Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial.

Importance: Contextualizing care is a process of incorporating information about the life circumstances and behavior of individual patients, termed contextual factors, into their plan of care. In 4 steps, clinicians recognize clues (termed contextual red flags), clinicians ask about them (probe for context), patients disclose contextual factors, and clinicians adapt care accordingly. The process is associated with a desired outcome resolution of the presenting contextual red flag. Objective: To determine whether contextualized clinical decision support (CDS) tools in the electronic health record (EHR) improve clinician contextual probing, attention to contextual factors in care planning, and the presentation of contextual red flags. Design, Setting, and Participants: This randomized clinical trial was performed at the primary care clinics of 2 academic medical centers with different EHR systems. Participants were adults 18 years or older consenting to audio record their visits and their physicians between September 6, 2018, and March 4, 2021. Patients were randomized to an intervention or a control group. Analyses were performed on an intention-to-treat basis. Interventions: Patients completed a previsit questionnaire that elicited contextual red flags and factors and appeared in the clinician's note template in a contextual care box. The EHR also culled red flags from the medical record, included them in the contextual care box, used passive and interruptive alerts, and proposed relevant orders. Main Outcomes and Measures: Proportion of contextual red flags noted at the index visit that resolved 6 months later (primary outcome), proportion of red flags probed (secondary outcome), and proportion of contextual factors addressed in the care plan by clinicians (secondary outcome), adjusted for study site and for multiple red flags and factors within a visit. Results: Four hundred fifty-two patients (291 women [65.1%]; mean [SD] age, 55.6 [15.1] years) completed encounters with 39 clinicians (23 women [59.0%]). Contextual red flags were not more likely to resolve in the intervention vs control group (adjusted odds ratio [aOR], 0.96 [95% CI, 0.57-1.63]). However, the intervention increased both contextual probing (aOR, 2.12 [95% CI, 1.14-3.93]) and contextualization of the care plan (aOR, 2.67 [95% CI, 1.32-5.41]), controlling for whether a factor was identified by probing or otherwise. Across study groups, contextualized care plans were more likely than noncontextualized plans to result in improvement in the presenting red flag (aOR, 2.13 [95% CI, 1.38-3.28]). Conclusions and Relevance: This randomized clinical trial found that contextualized CDS did not improve patients' outcomes but did increase contextualization of their care, suggesting that use of this technology could ultimately help improve outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03244033.

Impact of an unannounced standardized veteran program on access to community-based services for veterans experiencing homelessness.

BACKGROUND: The United States Department of Veterans Affairs established a program in which actors incognito portray veterans experiencing homelessness with pre-determined needs to identify barriers to access and services at community-based organizations. METHODS: From 2017 to 2019, actors who varied in gender, skin color and age portrayed one of three scripts at all VA Community-Based Resource and Referral Centers (CRRCs) serving veterans experiencing homelessness in 30 cities and completed an evaluative survey. They carried authentic VA identification and were registered in a VA patient database for each identity. CRRCs were provided with reports annually and asked to implement corrective plans. Data from the survey were analysed for change over time. RESULTS: Access to food, counselling, PTSD treatment, and hypertension/prediabetes care services increased significantly from 68-77% in year 2 to 83-97% in year 3 (each P < 0.05 adjusted for script present). A significant disparity in access for African American actors resolved following more uniform adherence to pre-existing policies. CONCLUSIONS: The 'unannounced standardized veteran' (USV) can identify previously unrecognized barriers to needed services and care. Audit and feedback programs based on direct covert observation with systematic data collection and rapid feedback may be an effective strategy for improving services to highly vulnerable populations.

Treatment access for opioid use disorder in pregnancy among rural and American Indian communities.

