Missing medical information adversely affects care of patients
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《英国医生杂志》
Missing clinical information on patients is common in the United States and may adversely affect the patients?health care, according to a study in JAMA (2005;293:565-71).
The authors, citing an article in the BMJ (1996;313:1062-8), wrote that managing clinical information effectively is an essential part of all medical care. But information on patients such as demographic data, medical history, treatments, test results, and family structure is often unavailable when a doctor greatly needs it, they say.
Peter Smith and colleagues at the University of Colorado Health Sciences Center surveyed 253 primary care clinicians during 1614 patients?visits between May and December 2003. For every visit during one half day session, each clinician completed a questionnaire about the characteristics of the patients and the visits and stated whether important clinical information had been missing.
"This is the first direct study of missing clinical information in primary care, in contrast to retrospective detection of missing information as the aetiology of a medical error or adverse event. It demonstrates reports of a high frequency of missing important clinical information, with a wide array of potential impact on patient care," the authors wrote.
The researchers found that clinicians reported missing clinical information, such as laboratory test results, letters, medical history, or treatment details, in 13.6% of visits, with laboratory results and letters being the most difficult to locate. Over half of the missing information was reported to be located outside their clinical system but available within the country. Forty four per cent of missing data were shown to be likely to adversely affect patients and 59.5% likely to result in delayed care.
The time spent unsuccessfully searching for missing information was found to be an important factor, with more than 10% of searches taking more than 10 minutes. Patients who were new or had several medical problems seemed to exacerbate the problem. But patients who were recent immigrants were the group with the largest number of such problems and were 80% more likely than other groups to have missing clinical information. Rural practices were 48% less likely to have missing information, and fully electronic records reduced the chances of information going missing by 60%.
Regulations on confidentiality, decentralised medical systems, poor communication among professionals, the transfer of patients?care around different settings, and the rapid turnover of patients?insurance plans were blamed for the poor management of patients?information.
The authors concluded: "If validated by future research, these results could have serious implications for the 220 million primary care visits that occur in the United States each year."
In an accompanying editorial Dr Nancy Elder of the University of Cincinnati, Ohio, and Dr John Hickner of the University of Chicago, wrote: "The first step toward improvement is awareness that a problem exists, and this study, along with the work of others, should engender a state of mindfulness about the frequent occurrence and importance of missing clinical information. Patient care is a team sport, and clinicians, patients, and family should be members of the team. Just as physicians strive to communicate effectively with patients, equal effort must be made to communicate effectively with all those involved in the care of patients."(London Kunal Khanna)
The authors, citing an article in the BMJ (1996;313:1062-8), wrote that managing clinical information effectively is an essential part of all medical care. But information on patients such as demographic data, medical history, treatments, test results, and family structure is often unavailable when a doctor greatly needs it, they say.
Peter Smith and colleagues at the University of Colorado Health Sciences Center surveyed 253 primary care clinicians during 1614 patients?visits between May and December 2003. For every visit during one half day session, each clinician completed a questionnaire about the characteristics of the patients and the visits and stated whether important clinical information had been missing.
"This is the first direct study of missing clinical information in primary care, in contrast to retrospective detection of missing information as the aetiology of a medical error or adverse event. It demonstrates reports of a high frequency of missing important clinical information, with a wide array of potential impact on patient care," the authors wrote.
The researchers found that clinicians reported missing clinical information, such as laboratory test results, letters, medical history, or treatment details, in 13.6% of visits, with laboratory results and letters being the most difficult to locate. Over half of the missing information was reported to be located outside their clinical system but available within the country. Forty four per cent of missing data were shown to be likely to adversely affect patients and 59.5% likely to result in delayed care.
The time spent unsuccessfully searching for missing information was found to be an important factor, with more than 10% of searches taking more than 10 minutes. Patients who were new or had several medical problems seemed to exacerbate the problem. But patients who were recent immigrants were the group with the largest number of such problems and were 80% more likely than other groups to have missing clinical information. Rural practices were 48% less likely to have missing information, and fully electronic records reduced the chances of information going missing by 60%.
Regulations on confidentiality, decentralised medical systems, poor communication among professionals, the transfer of patients?care around different settings, and the rapid turnover of patients?insurance plans were blamed for the poor management of patients?information.
The authors concluded: "If validated by future research, these results could have serious implications for the 220 million primary care visits that occur in the United States each year."
In an accompanying editorial Dr Nancy Elder of the University of Cincinnati, Ohio, and Dr John Hickner of the University of Chicago, wrote: "The first step toward improvement is awareness that a problem exists, and this study, along with the work of others, should engender a state of mindfulness about the frequent occurrence and importance of missing clinical information. Patient care is a team sport, and clinicians, patients, and family should be members of the team. Just as physicians strive to communicate effectively with patients, equal effort must be made to communicate effectively with all those involved in the care of patients."(London Kunal Khanna)