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Charting Diagnostic Safety: Exploring Patient-Provider Discordance in Medical Record Documentation.

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Area of Science:

  • Health Informatics
  • Patient Safety
  • Diagnostic Accuracy

Background:

  • The 21st Century Cures Act facilitates patient access to medical records.
  • This access presents opportunities for patient engagement in diagnostics.

Purpose of the Study:

  • To assess the agreement between patient-reported diagnostic concerns and clinician interpretations in electronic health records.
  • To identify discrepancies in understanding the diagnostic process between patients and clinicians.

Main Methods:

  • Mixed-methods analysis of 467 patients using the Safer Dx Patient instrument.
  • Qualitative content analysis of open-ended responses and clinician notes.
  • Independent chart reviews by blinded clinical reviewers using the Revised Safer Dx Instrument.
  • Multivariate logistic regression to compare patient-reported and clinician-identified concerns.

Main Results:

  • Chart review identified 31 diagnostic concerns; only 21.5% overlapped with 51 patient-reported concerns.
  • Qualitative analysis revealed differing patient-clinician understanding of diagnostic processes.
  • Clinician-identified concerns correlated with patients feeling incorrectly diagnosed (OR 1.65).

Conclusions:

  • Patients and clinicians exhibit distinct mental models regarding diagnostic concerns.
  • Integrating patient perspectives is crucial for enhancing diagnostic safety measurement.