BACKGROUND: Opioid use disorder (OUD) in pregnancy disproportionately impacts rural and American Indian (AI) communities. With limited data available about access to care for these populations, this study's objective was to assess clinic knowledge and new patient access for OUD treatment in three rural U.S. counties. MATERIAL AND METHODS: The research team used unannounced standardized patients (USPs) to request new patient appointments by phone for white and AI pregnant individuals with OUD at primary care and OB/GYN clinics that provide prenatal care in three rural Utah counties. We assessed a) clinic familiarity with buprenorphine for OUD; b) appointment availability for buprenorphine treatment; c) appointment wait times; d) referral provision when care was unavailable; and e) availability of OUD care at referral locations. We compared outcomes for AI and white USP profiles using descriptive statistics. RESULTS: The USPs made 34 calls to 17 clinics, including 4 with publicly listed buprenorphine prescribers on the Substance Abuse and Mental Health Services Administration website. Among clinical staff answering calls, 16 (47%) were unfamiliar with buprenorphine. OUD treatment was offered when requested in 6 calls (17.6%), with a median appointment wait time of 2.5 days (IQR 1-5). Among clinics with a listed buprenorphine prescriber, 2 of 4 (50%) offered OUD treatment. Most clinics (n = 24/28, 85.7%) not offering OUD treatment provided a referral; however, a buprenorphine provider was unavailable/unreachable 67% of the time. The study observed no differences in appointment availability between AI and white individuals. CONCLUSIONS: Rural-dwelling AI and white pregnant individuals with OUD experience significant barriers to accessing care. Improving OUD knowledge and referral practices among rural clinics may increase access to care for this high-risk population.

Implementation of a patient-collected audio recording audit & feedback quality improvement program to prevent contextual error: stakeholder perspective.

BACKGROUND: Using patient audio recordings of medical visits to provide clinicians with feedback on their attention to patient life context in care planning can improve health care delivery and outcomes, and reduce costs. However, such an initiative can raise concerns across stakeholders about surveillance, intrusiveness and merit. This study examined the perspectives of patients, physicians and other clinical staff, and facility leaders over 3 years at six sites during the implementation of a patient-collected audio quality improvement program designed to improve patient-centered care in a non-threatening manner and with minimal effort required of patients and clinicians. METHODS: Patients were invited during the first and third year to complete exit surveys when they returned their audio recorders following visits, and clinicians to complete surveys annually. Clinicians were invited to participate in focus groups in the first and third years. Facility leaders were interviewed individually during the last 6 months of the study. RESULTS: There were a total of 12 focus groups with 89 participants, and 30 leadership interviews. Two hundred fourteen clinicians and 800 patients completed surveys. In a qualitative analysis of focus group data employing NVivo, clinicians initially expressed concerns that the program could be disruptive and/or burdensome, but these diminished with program exposure and were substantially replaced by an appreciation for the value of low stakes constructive feedback. They were also significantly more confident in the value of the intervention in the final year (p = .008), more likely to agree that leadership supports continuous improvement of patient care and gives feedback on outcomes (p = .02), and at a time that is convenient (p = .04). Patients who volunteered sometimes expressed concerns they were "spying" on their doctors, but most saw it as an opportunity to improve care. Leaders were supportive of the program but not yet prepared to commit to funding it exclusively with facility resources. CONCLUSIONS: A patient-collected audio program can be implemented when it is perceived as safe, not disruptive or burdensome, and as contributing to better health care.

Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities.

BACKGROUND: Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited. METHODS: We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians. DISCUSSION: The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System.

Importance: Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. Objective: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. Design, Setting, and Participants: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. Interventions: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. Main Outcomes and Measures: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. Results: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. Conclusions and Relevance: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.

Listening to the Patient: A Typology of Contextual Red Flags in Disease Management Encounters.

PURPOSE: Patients send clues, often unwittingly, when they are grappling with a life challenge that complicates their care. For instance, a patient may lose control of a previously well-managed chronic condition or start missing appointments. When explored, these clues help clinicians uncover the life circumstance impacting the individual's ability to manage their health and health care. Such clues are termed "contextual red flags." Effective care requires recognizing them, asking about them, and customizing the care plan where feasible. We sought to develop a typology of contextual red flags by analyzing audio recordings along with the medical records of encounters between patients and providers in outpatient clinics. METHODS: During the course of 3 studies on physician attention to patient context conducted over a 5-year span (2012-2016), 4 full-time coders listened to the audios and reviewed the medical records of 2963 clinician-patient encounters. A list of contextual red flags was accrued and categorized until saturation was achieved. RESULTS: A total of 70 contextual red flags were sorted into 9 categories, comprising a typology of contextual red flags: uncontrolled chronic conditions; appointment adherence; resource utilization; medication adherence; adherence to plan of care; significant weight loss/gain; patient knowledge of health or health care status; medical equipment/supplies adherence; other. CONCLUSIONS: A relatively small number of clues that patients are struggling to self-manage their care warrant clinicians' exploring opportunities to adapt care plans to individual life circumstances. These contextual red flags group into an even smaller set of logical categories, providing a framework to guide clinicians about when to elicit additional information from patients about life challenges they are facing.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors.

