The impact of medical scribes on emergency physician diagnostic testing and diagnosis charting

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Brett R. Todd ◽  
Lucas N. Nelson
Keyword(s):  
Differential Diagnosis ◽  
Diagnostic Test ◽  
Chart Review ◽  
Diagnostic Testing ◽  
Differential Diagnoses ◽  
Diagnostic Process ◽  
Diagnostic Practices ◽  
Medical Scribes ◽  
The Impact ◽  
Test Ordering

Abstract Objectives Since the widespread adoption of electronic medical records (EMRs), medical scribes have been increasingly utilized in emergency department (ED) settings to offload the documentation burden of emergency physicians (EPs). Scribes have been shown to increase EP productivity and satisfaction; however, little is known about their effects on the EP’s diagnostic process. We aimed to assess what effect, if any, scribes have on EP diagnostic test ordering and their documentation of differential diagnoses. Methods We conducted a retrospective cohort study utilizing a chart review to compare diagnostic practices of EPs working both with and without scribes. We analyzed the number of laboratory and radiologic diagnostic studies ordered per encounter as well as characteristics of differential diagnosis documentation. Results Scribes did not affect laboratory studies ordered per encounter (mean 6.31 by scribes vs. 7.35 by EPs, difference −1.04; 95% confidence interval [CI] −2.34 to 0.26) or radiologic studies ordered per encounter (mean 1.49 by scribes vs. 1.39 by EPs, difference 0.10; 95% CI −0.15 to 0.35). Scribes did not affect the frequency of documenting a differential diagnosis or the number of diagnoses considered in each differential, but they were associated with higher word counts in EP differentials (mean 72.29 by scribes vs. 50.00 by EPs, mean difference 22.79; 95% CI 6.77 to 38.81). Conclusions Scribe use does not appear to affect EP diagnostic test ordering but may have a small effect on their documentation of differential diagnoses.

Diagnostic Reasoning in the Pain-Focused Encounter

2019 ◽  
pp. 103-116
Author(s):  
Beth B. Hogans
Keyword(s):  
Differential Diagnosis ◽  
Negative Impact ◽  
Diagnostic Testing ◽  
Clinical History ◽  
Diagnostic Reasoning ◽  
Problem List ◽  
Patient Centered ◽  
Clinical Model ◽  
Error Disclosure ◽  
The Impact

Chapter 7 addresses the processes and pitfalls of evaluating, reasoning about, and attending to the needs of patients with pain. This chapter builds on Chapter 6, which addressed clinical assessment, explaining in detail the process of extracting and abstracting information from the pain narrative (clinical history or interview) to lay the foundation for a problem list and differential diagnosis. The problem list and differential diagnosis are described and contrasted so that clinicians will be comfortable with both. A clinical model explains the need for patient-centered approaches to be omnipresent but balanced with an appropriate disease-centered knowledge base that is likewise informed by understanding the patient’s healthcare-related values and motivations. A balanced approach is emphasized. The process of planning for diagnostic testing, including imaging, laboratory testing, provocative maneuvers, and targeted referrals, is described. The last section of the chapter addresses the impact and nature of cognitive and affective biases that can mitigate the effectiveness of diagnostic reasoning. A coordinated strategy to limit the negative impact of diagnostic reasoning biases is presented in a memorable way. Finally, the ethics of errors and error disclosure are discussed as well as the process of error disclosure.

The management of unexplained collapse in service age personnel

2015 ◽  
Vol 101 (2) ◽  
pp. 160-166
Author(s):  
AS Martin ◽  
IA Edgar ◽  
J Walker
Keyword(s):  
Differential Diagnosis ◽  
Differential Diagnoses ◽  
Medical Practitioners ◽  
Diagnosis And Management ◽  
Common Presentation ◽  
Methodical Approach ◽  
Wide Range ◽  
Life Threatening ◽  
The Military ◽  
The Impact

AbstractUnexplained collapse is a common presentation to medical practitioners, with a wide range of differential diagnoses making assessment problematic. Without a methodical approach to the patient presenting with unexplained collapse, potentially life-threatening conditions may not be recognised, whilst benign presentations can be over-investigated. This article will review the assessment, differential diagnosis and management of unexplained collapse, whilst considering the impact in the military environment.

