Diagnostic Safety Research Improves Communication Tool for Older Adults and Primary Care Providers.

A MedStar Health Research Institute quality and patient safety study empowers older adults to communicate health concerns to providers more clearly for less risk of diagnostic error.

It’s often said communication is a two-way street. That’s especially true regarding diagnostic safety—efforts to foster timely and accurate diagnosis—in the primary care setting. Healthcare providers are medical experts, but patients are the experts of their health experience. Engaging patients in robust, well-rounded conversations about their health and wellness stories is paramount to quality care.

With grant funding from the Society to Improve Diagnosis in Medicine, we partnered with a small group of patients and providers from a large primary care clinic for a one-year pilot study. Our research focused on adapting and evaluating the effectiveness of the Agency for Healthcare Research and Quality (AHRQ) “Be the Expert on You” note sheet as a diagnostic communication tool for older adults (people over 65).

This one-page form asks three high-level questions:

• What’s prompting the visit?

• Any changes in health and providers?

• Open-ended opportunities for more information

But what’s missing?

Our study aimed to identify and make helpful modifications for older adult patients, implement the note sheet in clinical practice through plan-do-check-act (PDCA) phases, and evaluate the outcomes of this revised note sheet.

Primary care providers are trained in communication techniques that promote open and honest information sharing. Yet, older adults are at higher risk of experiencing diagnostic errors and some older adults may struggle to articulate health concerns. The reasons are as individual as the patient, ranging from managing multiple diseases to cognitive impairment to attributing pains to part of aging rather than a sign of a deeper issue. 

Communication breakdowns can make the complex diagnosis process even more challenging, contributing to an estimated 1 in 20 primary care patients who experience a diagnostic error each year across the U.S. This is why, from a quality perspective, practical communication tools are essential in capturing the older patient’s experience. 

Partnering with patients and providers to improve communication.

A diverse group of six patients participated in four in-person focus groups designed to help researchers understand their perspectives on the diagnostic process and AHRQ note sheet.

These candid conversations revealed opportunities to make meaningful language changes that encourage patient comfort and engagement, creating invitations to discuss concerns that patients may not volunteer, such as pain or mental health.

Physicians, nurses, and staff were trained on diagnostic safety concepts and implemented the revised sheet into a new workflow. This strengthened the note sheet through a checklist of diagnostic-related tasks and follow-up appointment information.

After a six-month, phased quality improvement period, survey data were examined to evaluate usability and effectiveness from the perspectives of both the clinic and its patients. The results were clear.

Clinic results indicated that 25% of clinic staff agreed their patients were organized with the critical health information needed to diagnose after implementing the note sheet, compared to only 4% before implementation. In addition, 83% of providers said patients effectively communicate their health needs compared to 33% before the note sheet was introduced. 

More than 30 older adult patients used the note sheet and responded to survey questions. Patient data showed 71% felt their thoughts were more organized with help from the note sheet, and 77% reported it helped them communicate with their physician.

This project demonstrates that the revised sheet is a relatively simple, helpful and appreciated diagnostic communication intervention that more efficiently engages older patients in their care team. 

Related reading: MedStar Health Researchers Partner with Patients to Improve Outcomes in Diagnostic Safety.

Benefits of the diagnostic communication note sheet.

This was a small study, but the positive response from both patients and providers within a short time period suggests that communication process improvements can impact patient care.

The positive results of this pilot study emphasize the benefits of using a simple form to improve communication, including:
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• A feasible process improvement within a busy clinic due to its ease of implementation

• Increased comfort using the printed note sheet format as opposed to other, potentially costly technologies that can be intimidating for some older patients

• The importance of partnering with patients and seeking input to guide successful quality improvement efforts

Diagnostic safety research for older adults continues.

We understand this is only one chapter in the story of improving older patient outcomes. There is still more work to be done as we expand our research to include caregivers and family members, who are critical historians and messengers about changes in older adult patients’ symptoms and can further improve diagnosis. 

We’ll consider how diagnostic communication can be expanded to better include caregiver involvement, and whether this or another similar intervention can capture their feedback and perspectives to help reduce diagnostic errors. We’ll also consider the diagnostic process for older adult patients with dementia, investigating whether an extended evaluation time for interventions can improve uptake and further impact outcomes.

If you or a loved one are interested in participating in future research on aging and safety, contact Dr. Alberta Tran.