A physical exam may include an analysis of many parts of the body, not just those suspected to be involved in the patient's current complaint. A careful physical exam can help a clinician refine the next steps in the diagnostic process, can prevent unnecessary diagnostic testing, and can aid in building trust with the patient Verghese, There is no universally agreed upon physical examination checklist; myriad versions exist online and in textbooks.
Due to the growing emphasis on diagnostic testing, there are concerns that physical exam skills have been underemphasized in current health care professional education and training Kassirer, ; Kugler and Verghese, For example, Kugler and Verghese have asserted that there is a high degree in variability in the way that trainees elicit physical signs and that residency programs have not done enough to evaluate and improve physical exam techniques.
Educators observe students and residents performing these 25 maneuvers to ensure that trainees are able to elicit the physical signs reliably Stanford Medicine 25 Team, Over the past years, diagnostic testing has become a critical feature of standard medical practice Berger, ; European Society of Radiology, Diagnostic testing may occur in successive rounds of information gathering, integration, and interpretation, as each round of information refines the working diagnosis.
In many cases, diagnostic testing can identify a condition before it is clinically apparent; for example, coronary artery disease can be identified by an imaging study indicating the presence of coronary artery blockage even in the absence of symptoms.
The primary emphasis of this section focuses on laboratory medicine, anatomic pathology, and medical imaging see Box However, there are many important forms of diagnostic testing that extend beyond these fields, and the committee's conceptual model is intended to be broadly applicable. Aditional forms of diagnostic testing include, for example, screening tools used in making mental health diagnoses SAMHSA and HRSA, , sleep apnea testing, neurocognitive assessment, and vision and hearing testing.
Although it was developed specifically for laboratory medicine, the brain-to-brain loop model is useful for describing the general process of diagnostic testing Lundberg, ; Plebani et al.
The model includes nine steps: test selection and ordering, sample collection, patient identification, sample transportation, sample preparation, sample analysis, result reporting, result interpretation, and clinical action Lundberg, These steps occur during five phases of diagnostic testing: prepre-analytic, pre-analytic, analytic, post-analytic, and post-post-analytic phases.
Errors related to diagnostic testing can occur in any of these five phases, but the analytic phase is the least susceptible to errors Eichbaum et al. The pre-pre-analytic phase, which involves clinician test selection and ordering, has been identified as a key point of vulnerability in the work process due to the large number and variety of available tests, which makes it difficult for nonspecialist clinicians to accurately select the correct test or series of tests Hickner et al.
The pre-analytic phase involves sample collection, patient identification, sample transportation, and sample preparation. During the analytic phase, the specimen is tested, examined, or both. Adequate performance in this phase depends on the correct execution of a chemical analysis or morphological examination Hollensead et al. The post-analytic phase includes the generation of results, reporting, interpretation, and follow-up. Ensuring accurate and timely reporting from the laboratory to the ordering clinician and patient is central to this phase.
During the post-post-analytic phase, the ordering clinician, sometimes in consultation with pathologists, incorporates the test results into the patient's clinical context, considers the probability of a particular diagnosis in light of the test results, and considers the harms and benefits of future tests and treatments, given the newly acquired information. Possible factors contributing to failure in this phase include an incorrect interpretation of the test result by the ordering clinician or pathologist and the failure by the ordering clinician to act on the test results: for example, not ordering a follow-up test or not providing treatment consistent with the test results Hickner et al.
The medical imaging work process parallels the work process described for pathology. There is a pre-pre-analytic phase the selection and ordering of medical imaging , a pre-analytic phase preparing the patient for imaging , an analytic phase image acquisition and analysis , a post-analytic phase the imaging results are interpreted and reported to the ordering clinician or the patient , and a post-post-analytic phase the integration of results into the patient context and further action.
The relevant differences between the medical imaging and pathology processes include the nature of the examination and the methods and technology used to interpret the results. Primary care clinicians order laboratory tests in slightly less than one third of patient visits CDC, ; Hickner et al. There are now thousands of molecular diagnostic tests available, and this number is expected to increase as the mechanisms of disease at the molecular level are better understood CDC, ; Johansen Taber et al.
