Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation

Abstract

BackgroundObservational and experimental studies of the diagnostic task have demonstrated the importance of the first hypotheses that come to mind for accurate diagnosis. A prototype decision support system (DSS) designed to support GPs’ first impressions has been integrated with a commercial electronic health record (EHR) system.AimTo evaluate the prototype DSS in a high-fidelity simulation.Design and settingWithin-participant design: 34 GPs consulted with six standardised patients (actors) using their usual EHR. On a different day, GPs used the EHR with the integrated DSS to consult with six other patients, matched for difficulty and counterbalanced.MethodEntering the reason for encounter triggered the DSS, which provided a patient-specific list of potential diagnoses, and supported coding of symptoms during the consultation. At each consultation, GPs recorded their diagnosis and management. At the end, they completed a usability questionnaire. The actors completed a satisfaction questionnaire after each consultation.ResultsThere was an 8–9% absolute improvement in diagnostic accuracy when the DSS was used. This improvement was significant (odds ratio [OR] 1.41, 95% confidence interval [CI] = 1.13 to 1.77, P<0.01). There was no associated increase of investigations ordered or consultation length. GPs coded significantly more data when using the DSS (mean 12.35 with the DSS versus 1.64 without), and were generally satisfied with its usability. Patient satisfaction ratings were the same for consultations with and without the DSS.ConclusionThe DSS prototype was successfully employed in simulated consultations of high fidelity, with no measurable influences on patient satisfaction. The substantially increased data coding can operate as motivation for future DSS adoption.

The information distortion bias: implications for medical decisions

“…A review of the field indicates the potential for decision support systems (DSSs) to provide tailored differential diagnoses . For example, in one simulation, a computerised DSS led to an 8–9% improvement in diagnostic accuracy . Because ID is attached to a leading option, ideally interventions should target an early stage of a consultation before physicians have engaged in any hypothesis generation .…”

“…62 For example, in one simulation, a computerised DSS led to an 8-9% improvement in diagnostic accuracy. 63 Because ID is attached to a leading option, ideally interventions should target an early stage of a consultation before physicians have engaged in any hypothesis generation. 64 Two studies confirm that, compared to later stages of a diagnosis, computerised DSS intervention was most effective early in the diagnostic process before physicians started gathering information.…”

Electronic health record reviews to measure diagnostic uncertainty in primary care

“…Developing new codes to denote diagnostic uncertainty in the patient‐provider encounter could be one possible way of ensuring that diagnostic uncertainty is appropriately captured in the medical record . Using separate coding systems for diagnosis (eg, ICD‐10) and reason for encounter (eg, SNOMED CT) within a linked Episode of Care could also be explored as it can allow the diagnosis to evolve over time accounting for uncertainty . Improvements in current EHR systems and coding terminologies to “code” diagnostic uncertainty in the medical record as “structured data” may also be explored .…”

The TRANSFoRm project: Experience and lessons learned regarding functional and interoperability requirements to support primary care

“…First, a retrospective diabetes clinical‐genomic study, which demonstrated that linked genomic and clinical data, could be used across several countries using the same platform. Second, a diagnostic decision support system in case of chest pain, abdominal pain, and shortness of breath, which demonstrated that giving early prompts of diagnosis to clinicians was more favorable than giving late prompts . Third, a prospective acid reflux clinical study, an international RCT evaluating dosing regimen of proton pumps inhibitors (medication used for gastric reflux) on multiple sites .…”

“…Second, a diagnostic decision support system in case of chest pain, abdominal pain, and shortness of breath, 28 which demonstrated that giving early prompts of diagnosis to clinicians was more favorable than giving late prompts. 29 The framework described above can address the challenges mentioned earlier in knowledge production, transfer, and application.…”