Frequency and Consequences of Routine Temperature Measurement at Well-Child Visits

PEDIATRICS ◽  
2021 ◽  
Author(s):  
Rebecca Dang ◽  
Anisha I. Patel ◽  
Julia Marlow ◽  
Yingjie Weng ◽  
Marie E. Wang ◽  
...  
Keyword(s):  
Temperature Measurement ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Chart Review ◽  
Antibiotic Prescription ◽  
Diagnostic Testing ◽  
Measured Temperature ◽  
Routine Measurement ◽  
Multivariable Regression ◽  
The Impact

OBJECTIVES: To determine the (1) frequency and visit characteristics of routine temperature measurement and (2) rates of interventions by temperature measurement practice and the probability of incidental fever detection. METHODS: In this retrospective cohort study, we analyzed well-child visits between 2014–2019. We performed multivariable regression to characterize visits associated with routine temperature measurement and conducted generalized estimating equations regression to determine adjusted rates of interventions (antibiotic prescription, and diagnostic testing) and vaccine deferral by temperature measurement and fever status, clustered by clinic and patient. Through dual independent chart review, fever (≥100.4°F) was categorized as probable, possible, or unlikely to be incidentally detected. RESULTS: Temperature measurement occurred at 155 527 of 274 351 (58.9%) well-child visits. Of 24 clinics, 16 measured temperature at >90% of visits (“routine measurement clinics”) and 8 at <20% of visits (“occasional measurement clinics”). After adjusting for age, ethnicity, race, and insurance, antibiotic prescription was more common (adjusted odds ratio: 1.21; 95% CI 1.13–1.29), whereas diagnostic testing was less common (adjusted odds ratio: 0.76; 95% CI 0.71–0.82) at routine measurement clinics. Fever was detected at 270 of 155 527 (0.2%) routine measurement clinic visits, 47 (17.4%) of which were classified as probable incidental fever. Antibiotic prescription and diagnostic testing were more common at visits with probable incidental fever than without fever (7.4% vs 1.7%; 14.8% vs 1.2%; P < .001), and vaccines were deferred at 50% such visits. CONCLUSIONS: Temperature measurement occurs at more than one-half of well-child visits and is a clinic-driven practice. Given the impact on subsequent interventions and vaccine deferral, the harm–benefit profile of this practice warrants consideration.

scholarly journals Efficient Diagnostic Process for Technical Vulnerability

2019 ◽  
Vol 8 (2S6) ◽  
pp. 1-5
Keyword(s):  
Environmental Factors ◽  
Web Services ◽  
Diagnostic Test ◽  
Cyber Attacks ◽  
Diagnostic Process ◽  
Technical Aspects ◽  
Security Levels ◽  
Security Checks ◽  
The Impact

With the development of IT came advances and expansions in major information and communications infrastructure, which have in turn resulted in studies being continuously conducted to analyze the administrative and physical vulnerabilities of the operating institutions. However, such institutions are exposed to the threat of cyber attacks because these studies often exclude technical aspects due to technological difficulty. Furthermore, web services limit their security checks to certain vendors and are therefore unable to identify the exact level of security in place. This paper demonstrates that these limitations, when performing a diagnostic test for technical vulnerability, can impact security levels. Therefore, this paper proposes a process that considers several environmental factors when checking for technical vulnerability in order to minimize the impact on security levels.