The task of selecting the appropriate diagnostic testing is challenging for clinicians, in part because of the sheer volume of choices. For example, Hickner and colleagues found that primary care clinicians report uncertainty in ordering laboratory medicine tests in approximately 15 percent of diagnostic encounters. Choosing the appropriate test requires understanding the patient's history and current signs and symptoms, as well as having a sufficient suspicion or pre-test probability of a disease or condition see section on probabilistic reasoning Pauker and Kassirer, , ; Sox, The likelihood of disease is inherently uncertain in this step; for instance, the clinician's patient population may not reflect epidemiological data, and the patient's history can be incomplete or otherwise complicated.
Advances in molecular diagnostic technologies and new diagnostic tests have introduced another layer of complexity. Many clinicians are struggling to keep up with the growing availability of such tests and have uncertainty about the best application of these tests in screening, diagnosis, and treatment IOM, a ; Johansen Taber et al.
Even if a test is performed correctly, there is a chance for a false positive or false negative result. Test interpretation involves reviewing numerical or qualitative yes or no results and combining those results with patient history, symptoms, and pretest disease likelihood. Test interpretation needs to be patient-specific and to consider information learned during the physical exam and the clinical history and interview. Several studies have highlighted test interpretation errors, such as the misinterpretation of a false positive human immunodeficiency virus HIV screening test for a low-risk patient as indicative of HIV infection Gigerenzer, ; Kleinman et al.
In addition, test performance may only be characterized in a limited patient population, leading to challenges with generalizability Whiting et al. The laboratories that conduct diagnostic testing are some of the most regulated and inspected areas in health care see Table Some of the relevant entities include The Joint Commission and other accreditors, the federal government, and various other organizations, such as the College of American Pathologists CAP and the American Society for Clinical Pathology.
There are many ways in which quality is assessed. Examples include proficiency testing of clinical laboratory assays and pathologists e. Medical imaging plays a critical role in establishing the diagnoses for innumerable conditions and it is used routinely in nearly every branch of medicine.
The advancement of imaging technologies has improved the ability of clinicians to detect, diagnose, and treat conditions while also allowing patients to avoid more invasive procedures European Society of Radiology, ; Gunderman, For many conditions e. The appropriate choice of imaging modality depends on the disease, organ, and specific clinical questions to be addressed.
Computed tomography CT and magnetic resonance imaging MRI are first-line methods for assessing conditions of the central and peripheral nervous system, while for musculoskeletal and a variety of other conditions, X-ray and ultrasound are often employed first because of their relatively low cost and ready availability, with CT and MRI being reserved as problem-solving modalities.
CT procedures are frequently used to assess and diagnose cancer, circulatory system diseases and conditions, inflammatory diseases, and head and internal organ injuries. A majority of MRI procedures are performed on the spine, brain, and musculoskeletal system, although usage for the breast, prostate, abdominal, and pelvic regions is rising IMV, Medical imaging is characterized not just by the increasingly precise anatomic detail it offers but also by an increasing capacity to illuminate biology.
For example, magnetic resonance spectroscopic imaging has allowed the assessment of metabolism, and a growing number of other MRI sequences are offering information about functional characteristics, such as blood perfusion or water diffusion. Functional and molecular imaging data may be assessed qualitatively, quantitatively, or both.
Although other forms of diagnostic testing can identify a wide array of molecular markers, molecular imaging is unique in its capacity to noninvasively show the locations of molecular processes in patients, and it is expected to play a critical role in advancing precision medicine, particularly for cancers, which often demonstrate both intra- and intertumoral biological heterogeneity Hricak, The growing body of medical knowledge, the variety of imaging options available, and the regular increases in the amounts and kinds of data that can be captured with imaging present tremendous challenges for radiologists, as no individual can be expected to achieve competency in all of the imaging modalities.
General radiologists continue to be essential in certain clinical settings, but extended training and sub-specialization are often necessary for optimal, clinically relevant image interpretation, as is involvement in multidisciplinary disease management teams. Furthermore, the use of structured reporting templates tailored to specific examinations can help to increase the clarity, thoroughness, and clinical relevance of image interpretation Schwartz et al.
Like other forms of diagnostic testing, medical imaging has limitations. Some studies have found that between 20 and 50 percent of all advanced imaging results fail to provide information that improves patient outcome, although these studies do not account for the value of negative imaging results in influencing decisions about patient management Hendee et al.
Imaging may fail to provide useful information because of modality sensitivity and specificity parameters; for example, the spatial resolution of an MRI may not be high enough to detect very small abnormalities.