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients' perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10-50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07-2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers' likelihood of exploring context but not contextualizing care. Information about patients' life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

Validating Domains of Patient Contextual Factors Essential to Preventing Contextual Errors: A Qualitative Study Conducted at Chicago Area Veterans Health Administration Sites.

PURPOSE: "Patient context" indicates patient circumstances and characteristics or states that are essential to address when planning patient care. Specific patient "contextual factors," if overlooked, result in an inappropriate plan of care, a medical error termed a "contextual error." The myriad contextual factors that constitute patient context have been grouped into broad domains to create a taxonomy of challenges to consider when planning care. This study sought to validate a previously identified list of contextual domains. METHOD: This qualitative study used directed content analysis. In 2014, 19 Department of Veterans Affairs (VA) providers (84% female) and 49 patients (86% male) from two VA medical centers and four outpatient clinics in the Chicago area participated in semistructured interviews and focus groups. Topics included patient-specific, community, and resource-related factors that affect patients' abilities to manage their care. Transcripts were analyzed with a previously identified list of contextual domains as a framework. RESULTS: Analysis of responses revealed that patients and providers identified the same 10 domains previously published, plus 3 additional ones. Based on comments made by patients and providers, the authors created a revised list of 12 domains from themes that emerged. Six pertain to patient circumstances such as access to care and financial situation, and 6 to patient characteristics/states including skills, abilities, and knowledge. CONCLUSIONS: Contextual factors in patients' lives may be essential to address for effective care planning. The rubric developed can serve as a "contextual differential" for clinicians to consider when addressing challenges patients face when planning their care.

Providers contextualise care more often when they discover patient context by asking: meta-analysis of three primary data sets.

OBJECTIVES: One important component of patient-centred care is provider incorporation of patient contextual factors-life circumstances relevant to their care-in managing the patient's health. The current study uses data sets collected from direct observation of care to examine if how a provider learns contextual information influences whether the provider incorporates the information into a care plan. METHODS: Three data sets were reanalysed: a research study with physicians, a quality improvement project with physicians and a performance measurement project with telephone health assistants. In each data set, investigators compute rates of incorporation of patient contextual factors into the care plan for encounters in which factors were elicited in response to a probe by the provider versus revealed spontaneously by the patient. We report the rates, CIs and associated ORs for each study and overall using a random effects meta-analysis. RESULTS: Providers elicited 57%, 49% and 30% of patient contextual factors identified in encounters in each data set. Patient contextual factors identified in response to probes were incorporated into the plan of care more frequently than those revealed spontaneously by patients (68% vs 46%, 71% vs 54% and 93% vs 77%, respectively). The summary OR for incorporation of patient contextual factors into the care plan when the factor was probed versus revealed spontaneously was 4.16 (95% CI 2.0 to 8.6). While this estimate was associated with significant heterogeneity (I(2)=76%), the ORs for the individual data sets were 2.53 (1.4 to 4.5), 6.25 (4.9 to 8.0) and 4.2 (0.9 to 19.3). CONCLUSIONS: In encounters where addressing patient contextual factors may play an important role in care decisions, factors that are elicited actively by the provider are more likely to be incorporated in the care plan than factors revealed spontaneously by the patient. These differences in the care process associated with provider performance can only be demonstrated through direct observation.

Content coding for contextualization of care: evaluating physician performance at patient-centered decision making.