Abstract 115: Improved Diagnostic Work-up of Patients Presenting to the Cardiologist with Symptoms of Suspected Obstructive Coronary Artery Disease: Results from the IMPACT (Investigation of a Molecular Personalized Coronary Gene Expression Test on Cardiology Practice Pattern) Trial

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
John A McPherson ◽  
Kelly Davis ◽  
May Yau ◽  
Phil Beineke ◽  
Steven Rosenberg ◽  
...  
Keyword(s):  
Gene Expression ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Diagnostic Test ◽  
Diagnostic Testing ◽  
Diagnostic Strategy ◽  
Control Cohort ◽  
Clinical Factors ◽  
Artery Disease ◽  
The Impact

Introduction: In a recently-published registry of over 14,000 patients (pts), the pretest probability of coronary artery disease (CAD) in pts referred for advanced cardiovascular imaging based on clinical factors overestimated the actual presence of disease. Better methods are needed to more accurately assess the CAD risk of pts in an office-based, non-invasive fashion. Hypothesis: We hypothesized that gene expression score (GES) results would lead to a change in the cardiologist’s diagnostic evaluation of stable pts presenting in the ambulatory setting with symptoms suggestive of obstructive CAD. Methods: The IMPACT Trial was a single center, prospective study which enrolled 88 consecutive pts with no history of CAD who were referred to five cardiologists for evaluation of chest pain and related symptoms. The cardiologist’s diagnostic strategy was evaluated before and after the GES was known (prospective arm) and was compared to the retrospective cohort. The retrospective control cohort was derived from pts matched by clinical factors to the prospective cohort. The GES is a validated quantitative blood-based diagnostic test for nondiabetic pts, measuring expression levels of 23 genes from peripheral blood cells to determine the likelihood of a patient having at least one vessel with ≥50% coronary artery stenosis. The primary outcome of interest was the change in the diagnostic testing pre/post GES as measured by McNemar’s test and logistic regression modeling. Results: Characteristics of the 83 pts eligible for primary endpoint analysis included 57 (69%) women, mean age of 53.3 years (SD±11), average BMI of 29.5 (SD±6), and mean GES of 12.5(SD±9). Chest pain was evaluated as typical, atypical and non-cardiac in 33%, 60%, and 7% of pts (n=27, 50 and 6), respectively. Hypertension and dyslipidemia was present in 55% and 48 % respectively. Following GES, a change in diagnostic testing (e.g. myocardial perfusion imaging, CTA and cardiac catheterization) was noted in 48 pts [58%, 95% CI (46%, 69%)]. More patients had a decreased versus increased level of testing (n=32 (39%) vs n=16 (19%), p=0.03). In particular, 91% (29 of 32) of pts with decreased testing had low GES (≤ 15), while 100% (16 of 16) of pts with increased testing had non-low GES (p<0.001). There were 13 pts referred to catheterization; 4/9 with non-low GES had lesions >70% stenosis and 0/4 with low GES had significant lesions. No major adverse cardiovascular events were observed for any patient at 30-day and at 6 months follow-up. The matched retrospective control cohort had higher rates of diagnostic test use compared with the post-GES evaluation of the prospective cohort (p<0.001). Conclusion: In this study of diagnostic evaluation for CAD, the GES was associated with a clinically relevant and statistically significant change in the diagnostic test utilization, including both decreased and increased use of testing in low and non-low GES pts, respectively. In conclusion, the addition of the GES showed clinical utility by simplifying the physician’s outpatient diagnostic strategy for suspected symptomatic CAD.

Multiple B-D Glucan and Cmv Test Ordering By Multiple Physicians – Analysis To Assess The Frequency Of Duplicate Test Orders

2020 ◽  
Vol 154 (Supplement_1) ◽  
pp. S152-S152
Author(s):  
S Fathima ◽  
A R Gardner ◽  
A J Sohn ◽  
R Benavides
Keyword(s):  
Viral Load ◽  
Chart Review ◽  
Medical Center ◽  
Direct Care ◽  
Teaching Hospitals ◽  
Multiple Test ◽  
Baylor University ◽  
Time Period ◽  
Time Stamps ◽  
Test Ordering

