An analysis of delays in diagnosis and treatment in the outpatient setting revealed a number of complex origins that call for even more advanced systems and performance measures to improve communication and coordination among providers.

“Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements,” wrote Traber Davis Giardina, MA, MSW, of Houston Veterans Affairs (VA) Center for Innovation in Quality, Effectiveness, and Safety, and colleagues. “At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.”

Giardina and colleagues’ findings were published in the August issue of Health Affairs and included reviews of root cause analysis reports submitted to the VA National Center for Patient Safety, which detailed adverse events and close calls in the VA health system. They focused on the outpatient setting because even though that’s where most care delivery takes place, there’s been less empirical study compared to the inpatient setting.

During the 2005–2012 study period, nearly 9,800 root cause analyses were submitted, and 111 met study inclusion criteria. The authors reviewed each report, classifying each delay into one of four dimensions of an adapted ambulatory care process framework: provider-patient encounter; performance and interpretation of diagnostic tests; follow-up and tracking of patients; and referral and consultation processes.

The most frequently involved dimension was follow-up and tracking of patients, which represented 30.2 percent of the breakdowns, according to the authors. Interpretation of diagnostic tests made up 27.5 percent of the breakdowns, followed by referral and consultation processes and provider-patient encounter, which made up 26.7 percent and 15.7 percent, respectively.

Imaging featured prominently among the root cause analysis reports. Nearly 70 percent of those reported involved diagnostic imaging or lab tests, with CT (28.6 percent), x-ray (16.9 percent) and MRI (13 percent) the most commonly involved imaging tests. Biopsy and serum chemistries were the most common lab tests.

Giardina and colleagues noted that the most common contributing factors in the reports involved coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Miscommunication of urgency between providers and providers’ lack of awareness of a patient’s situation were other contributing factors.

Widespread adoption of EHRs alone is likely not enough to solve the problems, according to the authors, and policy-based initiatives to reduce outpatient delays should focus on enhancing an EHR’s ability to facilitate communication. Current quality measures also need to be made more robust to address safety in terms of communication and coordination.

“These findings suggest that within the VA health system and possibly elsewhere, delays in ambulatory care are unlikely to be reduced to the extent desired unless multicomponent interventions concurrently address multiple process breakdowns and contributory factors.”