American College of Physicians: Internal Medicine — Doctors for Adults ®


When data go AWOL: filling the clinical gaps

A first-of-its-kind study found that patient information was missing in 13% of all office visits to 32 Colorado primary care practices

From the May ACP Observer, copyright 2005 by the American College of Physicians.

By Gina Shaw

Some practitioners may have been surprised by study results that appeared in the Feb. 2, 2005, Journal of the American Medical Association (JAMA). This first-of-its-kind study demonstrated that important patient information went missing in more than 13% of patient visits made to 32 Colorado primary care practices—a ratio of almost one out of every seven visits.

But general internist Kirsten Hohmann, FACP, said she'd "long suspected" that clinical information often goes AWOL. A participant in the Colorado study, she doesn't know yet just what her own practice's rate of missing data was. She said she does know, however, that her office's tracking system could be better organized.

"We have limited, simple tracking mechanisms in place," said Dr. Hohmann, who practices at Denver's High Street Primary Care Center, "but we must frequently make clinical decisions in the absence of clinical information."

Dr. Hohmann concluded—as did the Institute of Medicine in its 1999 "To Err is Human" report—that missing clinical information is a potential source of major medical errors. "If you're basing decisions on inadequate information, you may have to do stopgap interventions, continuing a patient on a present regimen until we figure out exactly what's going on," she said. "That delays care and increases the potential for medical error."

A study published in the March 30, 2004, Annals of Family Medicine indicated that as many as 15% of medical errors may be due to missing clinical information. In the Colorado study, based on clinician self-reports, physicians felt patients could be at least "somewhat likely" to suffer an adverse effect because information was missing in 44% of visits where key information couldn't be found.

Missing data

Although Dr. Hohmann and many of her colleagues have worried about the potential danger of information gaps, the JAMA study—authored by lead investigator Peter C. Smith, MD, at the University of Colorado Health Sciences Center in Aurora, Colo.—is the first to directly study missing clinical information in primary care.

"All the emphasis has been on hospital-based problems, error prevention and patient safety issues," said Kwabena Adubofour, FACP, medical director of the East Main Clinic and Stockton Diabetes Intervention Center in Stockton, Calif. "The primary-care setting ought to be receiving the same sort of scrutiny as the hospital environment, because that is where most care is rendered."

According to the JAMA study, several different types of clinical information went missing (See "Clinical information: a look at what's missing.") And while the study didn't directly track the consequences of missing data, more than 59% of the physicians who reported data as missing predicted either a delay in care or the need to order an additional service—such as duplicate images—as a result.

Why does so much information go missing? Part of the problem, Dr. Hohmann said, stems from the fact that many patients see multiple specialists who aren't part of a single integrated health care system. Often, patients return to the primary care office before specialists' notes arrive and patients often can't remember exactly what the specialist prescribed.

Another big gap: missed connections between physician practices and testing labs. That, said Craig Keenan, ACP Member, primary care residency program director and assistant clinical professor at University of California, Davis, represents an important missing piece of the information puzzle.

"Either you order the test—laboratory tests or imaging studies—and you never actually know whether the patient got the test and the results are back," Dr. Keenan said, "or there's an abnormal test, like a mammogram, that needs follow-up in three months, and nobody checks back to make sure it was done." Given the fact that most primary care physicians have between 2,000 and 3,000 patients, he added, "it's impossible to keep track of it all unless you have a system."

Another major cause is the constant churning of health care benefits, with many patients switching health plans on almost a yearly basis.

"We have such a patchwork of health insurance in this country, all using the laboratories and pharmacies of their choice, that the integration of a medical record for any physician is going to be well nigh impossible," said Ashok V. Daftary, FACP, assistant medical director of Sutter-Gould Medical Group in Stockton, Calif.

In fact, the Colorado study found that the practices that had the least amount of missing data were those in rural settings. (No other factors—including practice size or the presence of residents—made significant differences in the level of missing information.) Dr. Smith, the study author, speculated that "there are fewer 'cooks in the kitchen' in rural areas, and fewer insurers." That makes it easier to share data and leaves fewer chances for those data to go missing.

The e-practice solution?

One seemingly obvious solution to missing clinical information would be an electronic medical record (EMR) system.

Dr. Daftary, for one, is thrilled with Sutter Health's system, which sends his patients' lab results directly to his inbox with a link to the patient's EMR.

"I can look through all the labs and flag the ones that require immediate attention," he says. When it comes to using warfarin, for instance, "for patients who have subtherapeutic times, I can leave a message for my medical assistant to call the patient and have that readjusted." All messages become part of the EMR, he added, making it much easier to follow up on test results.