Inadequate patient education and preparation for an imaging test can also lead to suboptimal imaging quality that results in diagnostic error. Perceptual or cognitive errors made by radiologists are a source of diagnostic error Berlin, ; Krupinski et al. In addition, incomplete or incorrect patient information, as well as insufficient sharing of patient information, may lead to the use of an inadequate imaging protocol, an incorrect interpretation of imaging results, or the selection of an inappropriate imaging test by a referring clinician.
Referring clinicians often struggle with selecting the appropriate imaging test, in part because of the large number of available imaging options and gaps in the teaching of radiology in medical schools. Although consensus-based guidelines e. The use of clinical decision support systems at the point of care as well as direct consultations with radiologists have been proposed by the ACR as methods for improving imaging test selection Allen and Thorwarth, There are several mechanisms for ensuring the quality of medical imaging.
The Mammography Quality Standards Act MQSA —overseen by the Food and Drug Administration—was the first government-mandated accreditation program for any type of medical facility; it was focused on X-ray imaging for breast cancer.
MQSA provides a general framework for ensuring national quality standards in facilities that perform screening mammography IOM, MQSA requires all personnel at facilities to meet initial qualifications, to demonstrate continued experience, and to complete continuing education.
MQSA addresses protocol selection, image acquisition, interpretation and report generation, and the communication of results and recommendations. In addition, it provides facilities with data on diagnostic performance that can be used for benchmarking, self-monitoring, and improvement.
MQSA has decreased the variability in mammography performed across the United States and improved the quality of care Allen and Thorwarth, However, the ACR noted that MQSA is complex and specified in great detail, which makes it inflexible, leading to administrative burdens and the need for extensive training of staff for implementation Allen and Thorwarth, It also focuses on only one medical imaging modality in one disease area; thus, it does not address newer screening technologies IOM, The requirements include personnel qualifications, image quality, equipment performance, safety standards, and quality assurance and quality control ACR, a.
MIPPA also mandated that, beginning in , ordering clinicians will be required to consult appropriateness criteria to order advanced medical imaging procedures, and the act called for a demonstration project evaluating clinician compliance with appropriateness criteria Timbie et al. Clinicians may refer to or consult with other clinicians formally or informally to seek additional expertise about a patient's health problem.
The consult may help to confirm or reject the working diagnosis or may provide information on potential treatment options. If a patient's health problem is outside a clinician's area of expertise, he or she can refer the patient to a clinician who holds more suitable expertise.
Clinicians can also recommend that the patient seek a second opinion from another clinician to verify their impressions of an uncertain diagnosis or if they believe that this would be helpful to the patient. Diagnostic consultations can also be arranged through the use of integrated practice units or diagnostic management teams Govern, ; Porter, ; see Chapter 4. The committee elaborated on several aspects of the diagnostic process which are discussed below, including.
One of the complexities in the diagnostic process is the inherent uncertainty in diagnosis. As noted in the committee's conceptual model of the diagnostic process, an overarching question throughout the process is whether sufficient information has been collected to make a diagnosis.
This does not mean that a diagnosis needs to be absolutely certain in order to initiate treatment. Kassirer concluded that:. Absolute certainty in diagnosis is unattainable, no matter how much information we gather, how many observations we make, or how many tests we perform.
A diagnosis is a hypothesis about the nature of a patient's illness, one that is derived from observations by the use of inference. As the inferential process unfolds, our confidence as [clinicians] in a given diagnosis is enhanced by the gathering of data that either favor it or argue against competing hypotheses. Our task is not to attain certainty, but rather to reduce the level of diagnostic uncertainty enough to make optimal therapeutic decisions.
Kassirer, , p. Thus, the probability of disease does not have to be equal to one diagnostic certainty in order for treatment to be justified Pauker and Kassirer, The decision to begin treatment based on a working diagnosis is informed by: 1 the degree of certainty about the diagnosis; 2 the harms and benefits of treatment; and 3 the harms and benefits of further information-gathering activities, including the impact of delaying treatment.
The risks associated with diagnostic testing are important considerations when conducting information-gathering activities in the diagnostic process. While underuse of diagnostic testing has been a long-standing concern, overly aggressive diagnostic strategies have recently been recognized for their risks Zhi et al.
It's the scan, the test, the operation that I should have done that sticks with me—sometimes for years. However, there is growing recognition that overly aggressive diagnostic pursuits are putting patients at greater risk for harm, and they are not improving diagnostic certainty Kassirer, ; Welch, When considering diagnostic testing options, the harm from the procedure itself needs to be weighed against the potential information that could be gained.