Abstract Introduction/Objective In teaching hospitals, patients receive direct care from a succession of different physicians, each of whom may order diagnostic tests on the same patient resulting in multiple physicians unknowingly ordering the same test in the same time period, leading to overutilization. We examined the association of test-ordering by multiple physicians with duplication of two tests, Beta D-Glucan (BDG) and CMV Viral Load by PCR non blood, as aid for detection of fungal and cytomegaloviral infections, respectively Methods Retrospective medical records at Baylor University Medical Center, Dallas were examined in between 10/1/2019- 10/30/2019. A total 167 test orders were identified for CMV Viral Load non blood and BDG presence in blood. Each medical record was assessed for frequency of ordering along with the physicians who ordered them Results A total 167 tests were ordered in which, 120 times BDG was ordered and 52 times CMV was ordered. Singleton orders were noted in 85(50%) instances of BDG & 30(17%) for CMV.Multiple test orders were 44 (25%) for BDG and 8 (4%) for CMV respectively. Both CMV and BDG were ordered together 57 times. The time stamps of multiple test orders in individual patients was assessed for instances of orders that were less than 3 days apart and analysis showed out of the 44 multiple test orders, 34% (15) test orders were ordered less than 3 days apart and 66%(29) tests were ordered more than 3 days apart for BDG. Upon chart review, most of these quickly successive orders were by different physicians. The estimated costs of the duplicate orders are 4334.0$ & 1104.16$ for BDG and CMV respectively. Conclusion CMV and BDG are commonly ordered on many patients. Analysis shows that many times, physicians order testing when the same test has been ordered very recently by a separate physician. Note that for both tests, retesting in less than three days is not normally indicated, however this happens often, especially for BDG. This is most likely due to difficulty in determining within the EHR what tests are drawn and “pending’ but not yet finalized and reported. With usage of prompts/ alerts in EMR that warn of existing “pending’ orders by another caregiver, the frequency of duplicate test ordering for the same patient may be reduced, in turn reducing the costs of healthcare.

scholarly journals Validity and Cost-Effectiveness of Pediatric Home Respiratory Polygraphy for the Diagnosis of Obstructive Sleep Apnea in Children: Rationale, Study Design, and Methodology

2021 ◽  
Vol 4 (1) ◽  
pp. 9
Author(s):  
Esther Oceja ◽  
Paula Rodríguez ◽  
María Jurado ◽  
Maria Luz Alonso ◽  
Genoveva del Río ◽  
...  
Keyword(s):  
Obstructive Sleep Apnea ◽  
Cost Effectiveness ◽  
Sleep Apnea ◽  
Therapeutic Interventions ◽  
Diagnostic Process ◽  
Urine Biomarkers ◽  
Obstructive Sleep ◽  
Respiratory Polygraphy ◽  
The Cost ◽  
The Impact

Obstructive sleep apnea (OSA) in children is a prevalent, albeit largely undiagnosed disease associated with a large spectrum of morbidities. Overnight in-lab polysomnography remains the gold standard diagnostic approach, but is time-consuming, inconvenient, and expensive, and not readily available in many places. Simplified Home Respiratory Polygraphy (HRP) approaches have been proposed to reduce costs and facilitate the diagnostic process. However, evidence supporting the validity of HRP is still scarce, hampering its implementation in routine clinical use. The objectives were: Primary; to establish the diagnostic and therapeutic decision validity of a simplified HRP approach compared to PSG among children at risk of OSA. Secondary: (a) Analyze the cost-effectiveness of the HRP versus in-lab PSG in evaluation and treatment of pediatric OSA; (b) Evaluate the impact of therapeutic interventions based on HRP versus PSG findings six months after treatment using sleep and health parameters and quality of life instruments; (c) Discovery and validity of the urine biomarkers to establish the diagnosis of OSA and changes after treatment.

scholarly journals 154. Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Adults with Acute Pharyngitis

