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Introduction: Communication failings may compromise the diagnostic process and pose a risk to quality of care and patient safety. With a focus on emergency care settings, this project aims to examine the critical role and impact of communication in the diagnostic process, including in diagnosis-related health and research policy, and diagnostic patient-clinician interactions in emergency departments (EDs)., Methods and Analysis: This project uses a qualitatively driven multimethod design integrating findings from two research studies to gain a comprehensive understanding of the impact of context and communication on diagnostic excellence from diverse perspectives. Study 1 will map the diagnostic policy and practice landscape in Australia, New Zealand and the USA through qualitative expert interviews and policy analysis. Study 2 will investigate the communication of uncertainty in diagnostic interactions through a qualitative ethnography of two metropolitan Australian ED sites incorporating observations, field notes, video-recorded interactions, semistructured interviews and written medical documentation, including linguistic analysis of recorded diagnostic interactions and written documentation. This study will also feature a description of clinician, patient and carer perspectives on, and involvement in, interpersonal diagnostic interactions and will provide crucial new insights into the impact of communicating diagnostic uncertainty for these groups. Project-spanning patient and stakeholder involvement strategies will build research capacity among healthcare consumers via educational workshops, engage with community stakeholders in analysis and build consensus among stakeholders., Ethics and Dissemination: The project has received ethical approvals from the Human Research Ethics Committee at ACT Health, Northern Sydney Local Health District and the Australian National University. Findings will be disseminated to academic peers, clinicians and healthcare consumers, health policy-makers and the general public, using local and international academic and consumer channels (journals, evidence briefs and conferences) and outreach activities (workshops and seminars)., Competing Interests: Competing interests: JM is a member of the Council of Education of the Australasian College for Emergency Medicine., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To improve the effectiveness of nursing clinical handover through a qualitative, tailored communication intervention., Design: A multisite before and after intervention using qualitative ethnography combined with discourse analysis of nursing handover interactions., Methods: We implemented a tailored ward-based intervention to redesign nursing handover practice with co-constructed recommendations for organisational and cultural change on seven wards across three affiliated metropolitan hospitals between February 2020 and November 2022. The intervention was informed by pre-implementation interviews and focus groups with nursing, medical and allied health staff and patients (n = 151) and observed and/or audio-recorded handover events (n = 233). Post-intervention we conducted interviews and focus groups (n = 79) and observed and/or audio-recorded handover events (n = 129) to qualitatively evaluate impact., Results: Our translational approach resulted in substantial changes post-intervention. Nurses conducted more shift-to-shift handovers at the bedside, with greater patient interaction and better structured and more comprehensive information transfer, supported by revised handover documentation. Redesigned group handovers were focused and efficient, communicating critical patient information., Conclusion: Contextualised training combined with changes to ward-level systemic factors impeding communication results in improved nursing handovers. Practice change requires strong executive leadership and project governance, combined with effective ward-level leadership, collaboration and mentoring. The speed and degree of change post-intervention demonstrates the power of interdisciplinary collaborative research between hospital executive, ward leadership and communication specialists., Relevance to Clinical Practice: Nurses are more likely to conduct efficient group handovers and informative, patient-centred bedside handovers in line with policy when they understand the value of handover and have practical strategies to support communication. Communication training should be combined with broader ward-level changes to handover practice tailored to the ward context. A multilevel approach results in more effective practice change., Reporting Method: We adhered to the COREQ guidelines., Patient or Public Contribution: We interviewed patients on study wards pre and post intervention., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Objective: To describe and analyse the perspectives and communication practices of kidney clinicians and older patients (aged 60 +) during collaborative education and decision-making about dialysis., Methods: This qualitative study drew on pluralistic data sources and analytical approaches investigating elicited semi-structured interviews (n = 31) with doctors (n = 8), nurses (n = 8) and patients (n = 15), combined with ethnographic observations, written artefacts and audio-recorded naturally-occurring interactions (n = 23, education sessions n = 4; consultations n = 19) in a tertiary Australian kidney outpatient clinic. Data were analysed for themes and linguistic discourse features., Results: Five themes were identified across all data sources: 1) lost opportunity in education; 2) persistent disease knowledge gaps; 3) putting up with dialysis; 4) perceived and real involvement in decision-making and 5) complex role of family as decision-making brokers., Conclusion: As the first study to complement interviews with evidence from naturally-occurring kidney interactions, this study balances the perspectives of how older patients and their clinicians view chronic kidney disease education, with how decision-making about dialysis is reflected in practice., Practice Implications: The study provides suggestions for contextualized, multi-perspectives formal and informal training for improving decision-making about dialysis, spanning from indications to boost communication efficiency, to reducing unexplained jargon, incorporating patient navigators and exploring different dialysis modalities., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The Intensive Care Unit (ICU) is an information-intense environment where more patient data points are recorded than in other wards. The electronic Record for Intensive Care (eRIC) is an ICU information system that integrates patient data every minute from multiple systems. Once implemented across New South Wales (NSW), eRIC will be one of the largest system-wide ICU clinical information systems in the world. This study explored experiences with the use of eRIC by ICU clinicians at an Australian metropolitan teaching hospital. Semi-structured, in-depth interviews relating to physician electronic test management processes were conducted with 11 ICU clinicians and one clinical information system manager was observed in their use of the system. The introduction of eRIC resulted in an additional patient record, which was perceived to hold implications for workflow and patient safety. Study findings are valuable for informing implementation as the rollout of eRIC continues.

