Hardeep Singh

Publications of Hardeep Singh

• Electronic health record-based messages to primary care providers: valuable information or just noise?

  Authors: Daniel R Murphy, Brian Reis, Himabindu Kadiyala, Kamal Hirani, Dean F Sittig, Myrna M Khan, Hardeep Singh

  Archives of internal medicine. 02/2012; 172(3):283-5.

• Rights and responsibilities of users of electronic health records.

  Authors: Dean F Sittig, Hardeep Singh

  CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 02/2012;

• Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis.

  Authors: Daniel R Murphy, Brian Reis, Dean F Sittig, Hardeep Singh

  The American journal of medicine. 02/2012; 125(2):209.e1-7.

  Asynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer "pop-up" messages are understudied. OurAsynchronous electronic health record (EHR)-based alerts used to notify practitioners via an inbox-like format rather than through synchronous computer "pop-up" messages are understudied. Our objective was to create an asynchronous alert taxonomy and measure the impact of different alert types on practitioner workload. We quantified and categorized asynchronous alerts according to the information they conveyed and conducted a time-motion analysis to assess practitioner workload. We reviewed alert information transmitted to all 47 primary care practitioners (PCPs) at a large, tertiary care Veterans Affairs facility over 4 evenly spaced 28-day periods. An interdisciplinary team used content analysis to categorize alerts according to their conveyed information. We then created an alert taxonomy and used it to calculate the mean number of alerts of each type PCPs received each day. We conducted a time-motion study of 26 PCPs while they processed their alerts. We used these data to estimate the uninterrupted time practitioners spend processing alerts each day. We extracted 295,792 asynchronously generated alerts and created a taxonomy of 33 alert types categorized under 6 major categories: Test Results, Referrals, Note-Based Communication, Order Status, Patient Status Changes, and Incomplete Task Reminders. PCPs received a mean of 56.4 alerts/day containing new information. Based on 749 observed alert processing episodes, practitioners spent an estimated average of 49 minutes/day processing their alerts. PCPs receive a large number of EHR-based asynchronous alerts daily and spend significant time processing them. The utility of transmitting large quantities and varieties of alerts to PCPs warrants further investigation.

• Electronic health record-based surveillance of diagnostic errors in primary care.

  Authors: Hardeep Singh, Traber Davis Giardina, Samuel N Forjuoh, Michael D Reis, Steven Kosmach, Myrna M Khan, Eric J Thomas

  BMJ quality & safety. 02/2012; 21(2):93-100.

  Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary careDiagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice. The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer. Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44)). While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

• System-related interventions to reduce diagnostic errors: a narrative review.

  Authors: Hardeep Singh, Mark L Graber, Stephanie M Kissam, Asta V Sorensen, Nancy F Lenfestey, Elizabeth M Tant, Kerm Henriksen, Kenneth A LaBresh

  BMJ quality & safety. 11/2011; 21(2):160-70.

  Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recentDiagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors. The authors conducted a comprehensive search using multiple search strategies. First, they performed a PubMed search to identify articles exclusively related to diagnostic error or delay published in English between 2000 and 2009. They then sought papers from references in the initial dataset, searches of additional databases, and subject matter experts. Articles were included if they formally evaluated an intervention to prevent or reduce diagnostic error; however, papers were also included if interventions were suggested and not tested to inform the state of the science on the subject. Interventions were characterised according to the step in the diagnostic process they targeted: patient-provider encounter; performance and interpretation of diagnostic tests; follow-up and tracking of diagnostic information; subspecialty and referral-related issues; and patient-specific care-seeking and adherence processes. 43 articles were identified for full review, of which six reported tested interventions and 37 contained suggestions for possible interventions. Empirical studies, although somewhat positive, were non-experimental or quasi-experimental and included a small number of clinicians or healthcare sites. Outcome measures in general were underdeveloped and varied markedly among studies, depending on the setting or step in the diagnostic process. Despite a number of suggested interventions in the literature, few empirical studies in the past decade have tested interventions to reduce diagnostic errors. Advancing the science of diagnostic error prevention will require more robust study designs and rigorous definitions of diagnostic processes and outcomes to measure intervention effects.

• Should patients get direct access to their laboratory test results? An answer with many questions.

