · Physical & Occupational Therapy In Geriatrics · doi:10.3109/02703181.2011.552170 · Cited by 43
Missed Opportunities for the Diagnosis of Colorectal Cancer
Siminoff, L. A., Rogers, H. L., & Harris-Haywood, S. (2015) · BioMed Research International · doi:10.1155/2015/285096 · Cited by 41
“Other factors contributing to diagnostic delay may include poor physician-patient communication, resulting in physician or patient failure to explore symptoms or obtain follow-up tests or referrals to specialists [16].”
BackgroundWorkarounds and Test Results Follow-up in Electronic Health Record-Based Primary Care
Menon, S., Murphy, D. R., Singh, H., Meyer, A. N. D., & Sittig, D. F. (2016) · Applied Clinical Informatics · doi:10.4338/aci-2015-10-ra-0135 · Cited by 40
“Electronic health records (EHRs) facilitate reliable communication of test results to clinicians [1].”
BackgroundSelf-citationNaik, A. D., & Singh, H. (2010) · Medical Decision Making · doi:10.1177/0272989x10385846 · Cited by 35
“18,19 EHRs may indeed reduce some barriers to care coordination and decision making among providers, but their simple implementation within health care systems is unlikely to reduce all disin-centives to ineffective communication and may themselves contribute novel sources of system-related errors.”
BackgroundSelf-citationBayramzadeh, S., & Alkazemi, M. F. (2014) · HERD Health Environments Research & Design Journal · doi:10.1177/193758671400700406 · Cited by 37
Improving outpatient safety through effective electronic communication: a study protocol
Hysong, S. J., Sawhney, M. K., Wilson, L., Sittig, D. F., Esquivel, A., Watford, M., Giardina, T. D., Espadas, D., & Singh, H. (2009) · Implementation Science · doi:10.1186/1748-5908-4-62 · Cited by 34
“Health IT and EMRs are perhaps one of the most powerful systems-based interventions to facilitate the diagnostic process because they ensure the delivery of key findings and other health-related information to the practitioner [11].”
Self-citationSubbe, C. P., Tellier, G., & Barach, P. R. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-047446 · Cited by 36
Poon, E. G., Kachalia, A. B., Puopolo, A. L., Gandhi, T. K., & Studdert, D. M. (2012) · Journal of General Internal Medicine · doi:10.1007/s11606-012-2107-4 · Cited by 35
Powell, L., Sittig, D. F., Chrouser, K. L., & Singh, H. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.6752 · Cited by 34
Self-citationDiagnostic errors: moving beyond ‘no respect’ and getting ready for prime time
Singh, H. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-002387 · Cited by 32
Self-citationLacson, R. C., O’Connor, S. D., Sahni, V. A., Roy, C. L., Dalal, A. K., Desai, S. P., & Khorasani, R. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-004276 · Cited by 36
The Rate of Missed Test Results in an Emergency Department
Paoloni, R., Georgiou, A., Prgomet, M., Westbrook, J. I., & Callen, J. L. (2009) · Methods of Information in Medicine · doi:10.3414/me09-01-0011 · Cited by 32
“The strategy of transmission of results by more than one method has been suggested as a way of reducing missed results [32].”
BackgroundMethodSmith, M., Murphy, D., Laxmisan, A., Sittig, D., Reis, B., Esquivel, A., & Singh, H. (2013) · Applied Clinical Informatics · doi:10.4338/aci-2013-04-ra-0019 · Cited by 31
“In order to address this in a multifaceted sociotechnical context, we intended the functional prototype design to meet the following goals, many of which were conceived based on previous research findings: [1, 3, 4, 27–29, 33–37] 1.”
BackgroundMethodSelf-citationThe ACR Guideline on Communication: To Be or Not to Be, That Is the Question
Lucey, L. L., & Kushner, D. C. (2010) · Journal of the American College of Radiology · doi:10.1016/j.jacr.2009.11.007 · Cited by 31
Releasing test results directly to patients: A multisite survey of physician perspectives
Giardina, T. D., Callen, J. L., Georgiou, A., Westbrook, J. I., Greisinger, A. J., Esquivel, A., Forjuoh, S. N., Parrish, D. E., & Singh, H. (2015) · Patient Education and Counseling · doi:10.1016/j.pec.2015.02.011 · Cited by 30
“Although electronic health records are increasingly used to facilitate notification of abnormal test results to physicians [11], follow-up failures continue to occur [2,12].”