Background: Effective interpersonal communication is critical for shared decision-making (SDM). Previous SDM communication training in nephrology has lacked context-specific evidence from ethnographic analysis of SDM interactions with older patients considering treatment options of end stage kidney disease (ESKD). This study explores communication strategies in SDM discussions in nephrology, specifically focusing on older patients considering dialysis as kidney replacement therapy (KRT)., Methods: We conducted a qualitative study analysing naturally-occurring audio-recorded clinical interactions (n = 12) between Australian kidney doctors, patients aged 60+, and carers. Linguistic ethnography and qualitative socially-oriented functional approaches were used for analysis., Results: Two types of communication strategies emerged: (1) Managing and advancing treatment decisions: involving active checking of knowledge, clear explanations of options, and local issue resolution. (2) Pulling back: Deferring or delaying decisions through mixed messaging. Specifically for non-English speaking patients, pulling back was further characterised by communication challenges deferring decision-making including ineffective issue management, and reliance on family as interpreters. Age was not an explicit topic of discussion among participants when it came to making decisions about KRT but was highly relevant to treatment decision-making. Doctors appeared reluctant to broach non-dialysis conservative management, even when it appears clinically appropriate. Conservative care, an alternative to KRT suitable for older patients with co-morbidities, was only explicitly discussed when prompted by patients or carers., Conclusions: The findings highlight the impact of different communication strategies on SDM discussions in nephrology. This study calls for linguistic-informed contextualised communication training and provides foundational evidence for nephrology-specific communication skills training in SDM for KRT among older patients. There is urgent need for doctors to become confident and competent in discussing non-dialysis conservative management. Further international research should explore naturally-occurring SDM interactions in nephrology with other vulnerable groups to enhance evidence and training integration., (© 2023. The Author(s).)

Objective: Analyse the linguistic and numerical complexity of COVID-19-related health information communicated from Australian national and state governments and health agencies to national and local early childhood education (ECE) settings., Methods: Publicly available health information (n = 630) was collected from Australian national and state governments and health agencies, and ECE agencies and service providers. A purposive sample of documents (n = 33) from 2020 to 2021 was analysed inductively and deductively combining readability, health numeracy and linguistic analyses and focusing on the most frequent actionable health advice topics., Results: COVID-19 health advice most frequently related to hygiene, distancing and exclusion. Readability scores in 79% (n = 23) of documents were above the recommended grade 6 reading level for the public. Advice was delivered using direct linguistic strategies (n = 288), indirect strategies (n = 73), and frequent mitigating hedges (n = 142). Most numerical concepts were relatively simple, but lacked elaborative features (e.g., analogies) and/or required subjective interpretation., Conclusion: COVID-19 health advice available to the ECE sector included linguistic and numerical information open to mis/interpretation making it difficult to understand and implement., Practice Implications: Combining readability scores with measures of linguistic and numerical complexity offers a more holistic approach to assessing accessibility of health advice and improving health literacy among its recipients., Competing Interests: Declaration of Competing Interest All articles must include a separate file containing a statement declaring any competing interests that relate to any authors. Competing interests are defined as those potential influences that may undermine the objectivity, integrity, or perceived conflict of interest of a publication. Interactions that occur within 5 years before submission date of an article are pertinent., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: To increase the quality and safety of patient care, many hospitals have mandated that nursing clinical handover occur at the patient's bedside. This study aims to improve the patient-centredness of nursing handover by addressing the communication challenges of bedside handover and the organizational and cultural practices that shape handover., Design: Qualitative linguistic ethnographic design combining discourse analysis of actual handover interactions and interviews and focus groups before and after a tailored intervention., Methods: Pre-intervention we conducted interviews with nursing, medical and allied health staff (n = 14) and focus groups with nurses and students (n = 13) in one hospital's Rehabilitation ward. We recorded handovers (n = 16) and multidisciplinary team huddles (n = 3). An intervention of communication training and recommendations for organizational and cultural change was delivered to staff and championed by ward management. After the intervention we interviewed nurses and recorded and analyzed handovers. Data were collected from February to August 2020. Ward management collected hospital-acquired complication data., Results: Notable changes post-intervention included a shift to involve patients in bedside handovers, improved ward-level communication and culture, and an associated decrease in reported hospital-acquired complications., Conclusions: Effective change in handover practices is achieved through communication training combined with redesign of local practices inhibiting patient-centred handovers. Strong leadership to champion change, ongoing mentoring and reinforcement of new practices, and collaboration with nurses throughout the change process were critical to success., Impact: Ineffective communication during handover jeopardizes patient safety and limits patient involvement. Our targeted, locally designed communication intervention significantly improved handover practices and patient involvement through the use of informational and interactional protocols, and redesigned handover tools and meetings. Our approach promoted a ward culture that prioritizes patient-centred care and patient safety. This innovative intervention resulted in an associated decrease in hospital-acquired complications. The intervention has been rolled out to a further five wards across two hospitals., (© 2021 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Purpose: This study used a collaborative approach to explore the needs, barriers, and facilitators to developing cochlear implant referral information material that would be valuable for hard of hearing adults and referring audiologists., Method: During the development of a prototype referral aid to be used within the Australian context, a multistage qualitative study was conducted using a consultative process, informal and semistructured interviews, as well as online surveys. A deductive directed content analysis approach was applied to assess respondents' perspectives. A total of 106 participants (37 hard of hearing adults and 69 audiologists) were involved across the multiple phases of this study., Results: Referral practices for the evaluation of cochlear implantation candidacy in Australia are highly inconsistent, supporting the need to streamline referral information. The following facilitators were identified to support the development of referral material: appropriate content, perceived patient benefit, and objectivity. Areas for improvement related to the broadness of the content, impact on professional identity, and accessibility., Conclusions: Practical insight from patients and referrers can inform the development of patient-facing material related to cochlear implant referrals. Streamlining information used in educational material could alleviate confusion inherent to varied health literacy levels and support patients in making informed decisions related to pursuing, or not, cochlear implantation candidacy evaluation services.