  Authors: Traber Davis Giardina, Hardeep Singh

  JAMA : the journal of the American Medical Association. 11/2011; 306(22):2502-3.

• Creating an oversight infrastructure for electronic health record-related patient safety hazards.

  Authors: Hardeep Singh, David C Classen, Dean F Sittig

  Journal of patient safety. 11/2011; 7(4):169-74.

  Electronic health records (EHRs) have potential quality and safety benefits. However, reports of EHR-related safety hazards are now emerging. The Office of the National Coordinator for HealthElectronic health records (EHRs) have potential quality and safety benefits. However, reports of EHR-related safety hazards are now emerging. The Office of the National Coordinator for Health Information Technology recently sponsored an Institute of Medicine committee to evaluate how health information technology use affects patient safety. In this article, we propose the creation of a national EHR oversight program to provide dedicated surveillance of EHR-related safety hazards and to promote learning from identified errors, close calls, and adverse events. The program calls for data gathering, investigation/analysis, and regulatory components. The first 2 functions will depend on institution-level EHR safety committees that will investigate all known EHR-related adverse events and near-misses and report them nationally using standardized methods. These committees should also perform routine safety self-assessments to proactively identify new risks. Nationally, we propose the long-term creation of a centralized, nonpartisan board with an appropriate legal and regulatory infrastructure to ensure the safety of EHRs. We discuss the rationale of the proposed oversight program and its potential organizational components and functions. These include mechanisms for robust data collection and analyses of all safety concerns using multiple methods that extend beyond reporting, multidisciplinary investigation of selected high-risk safety events, and enhanced coordination with other national agencies to facilitate broad dissemination of hazards information. Implementation of this proposed infrastructure can facilitate identification of EHR-related adverse events and errors and potentially create a safer and more effective EHR-based health care delivery system.

• Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

  Authors: Michal Tamuz, Traber Davis Giardina, Eric J Thomas, Shailaja Menon, Hardeep Singh

  Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 10/2011; 6(8):445-52.

  Inadequate supervision is a significant contributing factor to medical errors involving trainees, but supervision in high-risk settings such as the intensive care unit (ICU) is not well studied. WeInadequate supervision is a significant contributing factor to medical errors involving trainees, but supervision in high-risk settings such as the intensive care unit (ICU) is not well studied. We explored how residents in the ICU experienced supervision related to medication safety, not only from supervising physicians but also from other professionals. DESIGN, SETTING, MEASUREMENTS: Using qualitative methods, we examined in-depth interviews with 17 residents working in ICUs of three tertiary-care hospitals. We analyzed residents' perspectives on receiving and initiating supervision from physicians within the traditional medical hierarchy, and from other professionals, including nurses, staff pharmacists, and clinical pharmacists ("interprofessional supervision"). While initiating their own supervision within the traditional hierarchy, residents believed in seeking assistance from fellows and attendings, and articulated rules of thumb for doing so; however, they also experienced difficulties. Some residents were concerned that their questions would reflect poorly on them; others were embarrassed by their mistaken decisions. Conversely, residents described receiving interprofessional supervision from nurses and pharmacists, who proactively monitored, intervened in, and guided residents' decisions. Residents relied on nurses and pharmacists for nonjudgmental answers to their queries, especially after-hours. To enhance both types of supervision, residents emphasized the importance of improving interpersonal communication skills. Residents depended on interprofessional supervision when making decisions regarding medications in the ICU. Improving interprofessional supervision, which thus far has been underrecognized and underemphasized in graduate medical education, can potentially improve medication safety in high-risk settings.

• Exploring situational awareness in diagnostic errors in primary care.

  Authors: Hardeep Singh, Traber Davis Giardina, Laura A Petersen, Michael W Smith, Lindsey Wilson Paul, Key Dismukes, Gayathri Bhagwath, Eric J Thomas

  BMJ quality & safety. 09/2011; 21(1):30-8.

  Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs),Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs), this study explored the use of the situational awareness (SA) framework from aviation human factors research. A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the USA. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process. Of 254 cases meeting inclusion criteria, errors were found in 30 of 92 (32.6%) lung cancer cases and 56 of 167 (33.5%) colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, application of the SA framework provided insight into processes involved in attention management. A framework of SA can help analyse and understand diagnostic errors in primary care settings that use EHRs.

