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Clinical Decisionmaking

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Missing clinical information during primary care visits is commonplace and can adversely affect patient care

In one of seven primary care visits, some important piece of data—a laboratory result, a letter from a consultant, a radiology report, or a hospital history—is not available at the time the patient is in the office, according to a study supported in part by the Agency for Healthcare Research and Quality (HS11878). The study was carried out by researchers at the University of Colorado Health Sciences Center in Denver.

Missing information leads to a waste of time and resources, and it may adversely affect patients. For example, in 60 percent of primary care visits with missing clinical information, clinicians reported that the lack of data was likely to result in either a delay in care or duplicate medical services. In 44 percent of such visits, physicians believed that the patients' well-being was likely to be placed at risk.

The researchers surveyed 253 clinicians in 32 primary care clinics within a Colorado consortium of practice-based research networks. The clinicians reported on 1,614 patient visits (patient and visit characteristics, including missing information) that occurred between May and December 2003. Clinicians reported missing clinical information in nearly 14 percent of visits. Missing information included laboratory results (6.1 percent of visits), letters/dictation (5.4 percent), radiology results (3.8 percent), history and physical examination findings (3.7 percent), and medication information (3.2 percent).

Missing information was reported to be somewhat likely to adversely affect patients (44 percent of visits) and to potentially result in delayed care or the need for additional services (59.5 percent of visits). Missing information was about twice as likely when patients were recent immigrants, new to the practice, or had multiple medical problems compared with no problems. Missing information was much less likely in rural practices, where patients see fewer health care providers, and in practices with full electronic records.

See "Missing clinical information during primary care visits," by Peter C. Smith, M.D., Rodrigo Araya-Guerra, B.A., Caroline Bublitz, M.S., and others, in the February 2, 2005, Journal of the American Medical Association 293(5), pp. 565-571.

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