Frequency of inappropriate medical exceptions to quality measures.
ABSTRACT Quality improvement programs that allow physicians to document medical reasons for deviating from guidelines preserve clinicians' judgment while enabling them to strive for high performance. However, physician misconceptions or gaming potentially limit programs.
To implement computerized decision support with mechanisms to document medical exceptions to quality measures and to perform peer review of exceptions and provide feedback when appropriate.
Large internal medicine practice.
Patients eligible for 1 or more quality measures.
A peer-review panel judged medical exceptions to 16 chronic disease and prevention quality measures as appropriate, inappropriate, or of uncertain appropriateness. Medical records were reviewed after feedback was given to determine whether care changed.
Physicians recorded 650 standardized medical exceptions during 7 months. The reporting tool was used without any medical reason 36 times (5.5%). Of the remaining 614 exceptions, 93.6% were medically appropriate, 3.1% were inappropriate, and 3.3% were of uncertain appropriateness. Frequencies of inappropriate exceptions were 7 (6.9%) for coronary heart disease, 0 (0%) for heart failure, 10 (10.8%) for diabetes, and 2 (0.6%) for preventive services. After physicians received direct feedback about inappropriate exceptions, 8 of 19 (42%) changed management. The peer-review process took less than 5 minutes per case, but for each change in clinical care, 65 reviews were required.
The findings could differ at other sites or if financial incentives were in place.
Physician-recorded medical exceptions were correct most of the time. Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable.
Agency for Healthcare Research and Quality.
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ABSTRACT: The aim of this study was to assess the accuracy of clinician-entered data in imaging clinical decision support (CDS). We used CDS-guided CT angiography (CTA) for pulmonary embolus (PE) in the emergency department as a case example because it required clinician entry of d-dimer results which could be unambiguously compared with actual laboratory values. Of 1296 patients with CTA orders for suspected PE during 2011, 1175 (90.7%) had accurate d-dimer values entered. In 55 orders (4.2%), incorrectly entered data shielded clinicians from intrusive computer alerts, resulting in potential CTA overuse. Remaining data entry errors did not affect user workflow. We found no missed PEs in our cohort. The majority of data entered by clinicians into imaging CDS are accurate. A small proportion may be intentionally erroneous to avoid intrusive computer alerts. Quality improvement methods, including academic detailing and improved integration between electronic medical record and CDS to minimize redundant data entry, may be necessary to optimize adoption of evidence presented through CDS.Journal of the American Medical Informatics Association 07/2013; 21(1). DOI:10.1136/amiajnl-2013-001617 · 3.57 Impact Factor
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ABSTRACT: Many healthcare providers are adopting clinical decision support (CDS) systems to improve patient safety and meet meaningful use requirements. Computerized alerts that prompt clinicians about drug-allergy, drug-drug, and drug-disease warnings or provide dosing guidance are most commonly implemented. Alert overrides, which occur when clinicians do not follow the guidance presented by the alert, can hinder improved patient outcomes.Ochsner Journal 01/2014; 14(2):195-202.