Communication Failures in Dermatopathology, Part 1 [Hot Topic]

Comfere
Nneka Comfere, M.D.

Communication failures occur frequently in the pre- and postanalytic phases of the skin pathology care coordination cycle, and may adversely impact diagnostic performance and the quality of patient care. Multiple modifiable factors influence the quality of communication. In Part 1 of a 3-part series, Nneka Comfere, M.D., provides a brief overview of the various components of the skin pathology care coordination cycle, common communication breakdowns, and barriers to effective communication among key stakeholders of the care coordination cycle.

Presenter and Credentials:
Nneka Comfere, M.D., Associate Professor of Dermatology and Laboratory Medicine and Pathology in the College of Medicine and Section Head in Dermatopathology in the Division of Dermatopathology and Cutaneous Immunopathology at Mayo Clinic in Rochester, Minn.

Transcript

Welcome to Mayo Medical Laboratories Hot Topics. These presentations provide short discussion of current topics and may be helpful to you in your practice. Today our presentation provides an overview of communication failures that occur during the skin pathology care coordination cycle.

Introduction

Our speaker for this program is Dr. Nneka Comfere, Associate Professor of Dermatology and Laboratory Medicine and Pathology in the College of Medicine and Section Head in Dermatopathology in the Division of Dermatopathology and Cutaneous Immunopathology at Mayo Clinic in Rochester, Minnesota

Dr. Comfere, thank you for presenting today.

Disclosures

I have no relevant disclosures.

Outline

This 3-part series will discuss communication failures that occur during the skin pathology care coordination cycle.

In Part 1 of this series, I will focus on a brief overview of the various components of the skin pathology care coordination cycle, common communication breakdowns, and barriers to effective communication between key stakeholders of the care coordination cycle.

Parts 2 and 3 of this series will provide a description of potential modifiable factors that may influence effective communication between key stakeholders – clinicians, pathologists, patients or caregivers in the pre- and postanalytic phases, respectively, of the skin pathology care coordination cycle.

Case Scenario

This case illustrates communication failures that result in diagnostic error and that are encountered in daily practice. A pathologist receives a shave biopsy of a nodule on the scalp.  It is clear from the slides that the submitted specimen is a sample of a larger lesion, but in the absence of critical clinical information including lesion size, morphology and duration, the pathologist would not consider a malignancy or melanoma. However, given the patient’s age, the pathologist suspects melanoma and recommends complete removal.  And this reveals a melanoma in the deep layers of the skin that was missed in the original biopsy. Inadequate clinical information resulted in delays in diagnosis and ultimately delays in cancer care.

Multiple similar such scenarios occur in daily dermatopathology practice.

Skin Pathology Care Coordination Cycle

This is a conceptual model of the skin pathology care coordination cycle. It is a closed loop cycle that starts and ends with the patient. The care coordination cycle is composed of preanalytic, analytic and postanalytic phases. Pre- and postanalytic phases encompass all the activities and interactions that support test ordering, specimen collection, and result reporting. The care coordination cycle, a multistep process that begins with the decision to obtain a skin biopsy in the context of the clinical encounter and leads to the generation of a pathology report which then factors into clinical management decisions, is complex. Each step in the skin pathology care coordination cycle is dependent on clear communication between multiple clinicians, members of the health care team and the patient or caregiver. Under ideal circumstances, the clinician articulates a specific question, that accompanies an adequate sample and the pathologist performs a histopathologic interpretation – the gold standard.  The pathologist then sends a timely report to the clinician that helps guide management.  However, this ideal often does not occur. A patient centered approach to quality and care experience improvement in skin pathology requires both the tailoring of diagnostic test selection to patient risk and optimization of communication between members of the health care team and patients or caregivers in order to deliver a safe, timely, effective, efficient and equitable care.

