checklist vs. checklist - and engaging patients in the check-up!

Diane Zuckerman diane at EBSOLUTIONS.COM
Fri May 3 17:35:11 UTC 2013


Yes, we have a PHR that allows patients to put in their "issue' prior to an appointment or anytime they like.  The subsequent questions are asked in a branched-logic manner.  Patients are asked questions reflecting Review of Systems (ROS) as well.  Physicians told us this would save them a great deal of time and the visit would be more robust and meaningful. The patient can print out the PDF or securely message if the physician uses the MD side of the site.

https://www.ebnavigator.com


Diane Zuckerman, RPh
Founder, CEO, Evidence-Based Solutions
41 East 11th Street
11th Floor, Suite  #53
New York, NY 10003
Cell: 917-256-9620
www.ebsolutions.com<http://www.ebsolutions.com>







On May 3, 2013, at 12:27 PM, <William.Strull at KP.ORG<mailto:William.Strull at KP.ORG>>
 <William.Strull at KP.ORG<mailto:William.Strull at KP.ORG>> wrote:

Yes - I agree that our patients can and should be our most powerful partners in achieving timely and accurate diagnosis.  In addition to the SMART tool that Bettygene is piloting, and approaches such as Ask Me 3, do others have specific tools/techniques to better engage patients in the diagnostic journey?


William Strull MD
Medical Director, Quality and Patient Safety
Kaiser Permanente

The Permanente Federation, LLC
One Kaiser Plaza, 23B
Oakland, California 94612
510-271-5987 (office)
8-423-5987 (tie-line)
510-271-6642 (fax)
415-601-6013 (mobile phone)

Debra C. Costa (assistant)
debra.c.costa at kp.org<mailto:debra.c.costa at kp.org>
510-271-6031

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From:        Bettygene Egan/CA/KAIPERM at Kaiperm
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Date:        05/03/2013 08:27 AM
Subject:        Re: checklist vs. checklist

________________________________




I have been reading the numerous emails on this subject and find the dialog robust.  It is also clear that this is a very challenging area with many opinions.  Ross and Harold's comments relate to a project that I have been working on and some of you may recall seeing at last year's DEM Conference in Baltimore.  Dr. William Strull and I briefly talked about a tool for patients named SMART Partners.  S=symptoms, M=medication/medical history, A= assessment, R= review, T= to do.  The concept of the SMART Partners is to provide patients with a tool to help prepare them for their appointment and to be engaged in their care, a checklist of sorts for the patient.

I ran a very small pilot in one of our medicine clinics and the results show that the patients like the guide, 86% (n=590) said they will use it at a future visit.  A post-survey for the physicians shows an increase in obtaining information from the patient in the first couple of minutes than before using the guide.

My point is ... I don't believe that we will ever be able to stop errors from occurring, similar to we will never stop car accidents from happening, however, as we remain open to opportunities for small changes, like seat belts, we can continue to minimize the risks. Small changes can have big impacts.





Bettygene Egan, MBA
Sr. Project Manager
National Risk Management
One Kaiser Plaza, 18 Bayside
Oakland, CA 94612
Office: (510) 271-5713  TL: 8-423-5713
Cell: (510) 912-5148
Fax: (510) 271-6988

Administrative Support:
Van B Nguyen - (510) 267-4892

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From:        Harold Lehmann <lehmann at JHMI.EDU<mailto:lehmann at JHMI.EDU>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Date:        05/03/2013 06:33 AM
Subject:        Re: checklist vs. checklist
________________________________



I have been thinking for a while of the concept of a "Task Guide"---where an authority (faculty member; a crowd) sets up the sequence of steps required to accomplish a task and, for each step, suggests a number of resources that could help the user. The classic use case is evidence-based medicine, where the steps are "Find appropriate guideline; find appropriate systematic review; search PubMed Clinical queries," etc. At each step, there are links, e.g., to databases of guidelines, to appraisal guides.

So when I look at this list that Ross has assembled, I am thinking, can we assemble resources that speak to each step? They may be System 1 or System 2 oriented, I suppose.

E.g., I can imagine a user asking, "Can you help me think of other known causes of this problem?" [Yes, these are differential-diagnosis lists from textbooks, review articles, or diagnostic decision support systems.] "Can you help me maintain an open mind?" [Probably the same list.] "How do I know when the timing is complete?" [Resources on good interview technique]. Etc.