BackgroundSelf-citationWeaver, S. J., Newman‐Toker, D. E., & Rosen, M. A. (2012) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.21155 · Cited by 33
Maynard, M. T., Marshall, D., & Dean, M. D. (2012) · Advances in health care management · doi:10.1108/s1474-8231(2012)0000013008 · Cited by 28
Cancer communication and informatics research across the cancer continuum.
Hesse, B. W., Beckjord, E. B., Rutten, L. J. F., Fagerlin, A., & Cameron, L. D. (2015) · American Psychologist · doi:10.1037/a0036852 · Cited by 25
Rights and responsibilities of users of electronic health records
Sittig, D. F., & Singh, H. (2012) · Canadian Medical Association Journal · doi:10.1503/cmaj.111599 · Cited by 30
“Comprehensive, well-implemented electronic health records with advanced clinical decision support interventions have potential to reduce errors with medications(8) and to increase the quality, efficiency and reliability of information transfer.(9,10)”
BackgroundSelf-citationProvision of mental health care services to deaf individuals using telehealth.
Wilson, J. A. B., & Schild, S. (2014) · Professional Psychology Research and Practice · doi:10.1037/a0036811 · Cited by 23
Exploring the Recent Trends in Management of Dementia and Frailty: Focus on Diagnosis and Treatment
Rahman, M. M., Mim, S. A., Islam, M. R., Parvez, A., Islam, F., Uddin, M. B., Rahaman, M. S., Shuvo, P. A., Ahmed, M., Greig, N. H., et al. (2022) · Current Medicinal Chemistry · doi:10.2174/0929867329666220408102051 · Cited by 23
Assigning responsibility to close the loop on radiology test results
Kwan, J. L., & Singh, H. (2017) · Diagnosis · doi:10.1515/dx-2017-0019 · Cited by 23
“Closed-loop communication includes not just a one-way transfer of information from sender to recipient, but also the acknowledgment of receipt by the recipient, and importantly in the case of test result communication, follow-up action on the test result [8].”
Self-citationMaintaining IoT Healthcare Records Using Cloud Storage
Chennam, K. K., Maheswari, V. U., & Aluvalu, R. (2021) · EAI/Springer Innovations in Communication and Computing · doi:10.1007/978-3-030-82715-1_10 · Cited by 21
Sterponi, L., Zucchermaglio, C., Alby, F., & Fatigante, M. (2017) · Written Communication · doi:10.1177/0741088317723304 · Cited by 24
An adverse event capture and management system for cancer studies
Lencioni, A., Hutchins, L. F., Annis, S., Chen, W., Ermisoglu, E., Feng, Z., Mack, K., Simpson, K., Lane, C., & Topaloĝlu, Ü. (2015) · BMC Bioinformatics · doi:10.1186/1471-2105-16-s13-s6 · Cited by 20
“When addressing new AEs, AERS will not allow the clinician to select an AE that is currently ongoing whether it was previously documented as a symptom or a diagnosis to eliminate duplicate reporting [10,11].”
BackgroundRecommendations From the Twitter Hashtag #DoctorsAreDickheads: Qualitative Analysis
Sharma, A. E., Mann, Z., Cherian, R., Rosario, J. B. D., Yang, J., & Sarkar, U. (2020) · Journal of Medical Internet Research · doi:10.2196/17595 · Cited by 18
“Improvements are urgently needed in how clinicians communicate and how patients are involved in the diagnostic pathway [24,25].”
BackgroundElectronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism
Meyer, A. N. D., Murphy, D. R., Al-Mutairi, A., Sittig, D. F., Wei, L., Russo, E. M., & Singh, H. (2017) · Journal of General Internal Medicine · doi:10.1007/s11606-017-3988-z · Cited by 14
Self-citationHerasevich, S., Soleimani, J., Huang, C., Pinevich, Y., Dong, Y., Pickering, B. W., Murad, M. H., & Barwise, A. K. (2023) · BMJ Quality & Safety · doi:10.1136/bmjqs-2022-015038 · Cited by 20
Do not assume that no news is good news: test result management and communication in primary care
Kwan, J. L., & Cram, P. M. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-004645 · Cited by 16
“However, these IT solutions have generated mixed results 10 – 12 and seem unlikely to deliver the silver bullet they were once touted to be.”