During the diagnostic process, clinicians may make assumptions, prematurely judge or diagnose patients based on their appearance, their speech or how they are portrayed by other clinicians. Such judgements can be a major source of diagnostic error and are often linked to unconscious cognitive biases - faulty quick-fire thinking patterns that impact clinical reasoning. Patient safety is profoundly influenced by cognitive bias and language, i.e. how information is presented or gathered, and then synthesised by clinicians to form and communicate diagnostic decisions. Here, we discuss the intricate links between interpersonal communication, cognitive bias, and diagnostic error from a patient's, a linguist's and clinician's perspective. We propose that through patient engagement and applied health communication research, we can enhance our understanding of how the interplay of communication behaviours, biases and errors can impact upon the patient experience and diagnostic error. In doing so, we provide new avenues for collaborative diagnostic error research striving towards healthcare improvements and safer diagnosis., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Suboptimal design of health information technology (IT) systems can lead to the introduction of errors in the diagnostic process. We aimed to identify mechanisms that can affect the safety and effectiveness of these systems in hospital settings thus contributing to the building of an explicit and replicable understanding of the variables that can affect the functioning of IT systems., Materials and Methods: This qualitative study drew from observations and semistructured interviews from a purposive sample of 46 participants (26 emergency department and 20 laboratory and medical imaging staff) across 3 Australian hospitals. Iterative, inductive coding of the data led to the development of higher-level themes based on relationships between codes., Results: Two overarching themes emerged: (1) usability and safety of the electronic test result management system; and (2) system redesign considerations about who is meant to follow up, when and how. The usability and safety of digital systems and the way these systems deal with accountability processes are triggered by mechanisms that are contextually dependent., Discussion: Our findings highlighted the multitransactional nature of the test result management process involving numerous healthcare professionals across different settings. This communication requires integration of the systems utilized by different departments and transparency of the test result follow-up process to facilitate clear lines of responsibility and accountability., Conclusion: Identifying mechanisms that shape the functionality and sustainability of electronic result management can offer a valuable appreciation of key elements that need to be accounted for, and the circumstances in which they need to operate effectively., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy., Methods: To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature., Results: Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9)., Conclusions: Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: Many Australians with disability live in residential care and require assistance to manage their health information across hybrid care settings encompassing residential care, primary and tertiary care, and allied health. In this study, we examined case study reports on people with disability living in residential care in New South Wales, Australia to (a) identify threats to the quality of care and safety for this vulnerable patient group in relation to health documentation and information infrastructure and (b) evaluate the applicability of a conceptual health information infrastructure model., Methods: All 99 case studies were extracted from eight New South Wales Ombudsmen reports of reviewable deaths for a directed content analysis applying a conceptual model of health information infrastructure in residential care., Results: Ninety-one percent of case studies (n = 90) contained information relation to documentation. Forty-seven percent of case studies (n = 47) linked failures in documentation to risk of death, and 12% (n = 12) described best practice use of documentation. Threats to quality of care and safety related to poor "coordination" of information, including information not being implemented, poor "communication" across services, and discrepancies between "policy and practice" in health management., Conclusions: The conceptual model demonstrated how "coordination" and "communication" of health information relate to tensions between "policy and practice," influencing the safety and quality of care for people with disability in residential care. The model was a good fit to investigate how health information infrastructure may affect the quality of residential care and could inform holistic digital solutions to deliver safer, integrated, and higher quality care for people with disability., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Up to one-third of laboratory tests ordered in the ED for adults presenting with undifferentiated chest pain are generally not indicated by current Australian guidelines. This study set out to undertake a qualitative investigation of clinician perceptions to identify the reasons for variations in pathology requesting., Methods: For this study, we draw on data from semistructured interviews (n=38) conducted in the EDs and laboratories across three hospitals as part of a larger study on the test result management process from test request to result follow-up. Thematic analysis was conducted to determine what aspects of the clinical routines and environment might contribute to variations in pathology requesting. Informed by the findings from the analysis, targeted questions were developed and further focus groups (n=5) were held with clinicians, hospital management and electronic medical record (eMR) analysts to investigate in more detail the reasons for requesting outside of guidelines., Results: Participants cited four main reasons for ordering outside of guidelines. Clinicians requested tests outside of guidelines and the ED scope of practice to facilitate the patient journey along the broader continuum of care, including admission to hospital or transfer to another site. Clinicians were also faced with multiple and inconsistent guidelines regarding appropriate test selection. Limited access to in-house specialty and diagnostic services also influenced ordering patterns in smaller non-referral hospitals. Finally, certain features of the current electronic ordering framework within the eMR facilitated overordering and failed to impose any real restrictions on ordering inappropriately or outside of scope of practice., Conclusion: Beyond the standardisation of pathology requesting advice across electronic decision support, order sets and guidelines, attempts to address issues related to the appropriateness and variation of laboratory test ordering should consider local and systemic factors which also shape the ordering process., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore how patients describe their diagnoses following Emergency Department (ED) discharge, and how this compares to electronic medical record (EMR) documentation., Methods: We conducted a cohort study of patients discharged from three EDs. Patients completed questionnaires regarding their understanding of their diagnosis. Inclusion criteria: adult ED patients aged 18 and older seen within the last seven days. We independently compared patient-reported new diagnoses following discharge to EMR-documented diagnoses regarding diagnostic content (identical, insignificantly different, different, not enough detail) and the level of technical language in diagnostic description (technical, semi-technical, lay)., Results: The majority of participants (n=95 out of 137) reported receiving a diagnosis and stated the given diagnosis. Of those who reported their diagnosis, 66%, were females (n=62), the average age was 43 (SD 16), and a fourth (n=24) were Black and 66% (n=63) were white. The majority (84%) described either the same or an insignificantly different diagnosis. For 11% the patient-reported diagnosis differed from the one documented. More than half reported their diagnosis using semi-technical (34%) or technical language (26%), and over a third (40%) described their diagnosis in lay language., Conclusions: Patient-reported diagnoses following ED discharge had moderate agreement with EMR-documented diagnoses. Findings suggest that patients might reproduce verbatim semi-technical or technical diagnoses they received from clinicians, but not fully understood what the diagnosis means for them., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Objectives: To investigate the communication processes involving test-related information in Australian Emergency Departments (EDs); specifically what and how ED clinicians communicate test-related information to patients, what patients know and understand about the provided information, and how patients view the potential to access their test-results electronically., Methods: We conducted face-to-face semi-structured interviews with clinicians (n = 26) and patients (n = 32) across three Australian EDs. Interviews were transcribed and analysed iteratively, following principles of qualitative content analysis and grounded theory., Results: Depending on various contextual (e.g. time pressures) and patient factors (e.g. perceived health literacy), ED clinicians provided, and patients recalled receiving, test-related information along a continuum, ranging from "no or limited" information to "specific" information. Many patients were confused about how to access their test-results. Patients welcomed the potential for future electronic access to results but viewed their individual health and/or computer literacy skills and knowledge as potential barriers., Conclusions: EDs are highly dynamic environments where contextual forces impinge on the amount and quality of test-related information that clinicians communicate to ED patients., Practice Implications: Systemic and patient factors need to be addressed to optimise the provision of test-related information in ED settings, improve patient understanding and foster patient empowerment., Competing Interests: Declaration of Competing Interest None to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Assessing the accuracy of diagnostic coding is essential to ensure the validity and reliability of administrative coded data. The aim of the study was to evaluate the accuracy of assigned International Classification of Diseases version 10-Australian Modification (ICD-10-AM) codes for influenza by comparing with patients' results of their polymerase chain reaction (PCR)-based laboratory tests., Method: A retrospective study was conducted across seven public hospitals in New South Wales, Australia. A total of 16,439 patients who were admitted and tested by either cartridge-based rapid PCR or batched multiplex PCR between January 2016 and December 2017 met the inclusion criteria. We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ICD-10-AM coding using laboratory results as a gold standard. Separate analyses were conducted to determine whether the availability of test results at the time of hospital discharge influenced diagnostic coding accuracy., Results: Laboratory results revealed 2759 positive influenza cases, while ICD-10-AM coding identified 2527 patients. Overall, 13.7% (n = 378) of test positive patients were not assigned an ICD-10-AM code for influenza. A further 5.8% (n = 146) patients with negative test results were incorrectly assigned an ICD-10-AM code for influenza. The sensitivity, specificity, PPV and NPV of ICD-10-AM coding were 93.1%; 98.9%; 94.5% and 98.6% respectively when test results were received before discharge and 32.7%; 99.2%; 87.8% and 89.8% respectively when test results were not available at discharge. The sensitivity of ICD-10-AM coding varied significantly across hospitals. The use of rapid PCR or hospitalisation during the influenza season were associated with greater coding accuracy., Conclusion: Although ICD-10-AM coding for influenza demonstrated high accuracy when laboratory results were received before discharge, its sensitivity was substantially lower for patients whose test results were not available at discharge. The timely availability of laboratory test results during the episode of care could contribute to improved coding accuracy.

