Higher accuracy of complex medication reconciliation through improved design of electronic tools.

Objective: Investigate the accuracy of 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) using a cognitively demanding scenario and complex medication history. Materials and Methods: Seventeen physicians reconciled medication lists for a polypharmacy patient using 2 EHRs in a simulation study. The lists contained 3 types of discrepancy and were transmitted between the systems via a Continuity of Care Document. Participants updated each EHR and their interactions were recorded and analyzed for the number and type of errors. Results: Participants made 748 drug comparisons that resulted in 53 errors (93% accuracy): 12 using EHR2 (3% rate, 0-3 range) and 41 using EHR1 (11% rate, 0-9 range; P < .0001). Twelve clinicians made completely accurate reconciliations with EHR2 (71%) and 6 with EHR1 (35%). Most errors (28, 53%) occurred in medication entries containing discrepancies: 4 in EHR2 and 24 in EHR1 (P = .008). The order in which participants used the EHRs to complete the task did not affect the results. Discussion: Significantly fewer errors were made with EHR2, which presented lists in a side-by-side view, automatically grouped medications by therapeutic class and more effectively identified duplicates. Participants favored this design and indicated that they routinely used several workarounds in EHR1. Conclusion: Accurate assessment of the safety and effectiveness of electronic reconciliation tools requires rigorous testing and should prioritize complex rather than simpler tasks that are currently used for EHR certification and product demonstration. Higher accuracy of reconciliation is likely when tools are designed to better support cognitively demanding tasks.

Accuracy and Completeness of Clinical Coding Using ICD-10 for Ambulatory Visits.

This study describes a simulation of diagnostic coding using an EHR. Twenty-three ambulatory clinicians were asked to enter appropriate codes for six standardized scenarios with two different EHRs. Their interactions with the query interface were analyzed for patterns and variations in search strategies and the resulting sets of entered codes for accuracy and completeness. Just over a half of entered codes were appropriate for a given scenario and about a quarter were omitted. Crohn's disease and diabetes scenarios had the highest rate of inappropriate coding and code variation. The omission rate was higher for secondary than for primary visit diagnoses. Codes for immunization, dialysis dependence and nicotine dependence were the most often omitted. We also found a high rate of variation in the search terms used to query the EHR for the same diagnoses. Changes to the training of clinicians and improved design of EHR query modules may lower the rate of inappropriate and omitted codes.

Small pulmonary nodules: detection at chest CT and outcome.

PURPOSE: To determine the outcome of pulmonary nodules less than 1 cm in diameter detected at chest computed tomography (CT). MATERIALS AND METHODS: Reports of chest CT performed during 6 months were reviewed to find patients with pulmonary nodules smaller than 1 cm in long axis for which repeat CT was recommended. Records were studied to determine whether follow-up had been performed, the initial nodules had changed in size, or nodules had been resected. RESULTS: A total of 3,446 chest CT examinations were performed, with 334 patients meeting inclusion criteria. Three patients underwent nodule resection and had pathologic examination results positive for cancer; 185 underwent follow-up, of whom 13 had results excluded as indeterminate. In the remaining 172 patients, 88 had incomplete characterization because of follow-up of less than 2 years, which left 84 with nodule characterization at follow-up. When these 84 patients were combined with the three patients with nodule resection, the number yielded was 87 patients. Seventy-seven of 87 had benign nodules because of resolution or 2-year stability, and 10 of 87 had malignant nodules because of growth or positive histologic examination results. Nine of 10 with malignant nodules had a known primary neoplasm. CONCLUSION: CT commonly helped identify small nodules. Increase in size occurred infrequently and almost exclusively in patients with a known malignancy.