Department of Health Systems Management, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts.
Now with Max Stern Yezreel Valley College, Yezreel Valle, Israel.
JAMA Netw Open. 2023 Mar 1;6(3):e232218. doi: 10.1001/jamanetworkopen.2023.2218.
Communication of information has emerged as a critical component of diagnostic quality. Communication of diagnostic uncertainty represents a key but inadequately examined element of diagnosis.
To identify key elements facilitating understanding and managing diagnostic uncertainty, examine optimal ways to convey uncertainty to patients, and develop and test a novel tool to communicate diagnostic uncertainty in actual clinical encounters.
DESIGN, SETTING, AND PARTICIPANTS: A 5-stage qualitative study was performed between July 2018 and April 2020, at an academic primary care clinic in Boston, Massachusetts, with a convenience sample of 24 primary care physicians (PCPs), 40 patients, and 5 informatics and quality/safety experts. First, a literature review and panel discussion with PCPs were conducted and 4 clinical vignettes of typical diagnostic uncertainty scenarios were developed. Second, these scenarios were tested during think-aloud simulated encounters with expert PCPs to iteratively draft a patient leaflet and a clinician guide. Third, the leaflet content was evaluated with 3 patient focus groups. Fourth, additional feedback was obtained from PCPs and informatics experts to iteratively redesign the leaflet content and workflow. Fifth, the refined leaflet was integrated into an electronic health record voice-enabled dictation template that was tested by 2 PCPs during 15 patient encounters for new diagnostic problems. Data were thematically analyzed using qualitative analysis software.
Perceptions and testing of content, feasibility, usability, and satisfaction with a prototype tool for communicating diagnostic uncertainty to patients.
Overall, 69 participants were interviewed. A clinician guide and a diagnostic uncertainty communication tool were developed based on the PCP interviews and patient feedback. The optimal tool requirements included 6 key domains: most likely diagnosis, follow-up plan, test limitations, expected improvement, contact information, and space for patient input. Patient feedback on the leaflet was iteratively incorporated into 4 successive versions, culminating in a successfully piloted prototype tool as an end-of-visit voice recognition dictation template with high levels of patient satisfaction for 15 patients with whom the tool was tested.
In this qualitative study, a diagnostic uncertainty communication tool was successfully designed and implemented during clinical encounters. The tool demonstrated good workflow integration and patient satisfaction.
信息交流已成为诊断质量的关键组成部分。诊断不确定性的交流代表了诊断中一个关键但未充分研究的要素。
确定有助于理解和管理诊断不确定性的关键要素，研究向患者传达不确定性的最佳方法，并开发和测试一种用于在实际临床接触中传达诊断不确定性的新工具。
设计、设置和参与者：这是一项 5 阶段的定性研究，于 2018 年 7 月至 2020 年 4 月在马萨诸塞州波士顿的一家学术初级保健诊所进行，采用便利抽样法招募了 24 名初级保健医生（PCP）、40 名患者和 5 名信息学和质量/安全专家。首先，进行了文献回顾和 PCP 小组讨论，并制定了 4 个典型诊断不确定性情景的临床案例。其次，在与专家 PCP 进行的出声思考模拟接触中测试了这些案例，以逐步起草患者传单和临床医生指南。第三，使用 3 个患者焦点小组评估传单内容。第四，向 PCP 和信息学专家征求额外反馈意见，以迭代方式重新设计传单内容和工作流程。第五，将改进后的传单整合到电子健康记录语音启用的语音听写模板中，由 2 名 PCP 在 15 名新诊断问题患者的就诊中进行测试。使用定性分析软件对数据进行主题分析。
对向患者传达诊断不确定性的原型工具的内容、可行性、可用性和满意度进行评估。
共有 69 名参与者接受了采访。根据 PCP 访谈和患者反馈，制定了临床医生指南和诊断不确定性沟通工具。最佳工具要求包括 6 个关键领域：最可能的诊断、随访计划、测试限制、预期改善、联系方式和患者意见空间。患者对传单的反馈不断纳入 4 个连续版本，最终成功试点了一个原型工具，作为结束就诊时的语音识别听写模板，在 15 名接受工具测试的患者中获得了高度的患者满意度。
在这项定性研究中，成功地在临床接触中设计和实施了诊断不确定性沟通工具。该工具显示出良好的工作流程集成和患者满意度。