For some patients, the risk of invasive diagnostic testing may be inappropriate due to the risk of mortality or morbidity from the test itself such as cardiac catheterization or invasive biopsies. In addition, the risk for harm needs to take into account the cascade of diagnostic testing and treatment decisions that could stem from a diagnostic test result.
Included in these assessments are the potential for false positives and ambiguous or slightly abnormal test results that lead to further diagnostic testing or unnecessary treatment.
There are some cases in which treatment is initiated even though there is limited certainty in a working diagnosis. For example, an individual who has been exposed to a tick bite or HIV may be treated with prophylactic antibiotics or antivirals, because the risk of treatment may be felt to be smaller than the risk of harm from tick-borne diseases or HIV infection. Clinicians sometimes employ empiric treatment strategies—or the provision of treatment with a very uncertain diagnosis—and use a patient's response to treatment as an information-gathering activity to help arrive at a working diagnosis.
However, it is important to note that response rates to treatment can be highly variable, and the failure to respond to treatment does not necessarily reflect that a diagnosis is incorrect. Nor does improvement in the patient's condition necessarily validate that the treatment conferred this benefit and, therefore, that the empirically tested diagnosis was in fact correct.
A treatment that is beneficial for some patients might not be beneficial for others with the same condition Kent and Hayward, , hence the interest in precision medicine, which is hoped to better tailor therapy to maximize efficacy and minimize toxicity Jameson and Longo, In addition, there are isolated cases where the morbidity and the mortality of a diagnostic procedure and the likelihood of disease is sufficiently high that significant therapy has been given empirically.
Moroff and Pauker described a decision analysis in which a year-old practicing lawyer with a new 1. Of major importance in the diagnostic process is the element of time. Most diseases evolve over time, and there can be a delay between the onset of disease and the onset of a patient's symptoms; time can also elapse before a patient's symptoms are recognized as a specific diagnosis Zwaan and Singh, Some diagnoses can be determined in a very short time frame, while months may elapse before other diagnoses can be made.
This is partially due to the growing recognition of the variability and complexity of disease presentation. Similar symptoms may be related to a number of different diagnoses, and symptoms may evolve in different ways as a disease progresses; for example, a disease affecting multiple organs may initially involve symptoms or signs from a single organ. The thousands of different diseases and health conditions do not present in thousands of unique ways; there are only a finite number of symptoms with which a patient may present.
At the outset, it can be very difficult to determine which particular diagnosis is indicated by a particular combination of symptoms, especially if symptoms are nonspecific, such as fatigue. Diseases may also present atypically, with an unusual and unexpected constellation of symptoms Emmett, Adding to the complexity of the time-dependent nature of the diagnostic process are the numerous settings of care in which diagnosis occurs and the potential involvement of multiple settings of care within a single diagnostic process.
Some diagnoses may be more important to establish immediately than others. These include diagnoses that can lead to significant patient harm if not recognized, diagnosed, and treated early, such as anthrax, aortic dissection, and pulmonary embolism.
Sometimes making a timely diagnosis relies on the fast recognition of symptoms outside of the health care setting e. In these cases, the benefit of treating the disease promptly can greatly exceed the potential harm from unnecessary treatment. Consequently, the threshold for ordering diagnostic testing or for initiating treatment becomes quite low for such health problems Pauker and Kassirer, , In other cases, the potential harm from rapidly and unnecessarily treating a diagnosed condition can lead to a more conservative or higher-threshold approach in the diagnostic process.
Population trends, such as the aging of the population, are adding significant complexity to the diagnostic process and require clinicians to consider such complicating factors in diagnosis as comorbidity, polypharmacy and attendant medication side effects, as well as disease and medication interactions IOM, , b.
Diagnosis can be especially challenging in older patients because classic presentations of disease are less common in older adults Jarrett et al. For example, infections such as pneumonia or urinary tract infections often do not present in older patients with fever, cough, and pain but rather with symptoms such as lethargy, incontinence, loss of appetite, or disruption of cognitive function Mouton et al.
Acute myocardial infarction MI may present with fatigue and confusion rather than with typical symptoms such as chest pain or radiating arm pain Bayer et al. Sensory limitations in older adults, such as hearing and vision impairments, can also contribute to challenges in making diagnoses Campbell et al.
