… to improve validity of research developed from EHR data. … Kostopoulou O, Tracey C, Delaney BC. Can decision support combat incompleteness and …

The recent National Academy of Medicine report on improving diagnosis cited the need for enhanced clinical decision support. This pre–post study used a simulation approach (standardized patients) to compare visits with and without use of a diagnostic clinical decision aid embedded in the electronic health record. The patients' visit satisfaction ratings did not differ in the visits with and without the decision support, although more patients in the decision support group noted that physicians focused more on the computer than the patient. The physicians reported high overall satisfaction with the decision tool, but they noted that it required inputting more clinical documentation during the visit, resulting in more time directed at the electronic health record. The authors conclude that the clinical decision support tool interface should be improved in order to facilitate adoption of real-time diagnostic support.

Improving diagnosis in outpatient care is a patient safety priority. This simulation study evaluated the process of diagnosis in the primary care setting. Investigators contrasted physicians' diagnostic accuracy conducting a primary care visit in their usual manner versus using a clinical decision support tool. Each visit employed a standardized patient (an actor reporting symptoms consistent with a given diagnosis) and the visits with and without decision support were matched for complexity. The tool improved diagnostic accuracy significantly: 68% of visits using decision support reached the correct diagnosis versus 59% of usual care visits. The duration of visits and number of subspecialty consultations did not change with or without decision support. Physician participants rated the usability of the decision support tool favorably overall. These data suggest that decision support can be feasibly integrated into primary care to improve diagnostic accuracy.

In this Greek study, providing early support (consisting of possible diagnoses for clinicians to consider) to primary care physicians improved their diagnostic accuracy on computerized vignettes. This finding matches a previous study that used the same methodology for primary care physicians in the United Kingdom, suggesting the intervention may have broad applicability.

Using simulated patient scenarios, this study found evidence for confirmation bias in the diagnostic reasoning process of family physicians.

This systematic review of 21 published studies found that missed diagnoses in primary care could often be attributed to atypical or nonspecific presentations. This is in contrast to a study of closed malpractice claims, in which system problems contributed to a majority of outpatient missed or delayed diagnoses.

This observational study analyzed nearly 80 reported events, many of which were near misses, and found that failures in cognitive activity often created the potential for harm. In addition to promoting the implementation of accepted ambulatory-based safety practices, the authors advocate for greater research on the relationship between clinical and administrative decision-making and adverse events.