Background: Missed test-results and failure to follow-up test-results are major patient safety concerns. Strategies to improve test-results management have predominantly focused on clinician-based interventions, with patients principally involved in studies of test-result communication preferences, the impact of patient portals or experiences with reporting processes in primary care., Objective: To identify consumer perspectives and experiences of the challenges they have faced with test-results management, through consumer participation in qualitative data analysis., Design and Participants: Volunteers (n = 10) were recruited to participate in a health consumer reference group workshop on test-results management. Prior to the workshop, consumers selected topics for discussion using a preference poll. During the workshop, consumers participated in qualitative data analysis of de-identified excerpts of previously collected interview data discussing hospital test-results management. Researchers (n = 5) guided consumers through the analytical process and discussion of themes. Discussions were audio-recorded and transcribed for qualitative analysis., Results: Consumer-selected topics for discussion were 'Transitions of Care' and 'Access'. Consumer data analysis prompted broader discussion including lived experiences. Following the workshop, a second level of content analysis pinpointed issues with implications for patient safety highlighting that consumers were astutely aware of macrolevel 'Systems Factors' relating to 'Emergency Departments' and the health system, as well as microlevel 'Patient Factors' (eg patient preferences and circumstances) which impact a patient's understanding during the 'Communication' (clinician to patient/between clinicians) of test-results 'Information' (or lack thereof)., Conclusions: Consumers identified the challenges patients experience with test-results management, and our findings highlight areas for potential improvement in patient safety., Patient or Public Contribution: Ten health consumer volunteers actively participated in the test-results management data analysis workshop conducted in this study. Two health consumers also volunteered to read and comment on the draft manuscript., (© 2020 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: This study examined the health literacy demands of My Health Record (MyHR) in the context of preparing for a government-announced opt-out system by repeating two studies of health information and usability conducted in 2016., Objective: To examine whether Australia's MyHR meets the information and usability needs of people at risk of low health literacy and changes since 2016., Method: Content analysis : Informed by the 2016 methods and findings, measures of information quality, themes and target audiences were recorded and reported for each online consumer-facing health information resource. Heuristic evaluation : An evaluation of the MyHR and supporting information website was conducted using a predetermined checklist of usability criteria. A list of usability violations for both websites was identified., Results: Total number of resources grew from 80 in 2016 to 233 in 2018. There was little change since 2016 to average readability levels, target audiences, presentation style, links between resources and usability of MyHR. Compared to 2016, this study demonstrated increases in resources from non-government organisations; video resources; translated resources; and resources with themes of privacy, security and post-registration use., Conclusion: This study identified some improvements in information quality since 2016, but gaps remain in information quality and usability which may negatively impact the ability for people with low health literacy to access and use MyHR., Implications: This study provides a framework for ongoing monitoring and evaluation of the suitability of MyHR for people at risk of low health literacy.

