Chicago - A survey of clinicians indicates that missing clinical information for patients is common and may adversely affect patients, according to a study in the February 2 issue of JAMA.
Effectively managing clinical information (patient information such as demographics, medical history, medications, test results, and family structure) is an essential part of all medical care, according to background information in the article. Unfortunately, multiple barriers complicate the collecting, synthesizing, recording, and sharing of clinical information, including privacy regulations, decentralized medical systems, inadequate interprofessional communication, the transfer of patients' care within and across care settings, and the rapid turnover of patients' insurance plans. Accordingly, physicians may not have clinical information available when it is important for a patient's care. Missing clinical information has been implicated in injurious adverse events, but has not yet been explicitly investigated in the primary care setting.
Peter C. Smith, M.D., and colleagues with the University of Colorado Health Sciences Center at Fitzsimons, Aurora, Colo., surveyed primary care clinicians about clinical information reported as missing during patient care visits. The survey was conducted at 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1,614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing.
The researchers found that clinicians reported missing clinical information in 13.6 percent of visits (nearly 1 in 7 visits); missing information included laboratory results (6.1 percent of all visits), letters/dictation (5.4 percent), radiology results (3.8 percent), history and physical examination (3.7 percent), and medications (3.2 percent). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3 percent), to be at least somewhat likely to adversely affect patients (44 percent), and to potentially result in delayed care or additional services (59.5 percent). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6 percent; greater than 10 minutes, 10.4 percent).
Reported missing clinical information was more likely when patients were recent immigrants (about 80 percent more likely), new patients (2.4 times more likely), or had multiple medical problems compared with no problems (2-5 problems: 87 percent more likely; more than 5 problems: 2.8 times more likely). Missing clinical information was less likely in rural practices (48 percent less likely) and when individual clinicians reported having full electronic records (60 percent less likely).
"If validated by future research, these results could have serious implications for the 220 million primary care visits that occur in the United States each year," the authors write.
"This is the first direct study of missing clinical information in primary care, in contrast to retrospective detection of missing information as the etiology of a medical error or adverse event. It demonstrates reports of a high frequency of missing important clinical information, with a wide array of potential impact on patient care. Additional research on missing clinical information should focus on validating clinicians' perceptions and conducting prospective studies of its actual causes and sequelae," the authors conclude.
(JAMA. 2005;293:565-571. Available post-embargo at JAMA.com)
Editor's Note: For funding and support information, please see the JAMA article.
