Answering the call to engage patients and families in the diagnostic process: A new patient-centered approach using health information transparency to identify diagnostic breakdowns in ambulatory care

门诊护理中的诊断错误是一个令人烦恼的挑战，至少部分原因是有限的 测量以确定随时间和空间展开的事件(各种医疗保健交互作用)。虽然 NAM报告强调从患者的角度出发，而传统的诊断误差测量方法则不是这样。新数据 提示患者对诊断错误的体验反映了当前指标中几乎不存在的主题： 忽视患者的知识、不尊重和其他不专业的行为和沟通障碍。 缺乏以患者为中心的衡量标准会缩短组织学习和更有意义地 防止未来的诊断错误，这会给患者带来巨大的负担--特别是病情最重的患者 无论是孩子还是成年人。幸运的是，随着健康信息透明度的普及，有了新的参与方式 患者在诊断过程中。通过患者门户与患者共享访问记录为他们提供了 有他们流动经历的书面记录，并代表了一个丰富但相对未开发的现存 为患者提供资源，以帮助确定诊断和护理中的故障。越来越多的证据表明 对患者的独特知识以及他们识别此类故障的能力。超过4000万名患者 美国现在可以访问未结票据。研究表明，患者的安全性和参与度从 开放笔记，特别是在更脆弱的患者中。在实施和实施方面进行第一手工作 衡量共享访问笔记的影响在过去十年中，我们的团队获得了细微差别 了解与几乎所有医疗领域的透明笔记相关的机遇和挑战。 我们还创新了两种新的方法，使患者能够a)对笔记做出贡献，b)报告 潜在的音符错误。我们的研究表明，频繁的患者报告的故障与诊断有关 进程。通过与患者/家属、卫生服务研究人员和诊断错误专家合作，我们 现在独一无二地准备：1A)建立一个新的以患者为中心的框架，与患者/家属共同设计 和护理合作伙伴对患者报告的诊断故障(PRDB)进行衡量和分类，以及b) 应用这一新的分析工具来确定PRDB的发生率、类型和促成因素 使用2个大型且独特的现有数据库进行门诊护理；2)开发和实施新的电子病历门户- 基于方法，使慢性病患者及其家人能够a)为访问记录做出贡献，并 诊断过程；b)利用现有的电子病历数据确定和报告诊断故障；以及3) 评估该方法的使用和对诊断过程测量安全性的影响(发病率/类型 (在慢性病患者中的PRDB)、实施和利益相关者体验结果。我们的发现 将提高我们对动态诊断故障的认识，并建立一种新的方法 组织在诊断过程中系统地与患者合作。研究结果将提供 为最终设计和测试干预措施以减少动态诊断错误奠定了基础。

Diagnostic errors in ambulatory care present a vexing challenge, at least in part because of limited measurements to identify events that unfold over time and space (various healthcare interactions). Although the NAM report emphasizes the patient perspective, traditional diagnostic error measures do not. New data suggest that patient experiences of diagnostic error reflect themes virtually absent from current metrics: ignoring patient knowledge, disrespect, and other unprofessional behavior and communication barriers. Lack of patient-centered metrics truncates organizational learning and the ability to more meaningfully prevent future diagnostic errors, which levy an enormous burden on patients -- particularly the sickest children and adults. Fortunately, as health information transparency spreads, there are new ways to engage patients in the diagnostic process. Sharing visit notes with patients through the patient portal provides them with a written record of their ambulatory experiences, and represents a rich but relatively untapped existing source for patients to help identify breakdowns in diagnosis and care. Growing evidence demonstrates the unique knowledge of patients and their ability to identify such breakdowns. Over 40 million patients across the US can now access open notes. Studies demonstrate patient safety and engagement benefits from open notes, especially among more vulnerable patients. Working firsthand on implementation and measurement of the effects of shared visit notes over the last decade, our team has gained a nuanced understanding of opportunities and challenges related to transparent notes in virtually every medical field. We have also innovated two new approaches, enabling patients to a) contribute to notes and b) to report on potential note errors. Our research shows frequent patient-reported breakdowns related to the diagnostic process. Partnering with patients/families, health services researchers, and diagnostic error experts, we are now uniquely poised to: 1a) Establish a new patient-centered framework co-designed with patients/families and care partners to measure and categorize patient-reported diagnostic breakdowns (PRDBs), and b) apply this new analytic tool to establish the incidence, types, and contributing factors to PRDBs in ambulatory care using 2 large and unique existing databases; 2) Develop and implement a new EHR portal- based method enabling chronically ill patients and their families to a) contribute to the visit note and diagnostic process and b) identify and report diagnostic breakdowns using existing EHR data; and 3) Assess the use and impact of this method on the diagnostic process measuring safety (incidence/types of PRDBs among chronically ill patients), implementation, and stakeholder experience outcomes. Our findings will improve our understanding of ambulatory diagnostic breakdowns and establish a new method for organizations to systematically partner with patients in the diagnostic process. Study results will provide the foundation to ultimately design and test interventions to reduce ambulatory diagnostic errors.