The purpose of this qualitative study was to identify differences in the utilisation of an electronic medical record test-result management system between two acute care departments. Field observations (130 min) and semi-structured interviews (n = 24) were conducted in the Intensive Care Unit and Emergency Department of an Australian hospital. Work processes identified from audio transcripts were modelled using business process modelling. Comparison of the Emergency Department and Intensive Care Unit identified the following: (1) test ordering variations according to clinical roles, (2) differences in the use of electronic medical record functionality according to specific demands of the clinical environment and (3) the non-linear components of the test-result management process. Variations were identified in the number of process decisions, external collaborations and temporal process workflows. Modelling the business processes, collaboration and communication needs of individual clinical environments can aid in enhancing the quality and appositeness of health information technology interventions and thus contribute to improving patient safety. Future health information technology interventions/evaluations aimed at improving the safety of test-result management processes need to address both the nuances of the clinical environment and accommodate the individual work practices of clinicians within that environment.

Objective: The management and follow-up of diagnostic test results is a major patient safety concern. The aim of this qualitative study was to explore how clinicians manage test results on an everyday basis (work-as-done) in a health information technology-enabled emergency department setting. The objectives were to identify (1) variations in work-as-done in test results management and (2) the strategies clinicians use to ensure optimal management of diagnostic test results., Materials and Methods: Qualitative interviews (n = 26) and field observations were conducted across 3 Australian emergency departments. Interview data coded for results management (ie, tracking, acknowledgment, and follow-up), and artifacts, were reviewed to identify variations in descriptions of work-as-done. Thematic analysis was performed to identify common themes., Results: Despite using the same test result management application, there were variations in how the system was used. We identified 5 themes relating to electronic test results management: (1) tracking test results, (2) use and understanding of system functionality, (3) visibility of result actions and acknowledgment, (4) results inbox use, and (5) challenges associated with the absence of an inbox for results notifications for advanced practice nurses., Discussion: Our findings highlight that variations in work-as-done can function to overcome perceived impediments to managing test results in a HIT-enabled environment and thus identify potential risks in the process. By illuminating work-as-done, we identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality., Conclusions: Test results tracking and follow-up is a priority area in need of health information technology development and training to improve team-based collaboration/communication of results follow-up and diagnostic safety., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

We sought (a) an inductive understanding of patient and clinician perspectives and experiences of the communication of diagnostic test information and (b) a normative understanding of the management of uncertainty that occurs during the clinical encounter in emergency care. Between 2016 and 2018, 58 interviews were conducted with patients and nursing, medical, and managerial staff. Interview data were sequentially analyzed through an inductive thematic analysis, then a normative theory of uncertainty management. Themes of "Ideals," "Service Efficiency," and "Managing Uncertainty" were inductively identified as influencing the communication of diagnostic test information. A normative theory of uncertainty management highlighted (a) how these themes reflected the interaction's sociocultural context, encapsulated various criteria by which clinicians and patients evaluated the appropriateness and effectiveness of their communication, and represented competing goals during the clinical encounter, and (b) how systemic tensions between themes accounted for when diagnostic test information communication occurred, was deferred or avoided.

Introduction: Despite advances in the co-creation of clinical research involving consumers in the last few decades, consumer engagement in health services research generally remains inconsistent and is too often treated as a perfunctory exercise., Objective: Drawing on a health services study on diagnostic test result management, communication and follow-up, we: (1) outline practical strategies used to enhance the contribution of health consumer representatives across all stages of health services research, including active involvement in prioritising objectives for data analysis and participating in data analysis and the dissemination of findings; and (2) describe the impact of continued engagement of consumers on the programme of research, the interpretation of findings and their translational potential., Key Innovations: Key enabling innovations for engagement included: (1) planned opportunities for long-term consumer involvement across all stages of the research process from conception to dissemination; (2) enhanced consumer engagement capacity; (3) purposeful recruitment of appropriately trained consumers; (4) provision of support structures for active consumer involvement in research design, analysis and write-up; and (5) financial support for consumer involvement., Impact/conclusion: Enhancing consumer contribution and establishing inclusive research design requires a negotiated, interactive, meaningful and transparent process. As a collaborative approach, consumer-driven research involvement offers opportunities for new, often unexpected or unexplored perspectives to feature across the whole research process. In a move away from tokenistic consumer involvement, consumers and researchers who participated in this novel and immersive research project identified inclusive research as a powerful tool to enhance health services research and its translation into effective policy., Competing Interests: Competing interests: DM wishes to declare that he is an appointed member of the Australian Digital Health Agency’s Consumer Advisory Committee. The other authors declare that they have no competing interests., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Diagnostic informatics encompasses the role of information technology in key areas of the diagnostic testing (pathology and medical imaging) process, including the selection of appropriate tests and interpretation and follow-up of test results. We present three case studies employing diagnostic informatics methodologies to demonstrate their potential use and value in health services research: (1) Data analytics applied to diagnostic data linked with patient outcome data as a means of enhanancing the monitoring of the quality and appropriateness of diagnostic test choices; (2) Business process modelling which can help to highlight healthcare processes in the diagnostic pathway as a means of improving safety and performance, and (3) Consumer involvement in the diagnostic research process to assist in the establishment of person-centred test result management systems. The case studies provide evidence of the role that diagnostic informatics can have in improving the quality and safety of patient care.

