The Electronic Health Record feedback journey of a thousand miles begins with . . .

At some point in most clinical careers, a patient recently seen by the clinician will be diagnosed by a subsequent clinician with something either unusual or unexpected. Ideally, the first clinician would learn of this new diagnosis quickly and have time and space for reflection, self-evaluation, and identification of anything they could have done differently. This type of diagnostic feedback may be most likely to occur during graduate medical education, where team structures are constructed to allow oversight and education, and feedback on medical knowledge and diagnostic reasoning are intended to be part of the educational process. However, such feedback loops often become much harder to create or identify after the end of graduate training, particularly when busy clinicians may be managing high patient volumes across large clinical networks and broad geographic areas.

In their recent article, Cifra and colleagues propose health information technology solutions to support clinical management feedback systems. In their model (Figure 1), either a downstream clinical team member or even the patient would communicate with the original clinician, and a formalized feedback system enabled through electronic health records (EHRs) would facilitate such communication in a timely manner. As the authors note, consistently providing and receiving such feedback would normalize use of such a system and reduce the need for upstream clinicians to proactively seek such feedback. Additionally, formalizing this practice as a standard of care would have the added benefit of removing some concerns around possible confrontation or judgment that may make clinicians reluctant to solicit feedback.

But how do we get there? The current state of clinical feedback often leaves both upstream and downstream clinicians unsatisfied, and numerous barriers to improved systems exist. Within a health system or shared EHR, pre-existing messaging functions could serve for many feedback communications; however, most clinicians already spend significant time outside clinical encounters managing EHR messaging and notifications1,2 and many messages may be withheld given medicolegal concerns. When crossing health systems or EHRs, a lack of interoperability may make even such messages impossible.

Eventually, larger multidisciplinary and policy decisions will be required to facilitate the creation, proliferation and use of robust feedback systems. In the interim, some possible first steps include creation of local, protected databases where downstream team members could flag a case for notification to other team members. These databases could be engineered to extract some patient identification and recent diagnosis data automatically, similar to many existing safety reporting systems, in an effort to minimize data entry burdens. To further streamline workflows, links could be designed to transfer downstream clinicians working in that patient’s record directly to this protected workspace. Once there, a thoughtful series of suggested standardized feedback notifications, similar to response prompts found in many current email systems, could save entry time and improve the quality of the feedback shared.

Additional thought should be given to the experience of upstream clinicians. First, feedback messages for the upstream clinicians should be presented non-judgmentally, inviting the clinician to review the case as an opportunity for learning. Second, not only should these team members be able to receive notification quickly and confidentially from downstream clinicians, they should also be able to request feedback on patients for whom they have diagnostic concerns through similar systems. Historically, many clinicians kept lists of patients whose course they wished to track as a personal audit mechanism; however, such paper lists have been discouraged in many settings3 and maintaining and reviewing such lists requires additional time and effort. If clinicians were able to flag a limited number of patients and receive automatic notifications about future diagnoses just as they receive standard notifications such as lab results, they could choose to spend additional time on reflective skill-building activities in almost real-time as additional information becomes available.

Overall, improving feedback on individual patient outcomes would strike many clinicians as an incredibly valuable benefit of working within an EHR. Integrating the process into current workflows with some degree of automation and standardization would reduce the time required for each individual case review and likely would increase the number of such reviews undertaken. As Cifra and colleagues note, hopefully, the technical, organisational, and political energy can now be gathered to help bridge this feedback gap.

Joel Boggan

1. Murphy D.R., et al., The burden of inbox notifications in commercial electronic health records. JAMA Intern Med. 2016;176(4):559-60.
2. Murphy D.R., et al. Notifications received by primary care practitioners in electronic health records: a taxonomy and time analysis. Am J Med. 2012;125(2):209.e1-209.e7.
3. Bowen J.L., et al. Chart stalking, list making, and physicians’ efforts to track patients’ outcomes after transitioning responsibility. Med Educ. 2018;52(4):404-413.

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