Physical illnesses often present with a change in cognitive status in older individuals without dementia Mouton et al. In older adults with mild to moderate dementia, such illnesses can manifest with worsening cognition. Older patients who have multiple comorbidities, medications, or cognitive and functional impairments are more likely to have atypical disease presentations, which may increase the risk of experiencing diagnostic errors Gray-Miceli, Communicating with diverse populations can also contribute to the complexity of the diagnostic process.
Language, health literacy, and cultural barriers can affect clinician—patient encounters and increase the potential for challenges in the diagnostic process Flores, ; IOM, ; The Joint Commission, There are indications that biases influence diagnosis; one well-known example is the differential referral of patients for cardiac catheterization by race and gender Schulman et al. In addition, women are more likely than men to experience a missed diagnosis of heart attack, a situation that has been partly attributed to real and perceived gender biases, but which may also be the result of physiologic differences, as women have a higher likelihood of presenting with atypical symptoms, including abdominal pain, shortness of breath, and congestive heart failure Pope et al.
Mental health diagnoses can be particularly challenging. Mental health diagnoses rely on the Diagnostic and Statistical Manual of Mental Disorders DSM ; each diagnosis in the DSM includes a set of diagnostic criteria that indicate the type and length of symptoms that need to be present, as well as the symptoms, disorders, and conditions that cannot be present, in order to be considered for a particular diagnosis APA, Compared to physical diagnoses, many mental health diagnoses rely on patient reports and observation; there are few biological tests that are used in such diagnoses Pincus, A key challenge can be distinguishing physical diagnoses from mental health diagnoses; sometimes physical conditions manifest as psychiatric ones, and vice versa Croskerry, a ; Hope et al.
In addition, there are concerns about missing psychiatric diagnoses, as well as overtreatment concerns Bor, ; Meyer and Meyer, ; Pincus, For example, clinician biases toward older adults can contribute to missed diagnoses of depression, because it may be perceived that older adults are likely to be depressed, lethargic, or have little interest in interactions. Patients with mental health—related symptoms may also be more vulnerable to diagnostic errors, a situation that is attributed partly to clinician biases; for example, clinicians may disregard symptoms in patients with previous diagnoses of mental illness or substance abuse and attribute new physical symptoms to a psychological cause Croskerry, a.
Individuals with health problems that are difficult to diagnose or those who have chronic pain may also be more likely to receive psychiatric diagnoses erroneously. Accurate, timely, and patient-centered diagnosis relies on proficiency in clinical reasoning, which is often regarded as the clinician's quintessential competency. Understanding the clinical reasoning process and the factors that can impact it are important to improving diagnosis, given that clinical reasoning processes contribute to diagnostic errors Croskerry, a ; Graber, Clinical reasoning occurs within clinicians' minds facilitated or impeded by the work system and involves judgment under uncertainty, with a consideration of possible diagnoses that might explain symptoms and signs, the harms and benefits of diagnostic testing and treatment for each of those diagnoses, and patient preferences and values.
The current understanding of clinical reasoning is based on the dual process theory, a widely accepted paradigm of decision making. The dual process theory integrates analytical and non-analytical models of decision making see Box Analytical models slow system 2 involve a conscious, deliberate process guided by critical thinking Kahneman, Nonanalytical models fast system 1 involve unconscious, intuitive, and automatic pattern recognition Kahneman, Fast system 1 nonanalytical, intuitive automatic processes require very little working memory capacity.
They are often triggered by stimuli or result from overlearned associations or implicitly learned activities. In contrast, slow system 2 reflective, analytical processing places a heavy load on working memory and involves hypothetical and counterfactual reasoning Evans and Stanovich, ; Stanovich and Toplak, System 2 processing requires individuals to generate mental models of what should or should not happen in particular situations, in order to test possible actions or to explore alternative causes of events Stanovich, Counterfactual reasoning occurs when one thinks about what should occur if the situation differed from how it actually is.
The deliberate, conscious, and reflective nature of both hypothetical and counterfactual reasoning illustrates the analytical nature of system 2. Heuristics—mental shortcuts or cognitive strategies that are automatically and unconsciously employed—are particularly important for decision making Gigerenzer and Goldstein, Heuristics can facilitate decision making but can also lead to errors, especially when patients present with atypical symptoms Cosmides and Tooby, ; Gigerenzer, ; Kahneman, ; Klein, ; Lipshitz et al.