Patient-centred care and the empowerment of patients through shared clinical decision-making is a key goal of healthcare systems internationally. The Emergency Department is one of the first opportunities for shared decision-making to occur, with information exchanged between patient and clinician, between clinical disciplines, across the continuum of care, and between clinicians and ancillary departments including radiology and pathology laboratories. The successful development and implementation of sustainable health information technology (HIT) to support shared decision-making in Emergency care requires an understanding of the factors affecting this context. From a purposive, maximum variation sample of clinicians and a convenience sample of patients across three metropolitan and regional Emergency Departments in Australia, we identified three divergent discourses from an in-depth qualitative exploration of issues around shared decision-making. This allowed us to identify unanticipated factors affecting patient-centred care to inform context-sensitive implementation of HIT in the Emergency Department.

Objective: A rapid molecular diagnostic test (RMDT) offers a fast and accurate detection of respiratory viruses, but its impact on the timeliness of care in the emergency department (ED) may depend on the timing of the test. The aim of the study was to determine if the timing of respiratory virus testing using a RMDT in the ED had an association with patient care outcomes., Design: Retrospective observational study., Setting: Linked ED and laboratory data from six EDs in New South Wales, Australia., Participants: Adult patients presenting to EDs during the 2017 influenza season and tested for respiratory viruses using a RMDT. The timing of respiratory virus testing was defined as the time from a patient's ED arrival to time of sample receipt at the hospital laboratory., Outcome Measures: ED length of stay (LOS), >4 hour ED LOS and having a pending RMDT result at ED disposition., Results: A total of 2168 patients were included. The median timing of respiratory virus testing was 224 min (IQR, 133-349). Every 30 min increase in the timing of respiratory virus testing was associated with a 24.0 min increase in the median ED LOS (95% CI, 21.8-26.1; p<0.001), a 51% increase in the likelihood of staying >4 hours in ED (OR, 1.51; 95% CI, 1.41 to 1.63; p<0.001) and a 4% increase in the likelihood of having a pending RMDT result at ED disposition (OR, 1.04; 95% CI, 1.02 to 1.05; p<0.001) after adjustment for confounders., Conclusion: The timing of respiratory virus molecular testing in EDs was significantly associated with a range of outcome indicators. Results suggest the potential to maximise the benefits of RMDT by introducing an early diagnostic protocol such as triage-initiated testing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To integrate findings on the information infrastructure for people with intellectual or developmental disability (I/DD) living in supported accommodation, to understand how documentation use impacts person-centred support., Methods: We conducted an integrative literature review. Following screening by two independent reviewers, we included English language peer-reviewed empirical studies (n = 34) on documentation use for people with I/DD in domestic-scale supported accommodation. We appraised quality and extracted information for iterative comparative thematic and content analysis., Result: All studies reported written documentation regarding either the person with disability or the residence. Eighteen studies focused on health-specific information. We identified three key themes impacting on the person-centred support; 1) level of inclusion and independence of people with I/DD, 2) the culture of support within group homes, and 3) the quality use of information., Conclusions: Information infrastructure is closely aligned with the support culture in residences and can affect whether and to what extent key stakeholders (i.e., people with I/DD, family members) are involved in making decisions about healthcare and support needs., Practice Implications: Surveying local service health information infrastructure can provide crucial insights which can be leveraged to improve the safety and quality of supports provided for people living in supported accommodation., (Copyright © 2019. Published by Elsevier B.V.)

Objective: To investigate the impact of health information technology (IT) systems on clinicians' work practices and patient engagement in the management and follow-up of test results., Materials and Methods: A search for studies reporting health IT systems and clinician test results management was conducted in the following databases: MEDLINE, EMBASE, CINAHL, Web of Science, ScienceDirect, ProQuest, and Scopus from January 1999 to June 2018. Test results follow-up was defined as provider follow-up of results for tests that were sent to the laboratory and radiology services for processing or analysis., Results: There are some findings from controlled studies showing that health IT can improve the proportion of tests followed-up (15 percentage point change) and increase physician awareness of test results that require action (24-28 percentage point change). Taken as whole, however, the evidence of the impact of health IT on test result management and follow-up is not strong., Discussion: The development of safe and effective test results management IT systems should pivot on several axes. These axes include 1) patient-centerd engagement (involving shared, timely, and meaningful information); 2) diagnostic processes (that involve the integration of multiple people and different clinical settings across the health care spectrum); and 3) organizational communications (the myriad of multi- transactional processes requiring feedback, iteration, and confirmation) that contribute to the patient care process., Conclusion: Existing evidence indicates that health IT in and of itself does not (and most likely cannot) provide a complete solution to issues related to test results management and follow-up., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Objective: To determine whether rapid polymerase chain reaction (PCR) testing for influenza and respiratory syncytial viruses (RSV) in emergency departments (EDs) is associated with better patient and laboratory outcomes than standard multiplex PCR testing., Design, Setting: A before-and-after study in four metropolitan EDs in New South Wales., Participants: 1491 consecutive patients tested by standard multiplex PCR during July-December 2016, and 2250 tested by rapid PCR during July-December 2017., Main Outcome Measures: Hospital admissions; ED length of stay (LOS); test turnaround time; patient receiving test result before leaving the ED; ordering of other laboratory tests., Results: Compared with those tested by standard PCR, fewer patients tested by rapid PCR were admitted to hospital (73.3% v 77.7%; P < 0.001) and more received their test results before leaving the ED (67.4% v 1.3%; P < 0.001); the median test turnaround time was also shorter (2.4 h [IQR, 1.6-3.9 h] v 26.7 h [IQR, 21.2-37.8 h]). The proportion of patients admitted to hospital was also lower in the rapid PCR group for both children under 18 (50.6% v 66.6%; P < 0.001) and patients over 60 years of age (84.3% v 91.8%; P < 0.001). Significantly fewer blood culture, blood gas, sputum culture, and respiratory bacterial and viral serology tests were ordered for patients tested by rapid PCR. ED LOS was similar for the rapid (7.4 h; IQR, 5.0-12.9 h) and standard PCR groups (6.5 h; IQR, 4.2-11.9 h; P = 0.27)., Conclusion: Rapid PCR testing of ED patients for influenza virus and RSV was associated with better outcomes on a range of indicators, suggesting benefits for patients and the health care system. A formal cost-benefit analysis should be undertaken., (© 2019 The Authors. Medical Journal of Australia published by AMPCo Pty Ltd.)

