A “contextual error” occurs when a care plan appears appropriate based on the limited information in the medical record, but is, in fact, inappropriate because it does not address specific life challenges the Veteran is facing that complicate their care. For example, increasing the insulin dose in a patient with uncontrolled diabetes when the underlying problem is that their vision is failing and they can’t read their insulin syringe, or that they have untreated depression and have stopped taking their medications consistently is a contextual error. In the Preventing Contextual Errors (PCE) program, Veterans are invited to carry an encrypted audio recorder into their visit when they check in for their appointment and return it when they leave. The data is uploaded to a secure server and audio-coded by a specialized team in Chicago that also has access to the patient’s medical record. Anonymized reports are sent back to care teams as feedback with examples of contextual errors and appropriately contextualized care. The program has measurably reduced contextual error rates and improved Veteran health care outcomes across multiple VHA ambulatory sites.
This practice is attempting to reduce the prevalence of contextual errors in medical decision making and care planning by providing clinicians with feedback based on analysis of audio recordings of their medical encounters. A contextual error occurs when a care plan does not take into account the life challenges of a veteran that are complicating their abil...
This practice is attempting to reduce the prevalence of contextual errors in medical decision making and care planning by providing clinicians with feedback based on analysis of audio recordings of their medical encounters. A contextual error occurs when a care plan does not take into account the life challenges of a veteran that are complicating their ability to self-manage their care. Contextual errors lead to poor control of chronic conditions, frequent missed appointments, increased hospitalization rates, medication non-adherence and a range of other avoidable adverse outcomes.
Patients who volunteer to audio record their visits are provided with audio recorders in the waiting area. They return the audio recorder after the visit and it is uploaded to a secure server. The audio is analyzes using a system called "Content Coding for Contextualization of Care" or "4C" at a VA in Chicago by a trained coding team, and the data is shared ...
Patients who volunteer to audio record their visits are provided with audio recorders in the waiting area. They return the audio recorder after the visit and it is uploaded to a secure server. The audio is analyzes using a system called "Content Coding for Contextualization of Care" or "4C" at a VA in Chicago by a trained coding team, and the data is shared (de-identified) with a clinical champion at the participating facility. The clinical champion then reviews the data with clinicians. Clinicians propose changes to their practice. In return for participating they receive Maintenance of Certification Credit from the American Board of Internal Medicine. This cycle of audit & feedback leads to fewer contextual errors and better patient outcomes.
A brief overview of contextualization of care, including a 4-step process to contextualizing care
How to Set Up Preventing Contextual Errors Ql Program
In a rigorous VA funded study of the program, attention to patient contextual factors across 666 VA clinicians increased from 67% to 72%, and contextualized care planning was associated with a greater likelihood of improved outcomes, resulting in an estimated cost savings of $25.2 million from avoided hospitalizations.
See publication which presents data on over 4000 audio recorded visits. Contextual error rates dropped by 15% over 2 years, and resulted in $25M in preventable hospitalizations. $75 was saved for each $1 invested in the program.
There are no in-progress adoptions for this innovation.
There are no unsuccessful adoptions for this innovation.
The blue line shows the percentage of audio recordings collected by patients and audio coded by the team in Chicago in which an identified challenge faced by the Veteran that was impacting their care (e.g. lack of transportation, loss of a caregiver) was addressed during the encounter. The yellow line shows the percentage of audio recordings in which a clue that a Veteran might be facing such a challenge (a “contextual red flag”) was explored (“probed”) by their physician during the visit. From June of 2017 to December of 2018, providers received regular feedback on their performance. Charts such as this one are generated for every participating site for clinical champions to review at each feedback session.
The Preventing Contextual Errors program offers an unusual opportunity for Veterans to play an essential role in helping improve care for other Veterans at their facility. In fact the program would not be possible if Veterans did not see value in volunteering to audio record their visits. Veterans have a high level of commitment to helping other Veterans. The PCE program produced several different kinds of “thank you” stickers, such as this one, given to Veterans when they returned their audio recorders. These stickers also help advertise the program to other Veterans who may not know about it.
Audio recording becomes less threatening when everyone understands that it serves an exclusively educational purpose, and will not be used to single out or rate any provider’s individual performance. Photos such as this one are included in a brochure about the program, illustrating a primary care physician interacting with a Veteran while data is collected via audio for the PCE program. Veterans who volunteer to record their visit are told they can conceal the recorder, carry it out in the open, or turn it off if they change their mind at any point in time. Most put it in their pocket. Surveys of participating physicians and Veterans indicate that few are distracted or bothered by the audio once they understand its purpose.
An overview of how clinical champions give colleagues feedback using Powerpoint slides we provide, customized for each clinic based on audio coded data, to improve patient care.
Facility clinical leader, e.g. a primary care physician director identifies a clinical champion
Clinical champion has telephone based coaching session with Chicago program director and reviews all materials in the toolkit, including PowerPoint, implementation plan, examples of feedback, and site promotional materials (poster, pamphlets)
Clinical champion presents PowerPoint to peer clinicians and any site specific stakeholders, including union representatives if present
Clinical leader and clinical champion identify approximately GS-7 level staff who will handout and collect audio recorders (“site project coordinator”), and upload to sever when data collection occurs, which varies based on site preferences (e.g. one week every 2 months)
Chicago based project manager and project coordinator have a coaching call regarding protocol for inviting Veteran participation in waiting areas of clinics, collecting audio, keeping a log, and uploading audio to secure server.
Audio recording collection begins.
Clinical champion provides first feedback to peer clinicians
The primary risk to implementation is distrust among providers and staff regarding an audio recording program.
The program must feel safe. A respected clinical champion who is a peer clinician presents the program to colleagues utilizing a PowerPoint that includes details of how data is securely collected and stored using encrypted technology, how it can only be used for its intended purpose, that identifiers are removed before data is shared, how it is legally protected by peer review laws from discovery, and that the only individuals who have access to the audio are the coding team based centrally in Chicago.
The second risk to implementation is the perception that it will be an added work-burden to participants.
All data collection occurs while providers are providing usual care, and all feedback occurs during standing meetings at which other performance data is discussed. Any additional effort, which includes occasional brief emailed opportunities to provide written feedback for continuing education or board re-certification credit are optional.
The third risk to implementation is skepticism the program will provide value.
At the start of the project the clinical champion shares data that the program does lead to better care for Veterans, with several examples of how it works. In addition, the physicians learn that the program is approved by both the American Board of Internal Medicine and the American Board of Family Medicine for maintenance of certification (MOC) credits. Nurses and pharmacists may also receive continuing education credits.
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As a primary care physician supervising residents, Dr. Weiner observed that oftentimes a plan of care sounded logical and appropriate until he walked into the room and learned through conversation that it didn’t take into account a variety of life challenges a Veteran was facing that the VA could help them with. Since 2004 he has worked closely with Dr. Ala...As a primary care physician supervising residents, Dr. Weiner observed that oftentimes a plan of care sounded logical and appropriate until he walked into the room and learned through conversation that it didn’t take into account a variety of life challenges a Veteran was facing that the VA could help them with. Since 2004 he has worked closely with Dr. Alan Schwartz, a cognitive psychologist, to study these “contextual errors” and learned that they are common, measurable and preventable. He subsequently partnered with VA colleagues, including other physicians, nurses, pharmacists, facility leaders, and front line staff, first regionally and then nationally, to try out and measure the effectiveness of various strategies for preventing contextual errors, which led to the current program.