When a heuristic fails, it is referred to as a cognitive bias. Cognitive biases, or predispositions to think in a way that leads to failures in judgment, can also be caused by affect and motivation Kahneman, Prolonged learning in a regular and predictable environment increases the success-fulness of heuristics, whereas uncertain and unpredictable environments are a chief cause of heuristic failure Kahneman, ; Kahneman and Klein, There are many heuristics and biases that affect clinical reasoning and decision making see Table for medical and nonmedical examples.
Additional examples of heuristics and biases that affect decision making and the potential for diagnostic errors are described below Croskerry, b :.
In addition to cognitive biases, research suggests that fallacies in reasoning, ethical violations, and financial and nonfinancial conflicts of interest can influence medical decision making Seshia et al. The interaction between fast system 1 and slow system 2 remains controversial. Some hold that these processes are constantly occurring in parallel and that any conflicts are resolved as they arise.
Others have argued that system 1 processes generate an individual's default response and that system 2 processes may or may not intervene and override system 1 processing Evans and Stanovich, ; Kahneman, When system 2 overrides system 1, this can lead to improved decision making, because engaging in analytical reasoning may correct for inaccuracies. It is important to note that slow system 2 processing does not guarantee correct decision making.
For instance, clinicians with an inadequate knowledge base may not have the information necessary to make a correct decision. There are some instances when system 1 processing is correct, and the override from system 2 can contribute to incorrect decision making. However, when system 1 overrides system 2 processing, this can also result in irrational decision making. Intervention by system 2 is likely to occur in novel situations when the task at hand is difficult; when an individual has minimal knowledge or experience Evans and Stanovich, ; Kahneman, ; or when an individual deliberately employs strategies to overcome known biases Croskerry et al.
Monitoring and intervention by system 2 on system 1 is unlikely to catch every failure because it is inefficient and would require sustained vigilance, given that system 1 processing often leads to correct solutions Kahneman, Factors that affect working memory can impede the ability of system 2 to monitor and, when necessary, intervene on system 1 processes Croskerry, b.
For example, if clinicians are tired or distracted by elements in the work system, they may fail to recognize when a decison provided by system 1 processing needs to be reconsidered Croskerry, b.
System 1 and system 2 perform optimally in different types of clinical practice settings. System 1 performs best in highly reliable and predictable environments but falls short in uncertain and irregular settings Kahneman and Klein, ; Stanovich, System 2 performs best in relaxed and unhurried environments.
This section applies the dual process theory of clinical reasoning to the diagnostic process Croskerry, a , b ; Norman and Eva, ; Pelaccia et al. Journal of the American Medical Informatics Association 15 6 — Divall, P. Camosso-Stefinovic, and R. The use of personal digital assistants in clinical decision making by health care professionals: A systematic review.
Health Informatics Journal 19 1 — Dunklin, R. Dallas Morning News , December 6. Dunn, B. Choi, D. Recla, S. Kerr, and B. Seminars in Diagnostic Pathology 26 4 — Dwoskin, E. Can data from your fitbit transform medicine? The Wall Street Journal, June El-Kareh, R.
Use of health information technology to reduce diagnostic error. Examining the U. October Epner, P. January 13, , Washington, DC. Fratzke, J. Tucker, H. Shedenhelm, J. Arnold, T. Belda, and M. Enhancing nursing practice by utilizing voice recognition for direct documentation. Journal of Nursing Administration 44 2 — Friedman, A. Crosson, J. Howard, E. Clark, M. Pellerano, B. Karsh, B. Crabtree, C. Jaen, and D.
A typology of electronic health record workarounds in small-to-medium size primary care practices. Journal of the American Medical Informatics Association 21 e1 :e78—e Friedman, C.
Elstein, F. Wolf, G. Murphy, T. Franz, P. Heckerling, P. Fine, T. Miller, and V. JAMA — Furukawa, M. King, V. Patel, C. Hsiao, J. Adler—Milstein, and A. Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings.
Health Affairs Millwood 33 9 — Gandhi, T. Sittig, M. Franklin, A. Sussman, D. Fairchild, and D. Communication breakdown in the outpatient referral process. Journal of General Internal Medicine 15 9 — Gasson, S. Human-centered vs. Journal of Information Technology Theory and Application 5 2 — Gawande, A. New York: Picador. Goddard, K. Roudsari, and J. Automation bias: A systematic review of frequency, effect mediators, and mitigators. Journal of the American Medical Informatics Association 19 1 — Goodman, K.