BackgroundVest, J. R., Unruh, M. A., Shapiro, J. S., & Casalino, L. P. (2019) · Health Services Research · doi:10.1111/1475-6773.13169 · Cited by 16
Harvey, H. B., Alkasab, T. K., Pandharipande, P. V., Zhao, J., Halpern, E. F., Salazar, G., Abujudeh, H. H., Rosenthal, D. I., & Gazelle, G. S. (2014) · Journal of the American College of Radiology · doi:10.1016/j.jacr.2014.08.013 · Cited by 16
“Failures of communication in these instances can result in preventable patient morbidity and mortality and associated legal liability [1-7].”
BackgroundClinical Dental Faculty Members’ Perceptions of Diagnostic Errors and How to Avoid Them
Nikdel, C., Nikdel, K., Ibarra-Noriega, A., Kalenderian, E., & Walji, M. F. (2018) · Journal of Dental Education · doi:10.21815/jde.018.037 · Cited by 14
Jabin, M. S. R., Schultz, T., Mandel, C., Bessen, T., Hibbert, P. D., Wiles, L., & Runciman, W. B. (2020) · Journal of Patient Safety · doi:10.1097/pts.0000000000000709 · Cited by 13
“Effective communication is considered one of the tools to mitigate diagnostic errors, which are a significant patient safety problem in radiology.(49,50) Training and education can improve teamwork and collaboration through the use of communication strategies and thus enhance the performance of radiology professionals.”
BackgroundA simulation framework for mapping risks in clinical processes: the case of in-patient transfers
Dunn, A. G., Ong, M., Westbrook, J. I., Magrabi, F., Coiera, E. W., & Wobcke, W. (2011) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2010-000075 · Cited by 16
“This particular process reflects a well-defined workflow with numerous checkpoints and redundant operations that are included with the aim of minimizing the potential for risk. Yet despite this, the potential for risk, either risk not mitigated by the process (in the misidentification scenario) or the risk generated b…”
MethodCochon, L. R., Lacson, R. C., Wang, A., Kapoor, N., Ip, I. K., Desai, S. P., Kachalia, A. B., Dennerlein, J. T., Benneyan, J. C., & Khorasani, R. (2018) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocy103 · Cited by 15
Integration of Blockchain and AI in EHR sharing: A survey
Omrčen, L., Leventić, H., Romić, K., et al. (2021) · International Symposium ELMAR · doi:10.1109/elmar52657.2021.9550953 · Cited by 12
Buja, A., Toffanin, R., Rigon, S., Sandonà, P., Carrara, T., Damiani, G., & Baldo, V. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-011526 · Cited by 10
Pharmacists and Health Information Technology: Emerging Issues in Patient Safety
Fuji, K. T., & Galt, K. A. (2008) · HEC Forum · doi:10.1007/s10730-008-9075-4 · Cited by 13
Perspective: Uses and Misuses of Thresholds in Diagnostic Decision Making
Warner, J. L., Najarían, R. M., & Tierney, L. M. (2010) · Academic Medicine · doi:10.1097/acm.0b013e3181ccd59b · Cited by 14
The influence of task environment and health literacy on the quality of parent-reported ADHD data
Porter, S. C., Guo, C.-Y., Molino, J. M., et al. (2012) · Applied Clinical Informatics · doi:10.4338/aci-2011-10-ra-0062 · Cited by 13
“Primary care practices are challenged by how to effectively create a mechanism to gather, process, interpret, and use data from parent-completed surveys about behavior, medications, and potential side effects [8, 9, 24–26].”
