Electronic diagnostic support in emergency physician triage: a qualitative study (Preprint)

Not thinking of a diagnosis is a leading cause of diagnostic error in the emergency room (ER) resulting in delayed treatment, morbidity and excess mortality. Electronic differential diagnostic support (EDS) results in small but significant reductions in diagnostic error. However, uptake of EDS by clinicians is limited.

We conducted a qualitative study using a research assistant to rapidly prototype embedded electronic differential diagnostic support into the ER triage process to understand factors that contribute to acceptability of a fully integrated EDS system.

Physicians involved in triage assessment of a busy ER were provided output of an EDS based on triage complaint by an embedded researcher to simulate an automated system that would draw from the electronic medical record. Physicians were interviewed immediately after their experience. Verbatim transcripts were analyzed by a team using open and axial coding, informed by direct content analysis.

Four themes emerged from 14 interviews: (1) quality of the EDS was inferred from the scope and prioritization of the diagnoses present in the EDS differential; (2) trust of EDS linked to varied beliefs around the diagnostic process and potential for bias; (3) clinicians foresaw more benefit to EDS use for colleagues and trainees rather than themselves; (4) clinicians felt strongly that EDS output should not be included in the patient record.

Adoption of an EDS into an ER triage process will require a system that provides diagnostic suggestions appropriate for the scope and context of the ER triage process, transparency of system design, affordances for clinician beliefs about the diagnostic process, and address clinician concern around including EDS output in the patient record.

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