Sands, P. Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: A report of an AMIA special task force. Journal of the American Medical Informatics Association 18 1 — Graber, M. The incidence of diagnostic error in medicine.
Performance of a web-based clinical diagnosis support system for internists. Journal of General Internal Medicine 23 Suppl 1 — Graham, A. Bhattacharyya, K. Scott, F. Lian, L. Grasso, L. Richter, J. Carpenter, S. Chiang, J. Henderson, A. Lopez, G.
Barker, and R. Virtual slide telepathology for an academic teaching hospital surgical pathology quality assurance program. Human Pathology 40 8 — Greenhalgh, T. Hinder, K. Stramer, T. Bratan, and J. Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace.
BMJ c Harrington, L. Kennerly, and C. Safety issues related to the electronic medical record EMR : Synthesis of the literature from the last decade, — Journal of Healthcare Management 56 1 —43; discussion 43— Hartung, D. Hunt, J. Siemienczuk, H. Miller, and D. Clinical implications of an accurate problem list on heart failure treatment.
Journal of General Internal Medicine 20 2 — Hawkins, C. Anton, W. Bankes, A. Leach, M. Zeno, R. Pryor, and D. Improving the availability of clinical history accompanying radiographic examinations in a large pediatric radiology department. American Journal of Roentgenology 4 — Clinical decision support CDS.
Hill, R. Sears, and S. American Journal of Emergency Medicine 31 11 — What is interoperability? Holmes, C. Brown, D. Hilaire, and A. Healthcare provider attitudes towards the problem list in an electronic health record: A mixed-methods qualitative study. Houston, J. Experience with implementation of a radiology speech recognition system. Journal of Digital Imaging 13 3 — Howard, J. Clark, A. Friedman, J. Crosson, M. Crabtree, B. Karsh, C. Jaen, D. Bell, and D. Electronic health record impact on work burden in small, unaffiliated, community-based primary care practices.
Journal of General Internal Medicine 28 1 — Hoyt, R. Lessons learned from implementation of voice recognition for documentation in the military electronic health record system.
Hripcsak, G. Innovations in clinical documentation. Arlington, Virginia, February 13, Vawdrey, M. Fred, and S. Use of electronic clinical documentation: Time spent and team interactions.
Journal of the American Medical Informatics Association 18 2 — Huff, C. Virtual visits pose real issues for physicians. The discipline of ergonomics. IOM Institute of Medicine. Health IT and patient safety: Building safer systems for better care. The role of telehealth in an evolving health care environment.
Ergonomic requirements for office work with visual display terminals VDTs —Part Guidance on usability. Jacobs, L. The Permanente Journal 13 3 — Johnson, M. Lapkin, V. Long, P. Sanchez, H. Suominen, J. Basilakis, and L. A systematic review of speech recognition technology in health care. Johnson, P. Zimmerman, D. Heath, J. Eng, K. Horton, W. Scott, and E. The iPad as a mobile device for CT display and interpretation: Diagnostic accuracy for identification of pulmonary embolism. Emergency Radiology 19 4 — The Joint Commission.
Preventing copy-and-paste errors in the EHR. Sentinel event alert. Jutel, A. Digitizing diagnosis: A review of mobile applications in the diagnostic process. Diagnosis 2 2 — Kayser, K. Beyer, S. Blum, and G. Recent developments and present status of telepathology. Analytical Cellular Pathology 21 3—4 — Koppel, R. Wetterneck, J. Telles, and B. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety.
Journal of the American Medical Informatics Association 15 4 — Kostopoulou, O. Rosen, T. Round, E. Wright, A. Douiri, and B. Early diagnostic suggestions improve accuracy of GPs: A randomised controlled trial using computer-simulated patients. British Journal of General Practice 65 :e49—e Krupinski, E.
Teleradiology: Current perspectives. Reports in Medical Imaging 7 :5— Kuhn, T. Basch, M. Barr, and T. Clinical documentation in the 21st century: Executive summary of a policy position paper from the American College of Physicians.
Annals of Internal Medicine 4 — Kuperman, G. Laksanasopin, T. Guo, S. Nayak, A. Sridhara, S. Xie, O. Olowookere, P. Cadinu, F.