Diagnostic tests including skin pathology are reliant on accurate and complete clinical information. Gaps in clinician-to-clinician communication account for 20% of laboratory test-related errors that result in patient harm. Ineffective communication among health care providers plays a role in 80% of sentinel events. Lack of face-to-face communication is responsible for critical medical incidents that result from failures in information transfer. A significant proportion of diagnostic errors in laboratory medicine and pathology occur because of communication gaps in the pre- and postanalytic phases of the test pathway. Diagnostic errors, broadly defined as diagnoses that are delayed, incorrect or missed occur with significant frequency in the order of 10 to 20% in medical practice and specifically in skin pathology. Such errors may occur at any point along the care coordination cycle and result in inappropriate patient care, adverse patient outcomes, and increased health care costs. Preanalytic errors accounted for 23% of medical errors in a physician reported survey of errors in dermatologic practice. A retrospective review of closed malpractice claims in the ambulatory setting, demonstrated that common process breakdowns in the diagnostic process occur in association with 25% of biopsies. Furthermore, communication failures contributed to diagnostic errors in 20% of these cases.

Our preliminary work on patient-centered skin pathology, uncovered modifiable factors that influence clinician-pathologist communication failures and that are amenable to potential interventions embedded in the electronic health record. A systematic review of this topic shows that the initial handoff from the clinician to the pathologist is crucial. Frequently, dermatopathologists are left with incomplete or inaccurate clinical information that impairs their ability to make diagnostic decisions.

Preanalytic phase

The key stakeholders in the preanalytic phase of the cycle include the patient or caregiver, ordering clinician and the pathologist.

This phase encompasses a discussion of the need for skin biopsy including risk communication, pretest probability of disease, potential diagnostic yield of a skin biopsy and discussion of skin biopsy type or specimen type necessary to make a definitive diagnosis.

Clinical information shared during this phase may include clinical impression, description of lesion morphology, clinical evolution and specimen type.

The communication of timely, accurate and complete clinical information between the ordering clinician and the pathologist is crucial for the provision of a timely and relevant diagnostic interpretation. The requisition form serves as the primary mode for such communication however is fraught with multiple deficiencies including limited to no clinical information requiring active pathologist-directed searches for clinical information, which impacts their diagnostic efficiency as well as vague and nonspecific interpretations and potentially unnecessary pathology studies or additional stains and surgical procedures.

 

Sources of Communication Failures Preanalytic Phase
In a recently completed national survey of the membership of the American Society of Dermatopathology , dermatopathologists expressed significant dissatisfaction with the quality of clinical information in the requisition form and the time spent gathering information necessary for accurate, timely, and clinically meaningful diagnosis. These findings have implications for the quality, safety, and efficiency of dermatologic care.

Key communication deficiencies during this phase include poor specimen quality which includes skin biopsy technique, specimen size and appropriateness of the specimen and the completeness and accuracy of clinical information in the requisition form.

Potential Outcomes of Communication Failures in Preanalytic Phase
The potential outcomes of communication failures in preanalytic phase include: vague or nonspecific pathology interpretations, delayed or missed diagnoses, unnecessary pathology stains or studies, and unnecessary surgical procedures.

Postanalytic Phase

The key stakeholders in the postanalytic phase of the care coordination cycle include the pathologist, the patient or caregiver and the ordering clinician.

This phase encompasses the reporting and resulting of the final pathology diagnosis including decision making on management or additional evaluation. The structure, format, and content of the pathology report as well as modes of delivery of the report are key components.

Patient and caregiver related communication barriers include comprehension of medical terms and concepts in the report and anxiety related to reviewing the report without synchronized access to clinician interpretation. These factors may influence the efficiency and utility of the patient or caregiver participation in informed and shared decision making with their providers.

Sources of Communication Failures Postanalytic Phase
Sources of communication failures in the postanalytic phase can be broken down into report structure and format and encompass the range of medical terms and concepts that are used in the report, the language within the report, and specific recommendations within the report regarding management.

Potential Outcomes of Communication Failures in Postanalytic Phase
Potential outcomes of communication failures that occur in the post analytic phase include decision-making ability of the patient and/or caregiver to participate in management decisions and ordering clinician decision-making abilities as well as anxiety related to report review by the patient and/or their caregivers.

Conclusions

In conclusion, communication failures occur frequently in the pre- and postanalytic phases of the skin pathology care coordination cycle. There are multiple modifiable factors influence the quality of communication during the skin pathology coordination cycle. And communication failures may adversely impact diagnostic performance and ultimately quality of patient care.

Thank you for your attention.

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