A standard multiplex PCR offers comprehensive testing for respiratory viruses. However, it has traditionally been performed in a referral laboratory with a lengthy turnaround time, which can reduce patient flow through the hospital. We aimed to determine whether the introduction of a rapid PCR, but with limited targets (Cepheid Xpert Flu/RSV XC), was associated with improved outcomes for adults hospitalized with respiratory illness. A controlled quasi-experimental study was conducted across three hospitals in New South Wales, Australia. Intervention groups received standard multiplex PCR during the preimplementation, July to December 2016 ( n = 953), and rapid PCR during the postimplementation, July to December 2017 ( n = 1,209). Control groups (preimplementation, n = 937, and postimplementation, n = 1,102) were randomly selected from adults hospitalized with respiratory illness during the same periods. The outcomes were hospital length of stay (LOS) and microbiology test utilization (blood culture, urine culture, sputum culture, and respiratory bacterial and virus serologies). The introduction of rapid PCR was associated with a nonsignificant 8.9-h reduction in median LOS (95% confidence interval [CI], -21.5 h to 3.7 h; P  = 0.17) for all patients and a significant 21.5-h reduction in median LOS (95% CI, -36.8 h to -6.2 h; P  < 0.01) among patients with positive test results in an adjusted difference-in-differences analysis. For patients receiving test results before disposition, rapid PCR use was associated with a significant reduction in LOS, irrespective of test results. Compared with standard PCR testing, rapid PCR use was significantly associated with fewer blood culture (adjusted odds ratio [aOR], 0.67; 95% CI, 0.5 to 0.82; P <  0.001), sputum culture (aOR, 0.56; 95% CI, 0.47 to 0.68, P <  0.001), bacterial serology (aOR, 0.44; 95% CI, 0.35 to 0.55, P <  0.001) and viral serology (aOR, 0.42; 95% CI, 0.33 to 0.53, P <  0.001) tests, but not with fewer urine culture tests (aOR, 0.94; 95% CI, 0.78 to 1.12, P =  0.48). Rapid PCR testing of adults hospitalized with respiratory illnesses can deliver benefits to patients and reduce resource utilization. Future research should consider a formal economic analysis and assess its potential impacts on clinical decision making., (Copyright © 2019 American Society for Microbiology.)

People with intellectual and/or developmental disability (I/DD) commonly have complex health care needs, but little is known about how their health information is managed in supported accommodation, and across health services providers. This study aimed to describe the current health information infrastructure (i.e., how data and information are collected, stored, communicated, and used) for people with I/DD living in supported accommodation in Australia. It involved a scoping review and synthesis of research, policies, and health documents relevant in this setting. Iterative database and hand searches were conducted across peer-reviewed articles internationally in English and grey literature in Australia (New South Wales) up to September 2015. Data were extracted from the selected relevant literature and analyzed for content themes. Expert stakeholders were consulted to verify the authors' interpretations of the information and content categories. The included 286 sources (peer-reviewed n = 27; grey literature n = 259) reflect that the health information for people with I/DD in supported accommodation is poorly communicated, coordinated and integrated across isolated systems. 'Work-as-imagined' as outlined in policies, does not align with 'work-as-done' in reality. This gap threatens the quality of care and safety of people with I/DD in these settings. The effectiveness of the health information infrastructure and services for people with I/DD can be improved by integrating the information sources and placing people with I/DD and their supporters at the centre of the information exchange process.

Objective: To determine variation in pathology test ordering practices and identify associated factors for adult patients presenting to emergency departments (ED) with chest pain and subsequently admitted with ischaemic heart disease., Methods: A retrospective study across six hospital EDs in New South Wales, Australia. A total of 6769 patient presentations between January 2014 and December 2017 met the inclusion criteria. Ordered pathology tests were grouped into three categories based on Australasian College for Emergency Medicine and the Royal College of Pathologists of Australasia recommendations: category I (no restriction in ordering), category II (can be ordered after consulting a supervisor) and category III (not for routine ordering in ED). The primary outcome was the proportion of category III test ordering across study EDs. Factors associated with category III test ordering were identified using a logistic regression., Results: A total of 34 936 pathology tests were ordered: 65.6% (n = 22 932) were category I/II tests and 34.4% (n = 12 004) were category III tests. Five tests (Calcium Magnesium Phosphate, Coagulation Studies, Lipase, C-reactive Protein and Blood Gas tests) accounted for 84.7% of all category III tests. The proportion of category III tests ordered varied by hospitals from 29.8% to 45.9%. The proportion of patients with at least one category III test was 76.3% (range across hospitals: 68.3%-95.6%). Increasing age, presentation to an ED at night, and those in an imminently life-threatening triage category were significantly associated with increased likelihood of category III test ordering. The proportion of category III tests decreased over time. EDs in medium and/or regional hospitals were more likely to order a category III test., Conclusion: Pathology investigations for patients presenting with chest pain varied significantly across EDs suggesting opportunities to improve standardisation of test ordering practices., (© 2018 John Wiley & Sons Ltd.)