Meng, N. Chee, J. Kim, C. Chin, E. Munyazesa, P. Mugwaneza, A. Rai, V. Mugisha, A. Castro, D. Steinmiller, V. Linder, J. Justman, S. Nsanzimana, and S. A smartphone dongle for diagnosis of infectious diseases at the point of care. Science Translational Medicine 7 re1. Lau, J. Lowres, L. Neubeck, D. Brieger, R. Sy, C. Galloway, D. Albert, and S. International Journal of Cardiology 1 — Lobach, D. Computerized decision support based on a clinical practice guideline improves compliance with care standards.
American Journal of Medicine 1 — Low, J. Makam, A. Lanham, K. Batchelor, L. Samal, B. Moran, T. Howell-Stampley, L. Kirk, M. Cherukuri, N. Santini, L. Leykum, and E. Use and satisfaction with key functions of a common commercial electronic health record: A survey of primary care providers. Mangalmurti, S.
Murtagh, and M. Medical malpractice liability in the age of electronic health records. The NT Elite diagnostic tool comes with latest software, which can be used out of box. No need to waste time to download the software first. Instead of taking your cars to dealership, this foxwell scanner will help you do a thorough scanning and detection for your lovely cars and pinpoint the problem for you, which saves time and money for you.
It will turn off the warning light for you after you fix the problem, making you to know more about your cars and do your own repair. In addition, live data stream, built-in DTC library, data play back and print, all these features are a big plus for it. However, NT Elite automotive scanner is equipped with solid protective case, preventing your scanner from damage.
Additional Info : Item Dimensions Height 1. Check out the video at the 7th image. Note: MD does not work on cars after To check compatibility, please send VIN number to autelonline outlook. This car diagnostic scanner can help mechanics or DIYers to locate misfire cause, malfunctioning injector, check transmission oil temperature and pinpoint why the check engine light, ABS, airbag warning lights are on!
Note: Service resets do not work on all cars. Please send VIN number and functions you need to autelonline outlook. MD scanner tool allows printing out diagnostic report for further review and analysis. Purchase now and go fix something like Scotty Kilmer! It is a vehicle code reader that reads and clears OBD engine codes and it also displays the code severity to let you know if your car needs an immediate fix.
Find the problem faster and spend less time scrolling through menus. Additional Info : Item Dimensions Height 0. With Code Severity Levels function of P ABS scanner, you can quickly identify if your vehicle needs an immediate fix or if it can wait until you get home to fix it yourself. It does so by checking if the batteries and alternators are in line with voltage specs recommended for the vehicle. Innova P car scanner empowers the home mechanics with its professional-level functionality but entry-level difficulty, for it is designed and developed in the US and supported by unmatched technical assistance from a staff of all ASE certified technicians.
At the same time, it is also the perfect gift for your family and friends. If any scratches are found, just tear off the screen protector from the upper left or upper right corner.
Appreciate very much! Features : Classic design, fast scan and erase trouble codes, even a beginner can use it read the error code, find out what the problem is and perhaps fix it. Save money and time. Easily determines the cause of the check engine light.
The AD scanner is well built with a large LCD display x 64 pixel that has white backlight and contrast adjustment, indicates test results directly. There are 4 buttons on AD The Up and Down button for scrolling the menu, the Enter and Exit button allow for navigation back and entering menu. Auto record diagnostic data, recorded data can be played back in text format and graph format.
Have suggestion to add? Contact us here. Enhances auscultation through amplification, Active Noise Cancellation, and software. Wirelessly connect to the Eko App to visualize, record and save sounds for further analysis, or securely share them for a second opinion. Pair with several telemedicine platforms for auscultation live streaming. Capture a medical-grade 6-lead ECG in 30 seconds. All without gels or wires. Handheld ultrasound scanners with a variety of versions for different clinical applications.
It is an upper arm blood pressure monitor that measures EKG readings using touchpad electrodes located on the top face and both sides of the monitor for easy access.
In addition to atrial fibrillation, Complete can also detect tachycardia, bradycardia and sinus rhythm. D-EYE turns an iPhone into a Digital Direct Ophthalmoscope, capable of recording and transmitting high-definition photos and videos of the fundus oculi for clinical assessment. The innovative D-EYE system allows regular screenings of the eye, providing information about noticeable eye diseases and capturing images for further evaluation of specific medical conditions.
For mobile eye diagnostics or vision screenings, the handheld NETRA auto-refractor measures sphere, cylinder, axis and pupillary distance through a series of game-like interactions in a virtual-reality environment. See it.
Share it. Save it.
0コメント