Charting Diagnostic Safety: Exploring Patient-Provider Discordance in Medical Record Documentation

• Published in: Journal of general internal medicine : JGIM Vol. 40; no. 4; pp. 773 - 781
• Main Authors: Giardina, Traber D., Vaghani, Viral, Upadhyay, Divvy K., Scott, Taylor M., Korukonda, Saritha, Spitzmueller, Christiane, Singh, Hardeep
• Format: Journal Article
• Language: English
• Published: United States Springer Nature B.V 01.03.2025
• Subjects: Adult; Aged; Algorithms; Charts; Cohort Studies; Content analysis; Data collection; Discordance; Documentation - methods; Documentation - standards; Electronic health records; Electronic Health Records - standards; Electronic medical records; Female; Humans; Male; Medical diagnosis; Medical records; Middle Aged; Multivariate analysis; Patient Safety - standards; Patients; Pennsylvania; Physician-Patient Relations; Primary care; Qualitative analysis; Regression analysis; Self Report; Structured data; Summaries; Web portals; Pennsylvania; patient safety; diagnostic errors; OpenNotes; communication; patient experience
• ISSN: 0884-8734; 1525-1497; 1525-1497
• DOI: 10.1007/s11606-024-09007-y

The 21st Century Cures Act enables patients to access their medical records, thus providing a unique opportunity to engage patients in their diagnostic journey. To explore the concordance between patients' self-reported diagnostic concerns and clinician-interpreted information in their electronic health records. We conducted a mixed-methods analysis of a cohort of 467 patients who completed a structured data collection instrument (the Safer Dx Patient) to identify diagnostic concerns while reviewing their clinician's notes. We conducted a qualitative content analysis of open-ended responses on both the tools and the case summaries. Two clinical chart reviewers, blinded to patient-reported diagnostic concerns, independently conducted chart reviews using a different structured instrument (the Revised Safer Dx Instrument) to identify diagnostic concerns and generate case summaries. The primary outcome variable was chart review-identified diagnostic concerns. Multivariate logistic regression tested whether the primary outcome was concordant with patient-reported diagnostic concerns. Geisinger, a large integrated healthcare organization in rural and semi-urban Pennsylvania. Cohort of adult patients actively using patient portals and identified as "at-risk" for diagnostic concerns using an electronic trigger algorithm based on unexpected visit patterns in a primary care setting. In 467 cohort patients, chart review identified 31 (6.4%) diagnostic concerns, of which only 11 (21.5%) overlapped with 51 patient-reported diagnostic concerns. Content analysis revealed several areas of discordant understanding of the diagnostic process between clinicians and patients. Multivariate logistic regression analysis showed that clinician-identified diagnostic concerns were associated with patients who self-reported "I feel I was incorrectly diagnosed during my visit" (odds ratio 1.65, 95% CI 1.17-2.3, p < 0.05). Patients and clinicians appear to have certain differences in their mental models of what is considered a diagnostic concern. Efforts to integrate patient perspectives and experiences with the diagnostic process can lead to better measurement of diagnostic safety.