Bhise Viraj, Rajan Suja S, Sittig Dean F, Vaghani Viralkumar, Morgan Robert O, Khanna Arushi, Singh Hardeep
Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
J Eval Clin Pract. 2018 Jun;24(3):545-551. doi: 10.1111/jep.12912. Epub 2018 Apr 20.
RATIONALE, AIMS AND OBJECTIVES: Diagnostic uncertainty is common in primary care. Because it is challenging to measure, there is inadequate scientific understanding of diagnostic decision-making during uncertainty. Our objective was to understand how diagnostic uncertainty was documented in the electronic health record (EHR) and explore a strategy to retrospectively identify it using clinician documentation.
We reviewed the literature to identify documentation language that could identify both direct expression and indirect inference of diagnostic uncertainty and designed an instrument to facilitate record review. Direct expression included clinician's use of question marks, differential diagnoses, symptoms as diagnosis, or vocabulary such as "probably, maybe, likely, unclear or unknown," while describing the diagnosis. Indirect inference included absence of documented diagnosis at the end of the visit, ordering of multiple consultations or diagnostic tests to resolve diagnostic uncertainty, and use of suspended judgement, test of treatment, and risk-averse disposition. Two physician-reviewers independently reviewed notes on a sample of outpatient visits to identify diagnostic uncertainty at the end of the visit. Documented Ninth Revision of the International Classification of Diseases (ICD-9) diagnosis codes and note quality were assessed.
Of 389 patient records reviewed, 218 had evidence of diagnostic activity and were included. In 156 visits (71.6%), reviewers identified clinicians who experienced diagnostic uncertainty with moderate inter-reviewer agreement (81.7%; Cohen's kappa: 0.609). Most cases (125, 80.1%) showed evidence of both direct expression and indirect inference. Uncertainty was directly expressed in 139 (89.1%) cases, most commonly by using symptoms as diagnosis (98, 62.8%), and inferred in 144 (92.3%). In more than 1/3 of visits (58, 37.2%), diagnostic uncertainty was recorded inappropriately using ICD-9 codes.
While current diagnosis coding mechanisms (ICD-9 and ICD-10) are unable to capture uncertainty, our study finds that review of EHR documentation can help identify diagnostic uncertainty with moderate reliability. Better measurement and understanding of diagnostic uncertainty could help inform strategies to improve the safety and efficiency of diagnosis.
原理、目的与目标：诊断不确定性在初级医疗中很常见。由于其难以衡量，目前对于不确定性情况下的诊断决策缺乏足够的科学认识。我们的目标是了解电子健康记录（EHR）中如何记录诊断不确定性，并探索一种利用临床医生记录进行回顾性识别的策略。
我们查阅文献，确定能够识别诊断不确定性直接表达和间接推断的记录语言，并设计了一种工具以方便病历审查。直接表达包括临床医生在描述诊断时使用问号、鉴别诊断、以症状作为诊断或使用“可能、也许、很可能、不清楚或未知”等词汇；间接推断包括就诊结束时未记录诊断、为解决诊断不确定性而安排多次会诊或诊断检查，以及使用暂缓判断、治疗性试验和规避风险的处置方式。两名医生审阅者独立审阅门诊就诊样本的病历，以确定就诊结束时的诊断不确定性。评估记录的国际疾病分类第九版（ICD - 9）诊断编码和病历质量。
在审阅的389份患者记录中，218份有诊断活动的证据并被纳入研究。在156次就诊（71.6%）中，审阅者识别出经历诊断不确定性的临床医生，审阅者间的一致性中等（81.7%；科恩kappa系数：0.609）。大多数病例（125例，80.1%）同时显示出直接表达和间接推断的证据。139例（89.1%）病例直接表达了不确定性，最常见的是以症状作为诊断（98例，62.8%），144例（92.3%）病例存在间接推断。在超过1/3的就诊（58例，37.2%）中，使用ICD - 9编码对诊断不确定性的记录不当。
虽然当前的诊断编码机制（ICD - 9和ICD - 10）无法捕捉不确定性，但我们的研究发现，审查电子健康记录文档可以以中等可靠性帮助识别诊断不确定性。更好地衡量和理解诊断不确定性有助于为提高诊断安全性和效率的策略提供信息。