• Towards successful coordination of electronic health record based-referrals: a qualitative analysis.

  Authors: Sylvia J Hysong, Adol Esquivel, Dean F Sittig, Lindsey A Paul, Donna Espadas, Simran Singh, Hardeep Singh

  Implementation science : IS. 07/2011; 6:84.

  ABSTRACT: Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may beABSTRACT: Successful subspecialty referrals require considerable coordination and interactive communication among the primary care provider (PCP), the subspecialist, and the patient, which may be challenging in the outpatient setting. Even when referrals are facilitated by electronic health records (EHRs) (i.e., e-referrals), lapses in patient follow-up might occur. Although compelling reasons exist why referral coordination should be improved, little is known about which elements of the complex referral coordination process should be targeted for improvement. Using Okhuysen & Bechky's coordination framework, this paper aims to understand the barriers, facilitators, and suggestions for improving communication and coordination of EHR-based referrals in an integrated healthcare system. We conducted a qualitative study to understand coordination breakdowns related to e-referrals in an integrated healthcare system and examined work-system factors that affect the timely receipt of subspecialty care. We conducted interviews with seven subject matter experts and six focus groups with a total of 30 PCPs and subspecialists at two tertiary care Department of Veterans Affairs (VA) medical centers. Using techniques from grounded theory and content analysis, we identified organizational themes that affected the referral process. Four themes emerged: lack of an institutional referral policy, lack of standardization in certain referral procedures, ambiguity in roles and responsibilities, and inadequate resources to adapt and respond to referral requests effectively. Marked differences in PCPs' and subspecialists' communication styles and individual mental models of the referral processes likely precluded the development of a shared mental model to facilitate coordination and successful referral completion. Notably, very few barriers related to the EHR were reported. Despite facilitating information transfer between PCPs and subspecialists, e-referrals remain prone to coordination breakdowns. Clear referral policies, well-defined roles and responsibilities for key personnel, standardized procedures and communication protocols, and adequate human resources must be in place before implementing an EHR to facilitate referrals.

• Defining health information technology-related errors: new developments since to err is human.

  Authors: Dean F Sittig, Hardeep Singh

  Archives of internal medicine. 07/2011; 171(14):1281-4.

  Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recentlyDespite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives.

• Primary care and communication in shared cancer care: a qualitative study.

  Authors: Yvonne H Sada, Richard L Street, Hardeep Singh, Rachel E Shada, Aanand D Naik

  The American journal of managed care. 04/2011; 17(4):259-65.

  To explore perceptions of primary care physicians' (PCPs') and oncologists' roles, responsibilities, and patterns of communication related to shared cancer care in 3 integrated health systems thatTo explore perceptions of primary care physicians' (PCPs') and oncologists' roles, responsibilities, and patterns of communication related to shared cancer care in 3 integrated health systems that used electronic health records. Qualitative study. We conducted semistructured interviews with 10 patients having early-stage colorectal cancer and with 14 oncologists and PCPs. Sample sizes were determined by thematic saturation. Dominant themes and codes were identified and subsequently applied to all transcripts. Physicians reported that electronic health records improved communication within integrated systems but that communication with physicians outside of their system was still difficult. Primary care physicians expressed uncertainty about their role during cancer care, although medical oncologists emphasized the importance of comorbidity control during cancer treatment. Patients and physicians described additional roles for PCPs, including psychological distress support and behavior modification counseling. Integrated systems that use electronic health records likely facilitate shared cancer care through improved PCP-oncologist communication. However, strategies to promote a more active role for PCPs in managing comorbidities, psychological distress, and behavior modification, as well as to overcome communication challenges between physicians not practicing within the same integrated system, are still needed to improve shared cancer care.

• Legal, ethical, and financial dilemmas in electronic health record adoption and use.

  Authors: Dean F Sittig, Hardeep Singh

  Pediatrics. 03/2011; 127(4):e1042-7.

  Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten theElectronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.

• Summarization of clinical information: a conceptual model.

  Authors: Joshua C Feblowitz, Adam Wright, Hardeep Singh, Lipika Samal, Dean F Sittig

  Journal of biomedical informatics. 03/2011; 44(4):688-99.