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S87-S87
Author(s):  
Ebbing Lautenbach ◽  
Keith W Hamilton ◽  
Robert Grundmeier ◽  
Melinda M Neuhauser ◽  
Lauri Hicks ◽  
...  
Keyword(s):  
Chart Review ◽  
Inappropriate Prescribing ◽  
Antibiotic Use ◽  
University Of Pennsylvania ◽  
Antibiotic Prescribing ◽  
Acute Pharyngitis ◽  
Test Characteristics ◽  
Appropriate Prescribing ◽  
Concurrent Infections ◽  
The Impact

Abstract Background Although most antibiotic use occurs in outpatients, antibiotic stewardship programs (ASPs) have primarily focused on inpatients. A major challenge for outpatient ASPs is lack of accurate and accessible electronic data to target interventions. We developed and validated an electronic algorithm to identify inappropriate antibiotic use for adult outpatients with acute pharyngitis. Methods In the University of Pennsylvania Health System, we used ICD-10 diagnostic codes to identify patient encounters for acute pharyngitis at outpatient practices between 3/15/17 – 3/14/18. Exclusion criteria included immunocompromising conditions, comorbidities, and concurrent infections that might require antibiotic use. We randomly selected 300 eligible subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration included positive streptococcal testing, use of penicillin/amoxicillin (absent b-lactam allergy), and 10 days maximum duration of therapy. Results Of 300 subjects, median age was 42, 75% were female, 64% were seen by internal medicine (vs. family medicine), and 69% were seen by a physician (vs. advanced practice provider). On chart review, 127 (42%) subjects received an antibiotic, of which 29 had a positive streptococcal test and 4 had another appropriate indication. Thus, 74% (94/127) of patients received antibiotics inappropriately. Of the 29 patients who received appropriate prescribing, 27 (93%) received an appropriate antibiotic. Finally, of the 29 patients who were appropriately treated, 29 (100%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table. Conclusion Inappropriate antibiotic prescribing for acute pharyngitis is common. An electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future work. Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration Disclosures All Authors: No reported disclosures

scholarly journals SARS-CoV-2/DENV co-infection: a series of cases from the Federal District, Midwestern Brazil

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Heidi Luise Schulte ◽  
José Diego Brito-Sousa ◽  
Marcus Vinicius Guimarães Lacerda ◽  
Luciana Ansaneli Naves ◽  
Eliana Teles de Gois ◽  
...  
Keyword(s):  
Clinical Signs ◽  
Federal District ◽  
Therapeutic Interventions ◽  
Diagnostic Process ◽  
The Novel ◽  
Prevention Measures ◽  
Laboratory Findings ◽  
Novel Coronavirus ◽  
The Impact

Abstract Background Since the novel coronavirus disease outbreak, over 179.7 million people have been infected by SARS-CoV-2 worldwide, including the population living in dengue-endemic regions, particularly Latin America and Southeast Asia, raising concern about the impact of possible co-infections. Methods Thirteen SARS-CoV-2/DENV co-infection cases reported in Midwestern Brazil between April and September of 2020 are described. Information was gathered from hospital medical records regarding the most relevant clinical and laboratory findings, diagnostic process, therapeutic interventions, together with clinician-assessed outcomes and follow-up. Results Of the 13 cases, seven patients presented Acute Undifferentiated Febrile Syndrome and six had pre-existing co-morbidities, such as diabetes, hypertension and hypopituitarism. Two patients were pregnant. The most common symptoms and clinical signs reported at first evaluation were myalgia, fever and dyspnea. In six cases, the initial diagnosis was dengue fever, which delayed the diagnosis of concomitant infections. The most frequently applied therapeutic interventions were antibiotics and analgesics. In total, four patients were hospitalized. None of them were transferred to the intensive care unit or died. Clinical improvement was verified in all patients after a maximum of 21 days. Conclusions The cases reported here highlight the challenges in differential diagnosis and the importance of considering concomitant infections, especially to improve clinical management and possible prevention measures. Failure to consider a SARS-CoV-2/DENV co-infection may impact both individual and community levels, especially in endemic areas.

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