A Turn-Key EHR Simulation Program to Reduce Diagnostic Error in Ambulatory Care

项目摘要：诊断错误被认为是最常见的患者安全事件类型。影响之间 5%-10%的患者遇到，这会导致显著的患者发病率和死亡率。门诊护理尤其是 易受此影响，诊断错误的数量超过其他类型的6：1和5%的寻求门诊护理的患者 遇到诊断错误。由延迟和漏诊组成，诊断错误经常是 无法有效地访问和/或合成用于医疗决策的复杂医疗信息的后果 制作。随着HITECH法案的通过，超过95%的医院和80%的办公室诊所使用电子 健康记录(EHR)作为其患者信息的主要来源。随着EHR的快速扩张，有越来越多的 赞赏企业人力资源机构导致信息收集和/或综合失败的各种方式。这些 EHR使用错误通常是系统设计问题和用户培训不足的综合结果。模拟提供了强大的 这是一种工具，既可以系统地研究电子病历造成上述错误的手段，也可以提供一个强大的 培训工具。我们之前在ICU演示了基于高保真EHR的模拟演习，有目的地使用 设计了电子病历图表，揭示了电子病历使用错误对诊断错误的贡献。参加这些演习 将对有效诊断准确性所需的患者信息中嵌入趋势的识别能力提高50%。 虽然我们已经为重症监护、工作流程、认知错误和EHR创建了许多基于模拟的练习 图表结构与门诊护理有根本的不同，代表了更大程度的纵向护理和 需要处理从多个单独的遭遇中获得的信息。这就更加重视 护理过渡期间的信息丢失。此外，实施以电子病历为基础的电子病历存在许多障碍 大多数医疗中心的模拟活动，这个问题在社区实践中被放大了。因此，这样做的目标是 建议创建和验证基于EHR的模拟的交钥匙库，以提高门诊诊断的安全性 既可泛化又可伸缩的CARE。在目标1中，我们将使用一个组合来执行问题分析 来自宾夕法尼亚州患者安全局的管理数据和来自医生公司的索赔数据 确定门诊护理中存在诊断错误风险的诊断，并使用与所述错误相关的错误。我们会 整合这些数据以创建标准，以便设计一个全面的基于EHR的模拟库进行研究 并减少5个主要门诊专科的诊断错误。在目标2中，我们将为以下目标开发这些模拟 5个门诊专科。我们将反过来验证模拟活动作为培训工具的能力，以 从根本上改变电子病历的使用模式，减少诊断错误。最后，这个库包括所有的模拟 材料、脚本和EHR图表将合并到AIM#3的在线存储库中。我们将进一步创建一系列 基于FHIR的应用程序，将促进将模拟的EHR图表“加载”到主要的EHR系统中。因此，通过 在资助期结束时，我们将创建一个经过验证的电子病历基础模拟演练库，以减少 在门诊护理中出现了诊断错误，并开发了新技术，以促进广泛实施。

Project Summary: Diagnostic error is believed to be the most common type of patient safety event. Affecting between 5-10% of all patient encounters, it results in significant patient morbidity and mortality. Ambulatory care is especially susceptible to this, with diagnostic errors outnumbering other types 6:1 and 5% of patients seeking ambulatory care experiencing diagnostic error. Comprised of delayed and missed diagnosis, diagnostic error is frequently the consequence of the inability to effectively access and/or synthesize complex medical information for medical decision making. With the adoption of the HITECH Act over 95% of hospitals and 80% of office based practice utilize Electronic Health Records (EHRs) as their primary source of patient information. With the rapid expansion of EHRs, there is growing appreciation of the myriad of ways in which EHRs contribute to failures in information gathering and/or synthesis. These EHR use errors are often a combination of system design issues and poor user training. Simulation affords a powerful tool to both study, in a systematic way, the means in which EHRs contribute to said errors as well as provide a powerful training tool. We previously demonstrated that hi-fidelity EHR based simulation exercises in the ICU, using purposively designed EHR charts, uncovers the contribution of EHR use errors to diagnostic error. Participation in these exercises improves the recognition of embedded trends in patient information required for effective diagnostic accuracy by 50%. While we have created a number of simulation based exercises for critical care, the workflow, cognitive errors and EHR chart structure are fundamentally different for ambulatory care, representing a greater degree of longitudinal care and the need to process information acquired across multiple individual encounters. This places even more importance on information loss during transitions of care. Further, a number of barriers exist to implementation of EHR based simulation activities at most medical centers, an issue magnified in community practices. Therefore the goal of this proposal is to create and validate a turn-key library of EHR based simulations to improve diagnostic safety in ambulatory care which is both generalizable and scalable. In Aim #1, we will perform our problem analysis by using a combination of administrative data from the Pennsylvania Patient Safety Authority and claims data from The Doctors Company to identify diagnoses at risk for diagnostic error in ambulatory care and EHR use errors associated with said errors. We will integrate these data to create a rubric to allow for the design of a comprehensive EHR based simulation library to study and reduce diagnostic error across the 5 major ambulatory specialties. In Aim #2, we will develop these simulations for 5 ambulatory specialties. We will in-turn validate the ability of the simulation activities to serve as a training tool to fundamentally change EHR use patterns and reduce diagnostic error. Finally, this library, including all simulation materials, scripts and EHR charts will be coalesced into an online repository in Aim #3. We will further create a series of FHIR based applications which will facilitate “loading” of the simulated EHR charts into the major EHR systems. Thus, by the end of the funding period, we will have created a library of validated EHR base simulation exercises to reduce diagnostic error in ambulatory care and developed novel technology to facilitate widespread implementation.