BACKGROUND AND OBJECTIVE: . Adapting best evidence to the care of the individual patient has been characterized as "contextualizing care" or "patient-centered decision making" (PCDM). PCDM incorporates clinically relevant, patient-specific circumstances and behaviors, that is, the patient's context, into formulating a contextually appropriate plan of care. The objective was to develop a method for analyzing physician-patient interactions to ascertain whether decision making is patient centered. METHODS: . Patients carried concealed audio recorders during encounters with their physicians. Recordings and medical records were reviewed for clues that contextual factors, such as an inability to pay for a medication or competing responsibilities, might undermine an otherwise appropriate care plan, rendering it ineffective. Iteratively, the team refined a coding process to achieve high interrater agreement in determining (a) whether the clinician explored the clues-termed "contextual red flags"-for possible underlying contextual factors affecting care, (b) whether the presence of contextual factors was confirmed and, if so, (c) whether they were addressed in the final care plan. RESULTS: . A medical record data extraction instrument was developed to identify contextual red flags such as missed appointments or loss of control of a treatable chronic condition which signal that contextual factors may be affecting care. Interrater agreement (Cohen's kappa) for coding whether the clinician explored contextual red flags, whether a contextual factor was identified, and whether the factors were addressed in the care plan was 88% (0.76, P < 0.001), 94% (0.88, P < 0.001), and 85% (0.69, P < 0.001) respectively. CONCLUSIONS: . PCDM can be assessed with high interrater agreement using a protocol that examines whether essential contextual information (when present) is addressed in the plan of care.

Patient-centered decision making and health care outcomes: an observational study.

BACKGROUND: Patient-centered decision making (PCDM) is the process of identifying clinically relevant, patient-specific circumstances and behaviors to formulate a contextually appropriate care plan. OBJECTIVE: To ascertain whether encounters in which PCDM occurs are followed by improved health care outcomes compared with encounters where there is inattention to patient context. DESIGN: Patients surreptitiously audio-recorded encounters with their physicians. Medical records of these encounters were then screened for "contextual red flags," such as deteriorating self-management of a chronic condition, that could reflect such underlying contextual factors as competing responsibilities or loss of social support. When a contextual factor was identified, either as a result of physician questioning or because a patient volunteered information, physicians were scored on the basis of whether they adapted the care plan to it. SETTING: Internal medicine clinics at 2 Veterans Affairs facilities. PARTICIPANTS: 774 patients audio-recorded encounters with 139 resident physicians. MEASUREMENTS: Individualized outcome measures were based on the contextual red flag, such as improved blood pressure control in a patient presenting with hypertension and loss of medication coverage. Outcome coders were blinded to physician performance. RESULTS: Among 548 contextual red flags, 208 contextual factors were confirmed, either when physicians probed or patients volunteered information. Physician attention to contextual factors (both probing for them and addressing them in care plans) varied according to the presenting contextual red flags. Outcome data were available for 157 contextual factors, of which PCDM was found to address 96. Of these, health care outcomes improved in 68 (71%), compared with 28 (46%) of the 61 that were not addressed by PCDM (P = 0.002). LIMITATION: The extent to which the findings can be generalized to other clinical settings is unknown. CONCLUSION: Attention to patient needs and circumstances when planning care is associated with improved health care outcomes. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs, Health Services Research & Development Service.

Comparing announced with unannounced standardized patients in performance assessment.

BACKGROUND: Accurately assessing how physicians perform in practice remains an unresolved psychometric challenge. Neither chart reviews nor patient surveys indicate when physicians overlook important information, which can result in a missed opportunity for a correct diagnosis and appropriate plan of care. Standardized patient (SP) assessments provide an opportunity for direct observation of clinical behavior and are increasingly used in licensure examinations. (SPs who are sent incognito are termed unannounced standardized patients [USPs].) One study showed that physicians had particular difficulty adapting care to individual patient context ("contextual error"). In a subsequent study with the same actors, SP cases, and outcomes, an intervention was deployed to reduce contextual error among medical students. In an exploratory reanalysis of data from the two studies, clinicians' assessments of SPs and USPs were compared. METHODS: Participants in the first study were 65 board-certified internists visited by USPs; the 59 participants in the second were fourth-year medical students examining SPs in a clinical performance center. RESULTS: Attending physicians measured with USPs significantly underperformed medical students measured with SPs in the probing of biomedical red flags (odds ratio [OR] = 0.45 [0.30 to 0.67]) and contextual red flags (OR = 0.66 [0.45 to 0.99]) and in planning appropriate care (OR = 0.43 [0.27 to 0.67]). CONCLUSIONS: Across these two studies, attending physicians underperformed medical students on the same outcomes, measured with the same patient cases presented by the same actors. Studies that seek to assess elicitation and incorporation of patient information by physicians as measures of individualization of care should weigh the benefits and costs of direct observation by USPs.