Background Diagnostic testing provides integral information for the prevention, diagnosis, treatment and management of disease. Inadequate test result reporting and follow-up is a major risk to patient safety. Factors contributing to failure to follow-up test results include unclear delineation of responsibility about who is meant to act on a test result; poor coordination across different levels of care; and the absence of integrated health information systems for the efficient information communication. Methods A 2016 Australian Stakeholder Forum brought together over 30 representatives from 14 different consumer, clinical and management stakeholder organisations to discuss safe and effective test result communication, management and follow-up. Thematic analysis was conducted drawing on multimodal data collected in the form of observational fieldnotes and document artefacts produced by participants. Results The forum identified major challenges which pose immediate risks to patient safety. Participants recommended priorities for addressing issues relating to: (i) the governance of test result management processes; (ii) integration of health care processes through the utilisation of effective digital health solutions; and (iii) involving patients as key partners in the decision-making and care process. Conclusions Stakeholder groups diverged slightly in their priorities. Consumers highlighted the lack of patient involvement in the test result management process but were less concerned about standardisation of reports and critical result thresholds than pathologists. The forum foregrounded the need for a systems approach, capable of identifying and addressing interconnections and multiple factors that contribute to poor test result follow-up, with a strong emphasis on enhancing the contribution of patients.

Introduction: The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems., Methods and Analysis: This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings., Ethics and Dissemination: Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Understanding the context and nuances of clinical performance at the front-line can provide valuable insights into why the effects of Health Information Technology implementation might differ across sites. It also helps to inform the design of systems that support performance flexibility as clinicians respond to the changing demands of the clinical environment. This study explored the use of an electronic result acknowledgement (eRA) system by physicians at two Emergency Departments (EDs) at Australian metropolitan teaching hospitals to understand how electronic result acknowledgement is managed differently in response to varying environmental demands. Semi-structured, in-depth interviews relating to physician electronic test result acknowledgement processes were conducted with 21 emergency physicians. Physician use of the eRA system differed in four aspects: i) responsibility (i.e. who acknowledges test results); ii) types of tests acknowledged; iii) coordination and synchronisation (i.e. when acknowledgement occurred); and iv) documentation of follow-up actions.

New South Wales (NSW) Health Pathology is implementing one of the world's largest managed PoCT services across rural and remote Emergency Departments (EDs) in New South Wales, Australia to improve patient access to care. The aim of this qualitative study was to gain a context-rich understanding of the operational impact of the NSW rollout of PoCT across rural and remote ED settings as experienced by frontline clinical staff. Clinical professionals (n=14) participated in interviews and focus groups in August 2015 at four rural and remote NSW EDs. Participants perceived that PoCT provided greater access to pathology thus facilitating more efficient and effective patient care via faster test turnaround and time to treatment and more effective decisions about the need to transfer patients to appropriate sites when required. These factors have a potentially important role in saving lives. Staff also identified innovative and disruptive challenges to clinical work patterns associated with PoCT implementation, particularly in relation to work flows, resource allocation and the governance arrangements.

In Australia, New South Wales Health Pathology's implementation of managed Point-of-Care Testing (PoCT) services across rural and remote emergency departments (EDs) has the potential to significantly improve access to results for certain types of pathology laboratory tests and help to deliver timely patient care. The aim of this study was to assess the quality of the datasets, including the integration of PoCT results into clinical systems, as a precursor to the application of an evaluation framework for monitoring the delivery of PoCT services and their impact on patient care. Three datasets, including laboratory, ED presentations and hospital admissions data were extracted from the relevant clinical information systems. Each dataset was assessed on six dimensions: completeness, uniqueness, timeliness, validity, accuracy, and consistency. Data incompleteness was the largest problem. Assessing the PoCT data integration and data quality is a precondition for the evaluation of PoCT and for monitoring and improving service delivery.

Context: International medical graduates (IMGs) make up one-third of the Australian medical workforce. Those from non-English-language backgrounds can face cultural and communication barriers, yet linguistic support is variable and medical educators are often required to provide feedback on both medical and communication issues. However, some communication difficulties may be very specific to the experiences of IMGs as second language users., Objectives: This interdisciplinary study combines perspectives from applied linguistics experts and clinical educators to address IMGs' difficulties from multiple dimensions and to enhance feedback quality., Methods: Five video-recorded patient encounters with five IMGs were collected at Launceston General Hospital. Three clinical educators gave quantitative and qualitative feedback using the Rating Instrument for Clinical Consulting Skills, and two applied linguistics experts analysed the data for language, pragmatic and communication difficulties. The comparison of the educators' language-related feedback with linguistic analyses of the same interactions facilitated the exploration of differences in the difficulties identified by the two expert groups., Results: Although the clinical educators were able to use their tacit intuitive understanding of communication issues to identify IMG difficulties, they less frequently addressed the underlying issues or suggested specific remedies in their feedback., Conclusions: This pilot study illustrates the effectiveness of interdisciplinary collaboration in highlighting the specific discourse features contributing to IMG communication difficulties and thus assists educators in deconstructing their intuitive knowledge. The authors suggest that linguistic insights can therefore improve communications training by assisting educators to provide more targeted feedback., (© 2015 John Wiley & Sons Ltd.)

The study of computer use during consultations and in clinical communication teaching has generated considerable research interest in recent decades, but few studies have investigated how the use of other technological devices such as the dictaphone may be linked to the acquisition of interpersonal communication skills. Research on the dictaphone has focused on "backstage" activity such as dictating consultation letters after consultations, and largely neglected its potential in "frontstage" interactions with patients or as an educational tool in teaching clinical communication. This article draws on 28 consultations recorded in a gastrointestinal clinic and a follow-up interview with the participating surgeon to explore the use of the dictaphone during consultations. All data were transcribed and reiterative thematic analyses were conducted. The analyses presented here show how the dictaphone can serve a range of important relational and medical functions when used to co-construct consultation letters with patients. These functions include establishing and maintaining rapport, building trust, checking and clarifying information, aiding information accuracy, and closing the consultation. This study shows how a technological device usually reserved for "backstage" medical communication can be successfully used as a communicative tool in "frontstage" interactions and illustrates the multifaceted and beneficial functions of the dictaphone.