  To provide high-quality and safe care, clinicians must be able to optimally collect, distill, and interpret patient information. Despite advances in text summarization, only limited research existsTo provide high-quality and safe care, clinicians must be able to optimally collect, distill, and interpret patient information. Despite advances in text summarization, only limited research exists on clinical summarization, the complex and heterogeneous process of gathering, organizing and presenting patient data in various forms. To develop a conceptual model for describing and understanding clinical summarization in both computer-independent and computer-supported clinical tasks. Based on extensive literature review and clinical input, we developed a conceptual model of clinical summarization to lay the foundation for future research on clinician workflow and automated summarization using electronic health records (EHRs). Our model identifies five distinct stages of clinical summarization: (1) Aggregation, (2) Organization, (3) Reduction and/or Transformation, (4) Interpretation and (5) Synthesis (AORTIS). The AORTIS model describes the creation of complex, task-specific clinical summaries and provides a framework for clinical workflow analysis and directed research on test results review, clinical documentation and medical decision-making. We describe a hypothetical case study to illustrate the application of this model in the primary care setting. Both practicing physicians and clinical informaticians need a structured method of developing, studying and evaluating clinical summaries in support of a wide range of clinical tasks. Our proposed model of clinical summarization provides a potential pathway to advance knowledge in this area and highlights directions for further research.

• Follow-up actions on electronic referral communication in a multispecialty outpatient setting.

  Authors: Hardeep Singh, Adol Esquivel, Dean F Sittig, Daniel Murphy, Himabindu Kadiyala, Rachel Schiesser, Donna Espadas, Laura A Petersen

  Journal of general internal medicine. 01/2011; 26(1):64-9.

  Electronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronicElectronic health records (EHR) enable transmission and tracking of referrals between primary-care practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

• Understanding the management of electronic test result notifications in the outpatient setting.

  Authors: Sylvia J Hysong, Mona K Sawhney, Lindsey Wilson, Dean F Sittig, Adol Esquivel, Simran Singh, Hardeep Singh

  BMC medical informatics and decision making. 01/2011; 11:22.

  Notifying clinicians about abnormal test results through electronic health record (EHR) -based "alert" notifications may not always lead to timely follow-up of patients. We sought to understandNotifying clinicians about abnormal test results through electronic health record (EHR) -based "alert" notifications may not always lead to timely follow-up of patients. We sought to understand barriers, facilitators, and potential interventions for safe and effective management of abnormal test result delivery via electronic alerts. We conducted a qualitative study consisting of six 6-8 member focus groups (N = 44) at two large, geographically dispersed Veterans Affairs facilities. Participants included full-time primary care providers, and personnel representing diagnostic services (radiology, laboratory) and information technology. We asked participants to discuss barriers, facilitators, and suggestions for improving timely management and follow-up of abnormal test result notifications and encouraged them to consider technological issues, as well as broader, human-factor-related aspects of EHR use such as organizational, personnel, and workflow. Providers reported receiving a large number of alerts containing information unrelated to abnormal test results, many of which were believed to be unnecessary. Some providers also reported lacking proficiency in use of certain EHR features that would enable them to manage alerts more efficiently. Suggestions for improvement included improving display and tracking processes for critical alerts in the EHR, redesigning clinical workflow, and streamlining policies and procedures related to test result notification. Providers perceive several challenges for fail-safe electronic communication and tracking of abnormal test results. A multi-dimensional approach that addresses technology as well as the many non-technological factors we elicited is essential to design interventions to reduce missed test results in EHRs.

• A prototype knowledge base and SMART app to facilitate organization of patient medications by clinical problems.

  Authors: Allison B McCoy, Adam Wright, Archana Laxmisan, Hardeep Singh, Dean F Sittig

  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 01/2011; 2011:888-94.