Dr. Smith's study found that clinicians with a fully integrated EMR were significantly less likely to report missing clinical information. But that's not the whole story.

"If there were, say, 10 doctors in the practice, and six of them said they had a full EMR while four thought they had a partial EMR, that didn't confer any protection," he said. "We interpreted that to mean that a system is only as good as its implementation and people's familiarity with it."

Keith Michl, FACP, agreed. In his general internal medicine and geriatrics practice in Bennington, Vt., he's been using an EMR for the past six to seven years—but his office still uses paper.

"My EMR system has a lot of strengths: good clinical documentation is one of them, while the ability to track lab tests that have been ordered is not," he said. "We still have other manual and electronic systems in our office to track certain things."

Dr. Michl uses the EMR exclusively in patient visits, but he still assigns a staff member the task of sorting reports from labs and imaging centers. And in his anticoagulation clinic, when a patient who's being treated with warfarin has a prothrombin time blood test performed, the lab technician still follows up to track the test results and make sure they're acted upon.

"We can use the EMR to enter the lab information into the chart," he said, "but one of the problems is that our reference laboratory results can't yet be ported into our electronic medical record, because the hospital's lab system doesn't have an interface with my EMR."

Dr. Daftary acknowledged that the best of systems can be flummoxed by these limitations. Although Sutter's is largely a closed system, about 25% of its patients use external labs and pharmacies—with results that must be scanned into the EMR.

Old-fashioned tracking

Until interoperability becomes a reality, experts say physicians need to rely on old-fashioned systems to follow results.

Dr. Keenan said that when he worked in a small practice in a satellite Veterans Affairs clinic, he used a simple paper-based desk calendar. "Each day, I would write down what tests I'd ordered and make a note on the day that I expected to get those results back," he said. "If I didn't get it back, I'd contact the patient. I had a big, long yellow pad for Pap smears and mammograms, which was time-consuming but necessary."

In Colorado, Dr. Smith said his practice is making changes in the way it tracks patient data. "We've begun using a dedicated, secure e-mail system that is also available to many specialists we use to help us communicate better," he says. "Time will tell if it makes a difference."

According to Dr. Smith, investing in a good systems design upfront can save much more time and money—and reduce errors—down the road. "Think about what information is going out of and coming into your practice and from where, and create a system that captures all that data and properly routes," he said. "You need to include some redundancies and failsafes. Then evaluate that system periodically to make sure it still meets your needs."

Here are some other low-tech solutions:

  • Put tracking policies in writing. "Sadly, many policies are written but not followed," noted Dr. Smith. "But from the perspectives of patient safety, customer service and risk management, the data are pretty obvious that it is important to have clear, written guidelines in your practice."

  • Do advance work. In Dr. Adubofour's office, the entire staff meets first thing in the morning in a "daily huddle" to discuss every patient on the schedule.

    "During the previous day or two, the staff will have pulled the charts of patients who are already in the system," he explained. "If the patient is coming in to discuss lab results, we'll make sure those results are already noted in the chart. If not, we'll make phone calls to whatever lab that patient went to." When physicians suspect that a lab result may be crucial, a red sheet is filled out and attached to the front of the patient chart.

  • Don't file anything before a doctor has seen it. That's the rule at Dr. Adubofour's practice. "Everyone in the clinic knows that any lab result received has to be placed in a central location until a clinician has signed off on it," he says. "On a daily basis, I look through them and sign them before they're filed away."

  • Check medications at each visit. Many physician offices ask patients to periodically bring in all their medications so physicians can make sure the medication record is up to date.

    But, said Dr. Adubofour, "you won't get an up-to-date list unless your clinic policy is to have everybody bring in their medications for every single visit.

  • Call with all results. Avoid the "no news is good news" approach to lab results. Instead, ask patients to contact the office at a prearranged time. "When they call, you're reminded to pull the lab results and check on them," Dr. Adubofour said. "You're recruiting the patient to be on your side."

  • Promote patient involvement. Getting patients more invested in their own health care information is an important part of the solution, said Dr. Hohmann. "Encourage patients not to leave office or emergency room visits without some kind of access to information about that visit," she said.

    And keep in mind that any recordkeeping or information-tracking system that only one or two people can use isn't very practical. What happens when they go on vacation?

Dr. Adubofour suggests a "rotation system" in which everyone in the practice knows how to do each other's work, including tracking clinical information. Likewise, all the physicians in a practice should use information systems in a consistent way.

"For tracking information, I've learned that you have to make the system the same for everyone, even though it may not be exactly the way everyone wants it," said Dr. Keenan. "You need a system that's foolproof for everyone, not just for some individuals."

Gina Shaw is a freelance health care writer based in Montclair, N.J.


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