Unannounced standardized patient assessment of the roter interaction analysis system: the challenge of measuring patient-centered communication.

BACKGROUND: Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. OBJECTIVE: To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. DESIGN: RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. PARTICIPANTS: Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. MAIN MEASURES: RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patient-centeredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. KEY RESULTS: None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. CONCLUSIONS: RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs.

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

CONTEXT: In a past study using unannounced standardised patients (USPs), substantial rates of diagnostic and treatment errors were documented among internists. Because the authors know the correct disposition of these encounters and obtained the physicians' notes, they can identify necessary treatment that was not provided and unnecessary treatment. They can also discern which errors can be identified exclusively from a review of the medical records. OBJECTIVE: To estimate the avoidable direct costs incurred by physicians making errors in our previous study. DESIGN: In the study, USPs visited 111 internal medicine attending physicians. They presented variants of four previously validated cases that jointly manipulate the presence or absence of contextual and biomedical factors that could lead to errors in management if overlooked. For example, in a patient with worsening asthma symptoms, a complicating biomedical factor was the presence of reflux disease and a complicating contextual factor was inability to afford the currently prescribed inhaler. Costs of missed or unnecessary services were computed using Medicare cost-based reimbursement data. SETTING: Fourteen practice locations, including two academic clinics, two community-based primary care networks with multiple sites, a core safety net provider, and three Veteran Administration government facilities. MAIN OUTCOME MEASURES: Contribution of errors to costs of care. RESULTS: Overall, errors in care resulted in predicted costs of approximately $174,000 across 399 visits, of which only $8745 was discernible from a review of the medical records alone (without knowledge of the correct diagnoses). The median cost of error per visit with an incorrect care plan differed by case and by presentation variant within case. CONCLUSIONS: Chart reviews alone underestimate costs of care because they typically reflect appropriate treatment decisions conditional on (potentially erroneous) diagnoses. Important information about patient context is often entirely missing from medical records. Experimental methods, including the use of USPs, reveal the substantial costs of these errors.

An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients.

CONTEXT: A contextual error occurs when a physician does not identify elements of a patient's environment or behavior, such as access to care, that must be addressed to appropriately plan care. Research has demonstrated that contextual errors can be identified using standardized patients. OBJECTIVE: To evaluate an educational intervention designed to increase physicians' skills in incorporating the patient's context in assessment and management of care and to thereby decrease the rate of contextual errors. DESIGN, SETTING, AND PARTICIPANTS: Quasi-randomized controlled trial, with assessments by blinded observers. Fourth-year medical students (n = 124) in internal medicine subinternships at the University of Illinois at Chicago or Jesse Brown Veterans Administration Medical Center between July 2008 and April 2009 and between August 2009 and April 2010 participated and were assessed. INTERVENTION: A 4-hour course on contextualization. MAIN OUTCOME MEASURES: Probing for contextual issues in an encounter, probing for medical issues in an encounter, and developing an appropriate treatment plan. Outcomes were assessed using 4 previously validated standardized patient encounters performed by each participant and were adjusted for subinternship site, academic year, time of year, and case scenario. RESULTS: Students who participated in the contextualization workshops were significantly more likely to probe for contextual issues in the standardized patient encounters than students who did not (90% [95% confidence interval {CI}, 87%-94% ] vs 62% [95% CI, 54%-69%], respectively) and significantly more likely to develop appropriate treatment plans for standardized patients with contextual issues (69% [95% CI, 57%-81%] vs 22% [95% CI, 12%-32%]. There was no difference between the groups in the rate of probing for medical issues (80% [95% CI, 75%-85%] vs 81% [95% CI, 76%-86%]) or developing appropriate treatment plans for standardized patients with medical issues (54% [95% CI, 42%-67%] vs 66% [95% CI, 53%-79%]). CONCLUSION: Medical students who underwent an educational intervention were more likely to contextualize care for individual standardized patients.

Contextual errors and failures in individualizing patient care: a multicenter study.

BACKGROUND: A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care. OBJECTIVE: To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes. DESIGN: An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked. SETTING: 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities. MEASUREMENTS: Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans. RESULTS: Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. LIMITATIONS: Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context. CONCLUSION: Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs Health Services Research and Development Service