  Increasing use of electronic health records requires comprehensive patient-centered views of clinical data. We describe a prototype knowledge base and SMART app that facilitates organization ofIncreasing use of electronic health records requires comprehensive patient-centered views of clinical data. We describe a prototype knowledge base and SMART app that facilitates organization of patient medications by clinical problems, comprising a preliminary step in building such patient-centered views. The knowledge base includes 7,164,444 distinct problem-medication links, generated from RxNorm, SNOMED CT, and NDF-RT within the UMLS Metathesaurus. In an evaluation of the knowledge base applied to 5000 de-identified patient records, 22.4% of medications linked to an entry in the patient's active problem list, compared to 32.6% of medications manually linked by providers; 46.5% of total links were unique to the knowledge base, not added by providers. Expert review of a random patient subset estimated a sensitivity of 37.1% and specificity of 98.9%. The SMART API successfully utilized the knowledge base to generate problem-medication links for test patients. Future work is necessary to improve knowledge base sensitivity and efficiency.

• The reply.

  Authors: Hardeep Singh, Laura A Petersen, Eric J Thomas, Lindsey Wilson, Dean F Sittig

  The American journal of medicine. 10/2010; 123(10):e21.

• Reducing referral delays in colorectal cancer diagnosis: is it about how you ask?

  Authors: Hardeep Singh, Laura A Petersen, Kuang Daci, Clyde Collins, Myrna Khan, Hashem B El-Serag

  Quality & safety in health care. 10/2010; 19(5):e27.

  Delays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised providerDelays in colorectal cancer (CRC) diagnosis related to colonoscopy referrals are not well studied. The authors tested whether certain details of information transmitted through computerised provider order entry (CPOE)-based referrals affected timeliness of diagnostic colonoscopy for patients with newly diagnosed CRC. The authors studied a 6-year cohort of all newly diagnosed patients with CRC at a large tertiary care Veterans Affairs hospital and its affiliated multispecialty clinics. Referring providers included primary care clinicians, resident trainees and other specialists. From the colonoscopy referral preceding CRC diagnosis, the authors determined request date, type and frequency of diagnostic clues provided (symptoms, signs, test results), notation of urgency, and documented evidence of verbal contact between referring provider and consultant to expedite referral. The authors compared distributions of proportions of diagnostic clues between patients with a lag of >60 and ≤60 day, and examined predictors of lag time. Of 367 electronic referrals identified with a median lag of 57 days, 178 (48.5%) had a lag of >60 days. Referrals associated with longer lag times included those with 'positive faecal occult blood test' (92 days, p<0.0001), 'haematochesia' (75 days, p=0.02), 'history of polyps' (221 days, p=0.0006) and when 'screening' (vs specific symptoms) was given as the reason for diagnostic colonoscopy (203 days, p=0.002). Independent predictors of shorter wait times included three diagnostic clues, notation of urgency and documentation of verbal contact. Attention to certain details of diagnostic information provided to consultants through CPOE-based referrals may help reduce delays in CRC diagnosis.

• A new sociotechnical model for studying health information technology in complex adaptive healthcare systems.

  Authors: Dean F Sittig, Hardeep Singh

  Quality & safety in health care. 10/2010; 19 Suppl 3:i68-74.

  Conceptual models have been developed to address challenges inherent in studying health information technology (HIT). This manuscript introduces an eight-dimensional model specifically designed toConceptual models have been developed to address challenges inherent in studying health information technology (HIT). This manuscript introduces an eight-dimensional model specifically designed to address the sociotechnical challenges involved in design, development, implementation, use and evaluation of HIT within complex adaptive healthcare systems. The eight dimensions are not independent, sequential or hierarchical, but rather are interdependent and inter-related concepts similar to compositions of other complex adaptive systems. Hardware and software computing infrastructure refers to equipment and software used to power, support and operate clinical applications and devices. Clinical content refers to textual or numeric data and images that constitute the 'language' of clinical applications. The human--computer interface includes all aspects of the computer that users can see, touch or hear as they interact with it. People refers to everyone who interacts in some way with the system, from developer to end user, including potential patient-users. Workflow and communication are the processes or steps involved in ensuring that patient care tasks are carried out effectively. Two additional dimensions of the model are internal organisational features (eg, policies, procedures and culture) and external rules and regulations, both of which may facilitate or constrain many aspects of the preceding dimensions. The final dimension is measurement and monitoring, which refers to the process of measuring and evaluating both intended and unintended consequences of HIT implementation and use. We illustrate how our model has been successfully applied in real-world complex adaptive settings to understand and improve HIT applications at various stages of development and implementation.