Closing the Feedback Loop to Improve Diagnostic Quality

Distinct from the inpatient setting, ambulatory-based clinicians rarely have the opportunity to witness the impact of their treatment in a timely fashion. They therefore rarely learn whether their assessment was accurate and whether the prescribed treatment accomplished the desired effect. This lack of feedback means that incorrect diagnoses may not be detected, medication adverse events may not be recorded, and issues with medication adherence may not be addressed. This project developed an automated system to provide feedback on patient outcomes to clinicians working in ambulatory settings.

The main objectives of this project were to:

• Develop a system within three different ambulatory electronic health record systems in three different types of ambulatory settings that includes proactive followup of patients’ response to treatment (including medication adherence and adverse events) and feedback to health care providers.
• Assess the impact of automating the followup and feedback system. Impact will be measured in terms of: 1) diagnostic quality; 2) prevention of adverse events; 3) patient satisfaction with clinical care; and 4) health care costs.
• Develop and evaluate an automated system for feedback to emergency medicine physicians of the concordance between their initial diagnoses and patients’ final diagnostic outcomes.

There were three data collection phases in the primary study: 1) a telephone call to the patient 1 week after a visit with feedback provided to the physician; 2) contact with the patient via an interactive voice response (IVR) system, also conducted 1 week after a visit with feedback provided to the physician; and 3) a telephone call to the patient 3 weeks after a visit with no physician feedback provided. Measures included problem resolution, medication adherence, patient satisfaction, physician satisfaction, and cost impact. A secondary study conducted in the emergency department (ED) setting looked at the agreement between diagnoses made in the ED versus those given at the time of hospital discharge.

Approximately 15 percent of patients contacted at 1 week by telephone and IVR stated that their presenting issue remained unresolved. The IVR system reached fewer patients than the group who received a telephone call. Of those reached by IVR, a greater number of patients had problems which remained unresolved. Most of the individuals who did not improve had not contacted their providers to let them know their problem had continued.

Physicians who reviewed the provided feedback reported finding it helpful. Patient satisfaction was high for all three phases of the study, with those patients who received followup calls reporting more satisfaction with their overall care than those who did not receive calls. In the ED portion of the study, the diagnoses made in the ED differed from those made at the time of hospital discharge 10 percent of the time. The project team concluded that timely followup is feasible in the ambulatory setting and may catch issues at an earlier stage. The cost for such a system can be offset by an increase in revenue, improvements in the quality of care, and reduced costs due to the avoidance of hospitalizations.