Such a resource list yoked to good practice might provide a way of us projecting to the larger community what we know about overcoming barriers to improving diagnosis in medicine and providing direct help.

Harold

--
***************************************************************************
Harold P. Lehmann, MD PhD
Interim Director, Division of Health Sciences Informatics
Johns Hopkins University School of Medicine



From: Ross Koppel <rkoppel at sas.upenn.edu<mailto:rkoppel at sas.upenn.edu>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Ross Koppel <rkoppel at sas.upenn.edu<mailto:rkoppel at sas.upenn.edu>>
Date: Thursday, May 2, 2013 9:54 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: checklist vs. checklist

Checklist for what?

A checklist for a procedure is one thing.  A check list to improve Dx is another.   For the procedure, you want tools, steps, etc.  Checklists are great.  (OK, also see Peter P's very nuanced article in Millbank Memorial Quarterly...maybe not so cut and dry)

For Dx, on the other hand, I can imagine a checklist that's a bolus of difficult questions that may not improve outcomes, but rather just anger the clinician.  Consider the following almost absurd but not irrelevant questions:
   Do you remember other known causes of this problem?
  Have you prematurely closed inquiry?
  Did you take enough time?
  Have you examined the pt's history carefully enough?
  Do you remember your pharmacology well enough?
  Did you meet with the radiologist(s) for fully explore the ambiguities?
  When you go into another room, do you increasingly wonder why you are there?
  Are you willing to admit your ignorance?
  Should you talk to someone else?
  Did you do the all of the appropriate tests but none extra?


I would suggest that some of the Dx-related questions are very different than asking about the availability of gloves.  More important, some are unlikely to get answers beyond annoyance.

Ross Koppel, Ph.D. FACMI
Sociology Dept and Sch. of Medicine
University of Pennsylvania, Phila, PA 19104-6299
215 576 8221 C: 215 518 0134
On 5/2/2013 8:37 PM, Robert L Wears, MD, MS, PhD wrote:
Certainly it can often be used as an excuse, but the effects of time/production pressure are
often more subtle and distributed.  People habituate to various constraints -- if they are
often time pressured, and must sacrifice thoroughness for efficiency, those behavioural
patterns tend to carry over into other instances where time pressure may be absent.

I'd suggest reading Erik Hollnagel's book on the efficiency-thoroughness tradeoff.  One idea
he brings up is that people tend to be biased to favour efficiency over thoroughness, and
that this is so deeply ingrained one would suspect an evolutionary basis for it.  Saving a bit
of time is not often important, but in an open system, a world with uncertainty, risk, and
unexpected events in it, a bit of extra time sometimes turns out to be critical in dealing w/
the unexpected.

The full reference is:

Hollnagel, E. (2009). The ETTO Principle:  Efficiency-Thoroughness Tradeoff (Why Things That Go Right Sometimes Go Wrong). Farnham, UK: Ashgate.

bob

On 2 May 2013 at 3:19, Jason Maude wrote:

> I initially saw my GP (very experienced and senior partner in the
> practice) who was certainly not rushed as he even asked me about some
> other things I had seen him with before. The x-ray was carried out at
> the small local hospital that was attached to the practice. There was
> no queue to get the x-ray done so I don't believe that the radiologist
> was rushed. It was then looked at again by a couple of nurse
> practitioners, all in the calm of a sleepy English country town
> hospital!
>
> This is why I started to conclude that lack of time could often be an
> excuse rather than a legitimate explanation. I also blamed myself for
> too easily accepting what seemed a plausible diagnosis. I should have
> asked "what else could it be" and acted as the trigger for more
> thinking. The whole episode showed me what an easy trap it is to fall
> into.
>
> So do we either accept this as the norm and say that nothing can be
> done (not enough time etc)- in other words there will be an inbuilt
> industry dx error of 10-20% - or is there a way we can force change.
> My view, reinforced by this episode, remains that the differential (or
> say 3 diagnoses) must be recorded in the medical notes at the time of
> the consultation.
>

Robert L Wears, MD, MS, PhD
University of Florida    Imperial College London
wears at ufl.edu<mailto:wears at ufl.edu>            r.wears at imperial.ac.uk<mailto:r.wears at imperial.ac.uk>
1-904-244-4405 (ass't)            +44 (0)791 015 2219
What hits the fan will not be evenly distributed.


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