Targeted EHR-based Communication of Diagnostic Uncertainty (TECU) in the ED: An Effectiveness Implementation Trial

项目总结 在急诊科(ED)接受治疗的患者中，至少有37%在没有明确诊断的情况下出院 诊断，从而使遇到的诊断具有不确定性。护理过渡是以下方面的高风险时期 患者安全，特别是当患者因诊断不确定而出院时，因此仍在 诊断过程。临床医生与患者之间的有效沟通是提高质量的关键 在这些护理过渡中。在之前由AHRQ资助的研究中，我们开发了几个工具来支持高质量 在诊断不确定度设置中的排放，包括通信核对表、培训方案 不确定沟通中的医生，以及一张1页的面向患者的信息表 不确定地退伍了。我们现在建议利用电子健康记录(EHR)实施 多方面策略促进急症室出院病人更高质素的出院过渡 诊断的不确定性。我们有针对性的基于电子病历的不确定性沟通(Tecu)战略将是 每次急诊临床医生对出院患者输入不确定的诊断时激活，并将 通知临床医生对患者的不确定性进行咨询，同时另外触发自动插入 以及打印患者讲义，2)打印面向临床医生的检查表以指导出院 对话，以及3)向初级保健提供者(PCP)发送收件箱消息。我们将进行一次预审- 采用混合类型1有效性实施设计的试行后试验，目标为：1)测试 与标准护理相比，TECU在减少患者不确定性和返回边缘方面的初步效果 访问和2)评估采用Tecu的情况，并探索患者和临床医生的障碍和促进者 TECU实施。这项工作将由具有卫生服务专业知识的经验丰富的研究人员领导 急诊医学研究、临床试验、患者沟通、健康素养、诊断不确定性、 信息学和实施学。TECU战略将很容易传播，因为它将被内置 EPIC，世界领先的EHR供应商，并将通过EPIC提供给卫生系统实施 社区图书馆。该项目有可能显著影响护理过渡的质量和安全 对于三分之一的带着诊断不确定性离开急诊科的患者。

PROJECT SUMMARY At least 37% of patients treated in the emergency department (ED) are discharged without a definitive diagnosis, thus leaving the encounter with diagnostic uncertainty. Transitions of care are high-risk periods for patient safety, especially when patients are discharged with diagnostic uncertainty, and thus are still within the diagnostic process. Effective communication between clinicians and patients is essential to improve the quality of these care transitions. In prior AHRQ-funded research, we developed several tools to support high quality discharge in the setting of diagnostic uncertainty, including a communication checklist, a training program for physicians in uncertainty communication, and a patient-facing 1-page information sheet about being discharged with uncertainty. We now propose to leverage the electronic health record (EHR) to implement a multifaceted strategy to facilitate higher quality discharge transitions for patients discharged from the ED with diagnostic uncertainty. Our Targeted EHR-based Communication about Uncertainty (TECU) strategy will be activated every time an ED clinician enters an uncertain diagnosis for a patient being discharged, and will notify the clinician to counsel the patient about uncertainty while additionally triggering automated 1) insertion and printing of the patient handout, 2) printing of the clinician-facing checklist to guide the discharge conversation, and 3) sending of an inbox message to the primary care provider (PCP). We will conduct a pre- post pilot trial with a hybrid type 1 effectiveness implementation design with the goals of: 1) Testing the preliminary effectiveness of TECU compared to standard of care in reducing patient uncertainty and return ED visits and 2) Evaluating the adoption of TECU and exploring patient and clinician barriers and facilitators to TECU implementation. This work will be led by experienced researchers with expertise in health services research, clinical trials in emergency medicine, patient communication, health literacy, diagnostic uncertainty, informatics, and implementation science. The TECU strategy will be easily disseminated as it will be built in Epic, the world’s leading EHR vendor, and will be available for health systems to implement through the Epic Community Library. This project has potential to significantly impact the quality and safety of care transitions for the one-third of patients leaving the emergency department with diagnostic uncertainty.