BackgroundTest Result Management Practices of Canadian Internal Medicine Physicians and Trainees
Bodley, T. F., Kwan, J. L., Matelski, J. J., Darragh, P. J., & Cram, P. M. (2018) · Journal of General Internal Medicine · doi:10.1007/s11606-018-4656-7 · Cited by 12
Lin, J. J., & Moore, C. (2011) · American Journal of Medical Quality · doi:10.1177/1062860610385333 · Cited by 12
“The use of electronic health records (EHRs) with test results management functionality is a systems-based approach to improve test result follow-up and reduce adverse events.(8-10) Some studies have shown that these systems may improve follow-up of laboratory results,(9,11) screening practices,(12) and medication safe…”
MethodNext steps for electronic health records to improve the diagnostic process
Liebovitz, D. (2015) · Diagnosis · doi:10.1515/dx-2014-0070 · Cited by 9
Anti-MDA5-Positive Dermatomyositis Presenting as Fever of Unknown Origin
Lee, L. W., Narang, N. S., Postolova, A., et al. (2016) · Journal of General Internal Medicine · doi:10.1007/s11606-016-3769-0 · Cited by 12
“While this could lead to a Bfresh^ perspective, it also hindered the clinicians’ ability to assess changes over time and likely decreased the quality of information transfer.(36) Moreover, numerous hospitalizations and diagnostic tests made the patient’s medical record long and cumbersome to review, potentially contri…”
BackgroundPro-active medical information retrieval
Braun, L. (2008) · doi:10.26481/dis.20081029lb · Cited by 12
Redmond, S. A., Barwise, A. K., Zornes, S., Dong, Y., Herasevich, S., Pinevich, Y., Soleimani, J., LeMahieu, A., Leppin, A. L., & Pickering, B. W. (2022) · Health Services Insights · doi:10.1177/11786329221123540 · Cited by 11
Teaching for reducing diagnostic errors
Mishra, D., Gupta, P., & Singh, T. (2017) · Indian Pediatrics · doi:10.1007/s13312-017-0994-5 · Cited by 9
A Concept Analysis of Organizational Health and Communication
Brittain, A. C., & Carrington, J. M. (2018) · Nursing Administration Quarterly · doi:10.1097/naq.0000000000000331 · Cited by 10
McCoy, A. B., Wright, A. T., Laxmisan, A., Singh, H., & Sittig, D. F. (2011) · Europe PMC (PubMed Central) · Cited by 9
Self-citationCan Hospital Rankings Measure Clinical and Educational Quality?
Philibert, I. (2009) · Academic Medicine · doi:10.1097/acm.0b013e3181939034 · Cited by 8
Diagnostic evaluation of patients presenting with hematuria: An electronic health record-based study
Richards, K. A., Ruiz, V. L., Murphy, D. R., Downs, T. M., Abel, E. J., Jarrard, D. F., & Singh, H. (2017) · Urologic Oncology Seminars and Original Investigations · doi:10.1016/j.urolonc.2017.11.004 · Cited by 9
Self-citationDichlorvos Induced Autoimmune Hepatitis: A Case Report and Review of Literature
Zhao, S. X., Zhang, Q. S., Kong, L., et al. (2015) · Hepatitis Monthly · doi:10.5812/hepatmon.25469 · Cited by 9
“Therefore, a thorough medical history from the patient is very important for the physician in the diagnosis of liver diseases (13).”
BackgroundLeotin, S. (2025) · Journal of Patient Experience · doi:10.1177/23743735251334015 · Cited by 12
A Follow-Up Report Card on Computer-Assisted Diagnosis—the Grade: C+
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Metadata
- Authors
- Singh, H., Naik, A. D., Rao, R., & Petersen, L. A.
- Affiliations
- Michael E. DeBakey VA Medical Center (US)
- Baylor College of Medicine (US)
- Corresponding author
- Singh, Hardeep
- Venue
- Journal of General Internal Medicine
- Published
- 2008-03-29
- Volume
- 23
- Issue
- 4
- Pages
- 489-494
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC2359508
- OpenAlex
- W2086374949
- Semantic Scholar
- 17711845dc04a672bc6ed5878097ed52537953ab
- Cited by
- 162
- References
- 76
- Citations by year
- 2026: 4 · 2025: 8 · 2024: 3 · 2023: 8 · 2022: 2 · 2021: 9 · 2020: 8 · 2019: 6 · 2018: 13 · 2017: 9 · 2016: 9 · 2015: 17 · 2014: 10 · 2013: 7 · 2012: 10
- FWCI
- 8.98
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Journal of General Internal Medicine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Agency for Healthcare Research and Quality
- National Institute on Aging (K23AG027144)
- National Cancer Institute (K23CA125585)
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Keywords
- diagnostic errors, communication breakdown, diagnostic error prevention, medical errors, patient involvement, medical records management, diagnostic process
- MeSH terms
- Diagnostic Errors, Hospital Information Systems, Humans, Interprofessional Relations, Medical Records Systems, Computerized, Biomedical Technology
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-07, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-07 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
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