[EXTERNAL] Re: [IMPROVEDX] quick ?

Xavier Prida dr.xavier.prida at GMAIL.COM
Mon Apr 28 20:30:29 UTC 2014


Dr. Swerlik,
                 You are on point-  that the processes of care and
desirable endpoints of those measured processes(time in ED, length of stay)
have become the targets of measured performance(they are easily measurable-
a clock, check a box etc. which results in gaming)) rather than accurate
diagnosis and propriety of assigned treatment.

Your taxonomy of diagnostic circumstance is very insightful and one of the
tools to address "timeliness", the latter which is intrinsic in each of the
5 proposed(I'm sure not yet exhaustive) circumstances, is a statistical
concept of "TUTE"- Time Until Treatment Equipoise(*JAMA
Surg.*2014;149(2):109-111.
doi:.10.1001/jamasurg.2013.3066.).
Although TUTE, as proposed, applies to comparative benefits and risks
between two treatments, (where do the survival curves cross, for instance
between CABG and medical therapy for CAD), this could be modified to "Time
Until Diagnosis Equipoise" where time to accurate diagnosis would have a
cut point of harmful vs. beneficial effects. As you implied in your ED
vignette, not all diagnosis lend themselves to immediacy and awaiting a
line of investigation to be fulfilled is often necessary(I would posit
desirable) prior to inclusion or exclusion of diagnosis.

Xavier


On Sun, Apr 27, 2014 at 9:44 PM, Swerlick, Robert A <rswerli at emory.edu>wrote:

>  Art,
>
>
>
> I am aware of this work but I cannot conceive how this approach could be
> scaled to look at other, especially outpatient contexts. It involves such a
> manual, time consuming, and expensive process. I realize when the switch
> flips, what now appears expensive may end up being cost saving.
>
>
>
> I also wonder if part of the bilateral cellulitis problem is now an
> unintended consequence of driving ED through put. Diagnosing cellulitis
> creates rapid closure in the ED and activates a pathway which gets patients
> out of the ED quickly. That is the measurement which is now essential.
> There is no pathway to deal with severe stasis dermatitis expeditiously in
> the ED. Perhaps better to get the diagnosis wrong and patient out of the ED
> fast given the present incentives.
>
>
>
>  Bob
>
>
>  Robert A. Swerlick, MD
> Alicia Leizman Stonecipher Chair of Dermatology
> Professor and Chairman, Department of Dermatology
> Emory University School of Medicine
> 404-727-3669
>   ------------------------------
> *From:* Art Papier MD [apapier at logicalimages.com]
> *Sent:* Sunday, April 27, 2014 7:56 PM
> *To:* 'Society to Improve Diagnosis in Medicine'; Swerlick, Robert A
> *Subject:* RE: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
>   Bob you are well aware of the research around cellulitis diagnostic
> error, but to summarize for the list….  We measured the errors, once again
> by prospectively going to the bedside and collecting data on patients,
> photographing patients and completing a profile of the clinical
> presentation.   We had dermatologists and infectious disease physicians
> examine patients in our initial pilot and there was 100% agreement between
> the specialists on what was cellulitis and what was not.  Ambiguous
> presentations even received biopsies and were treated as consults.  Biopsy
> results include panniculitis and other diagnoses.  Admittedly this
> diagnostic problem area might be unique, but on the other hand it might be
> a method to get at diagnostic error rates for other diagnoses in
> hospitalized patients.  By visiting the patients hours after they are
> admitted and having specialists re-examine the patients without the
> admitting physicians knowing you can track consecutive admissions and get
> at least a better idea of the error rate then saying retrospectively
> reviewing records.  It is a very important point that while stasis
> dermatitis is well known to dermatologists, it is apparently not to many
> others.  Common diagnosis, common area of misdiagnosis and many, many
> people harmed by unnecessary admissions.  Daniella Kroshinsky MD at MGH and
> others around the country are working on this problem as well.  Much
> evidence developing and one more example of why we need SIDM.   Once again,
> data:
>
> We looked at consecutive admissions for cellulitis at 2 major teaching
> centers and showed that on average 28% of patients admitted for cellulitis,
> did not have cellulitis http://www.ncbi.nlm.nih.gov/pubmed/21426867 (also presented a poster on this at DEM) a similar study in the UK showed
> the error rate to be 33% http://www.ncbi.nlm.nih.gov/pubmed/21564054
>
>
>
>
>
> Art Papier MD
>
> Chief Executive Officer
>
> 3445 Winton Place *.* Suite 240 *.* Rochester NY 14623
>
> (585) 427-2790 x230* .* apapier at logicalimages.com
>
> * www.visualdx.com <https://owa.emory.edu/owa/UrlBlockedError.aspx>*
>
> *www.skinsight.com <https://owa.emory.edu/owa/UrlBlockedError.aspx>*
>
> [image: Logical Images]
>
>
>
>
>
> *From:* Swerlick, Robert A [mailto:rswerli at EMORY.EDU]
> *Sent:* Sunday, April 27, 2014 4:03 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
>
>
> This is a very interesting discussion, which as far as I can tell started
> with Hardeep's article estimating the frequency of diagnostic errors in
> outpatient settings but has moved on to discussions of best approaches to
> reduce diagnostic error. I think the discussion should move back to where
> it started.
>
>
>
> That is because I believe that any discussion which weighs the options for
> improving diagnostic accuracy and avoiding diagnostic errors without being
> able to measure actual errors is not going anywhere. Yes, this task or sets
> of tasks will be very difficult and may appear at times to be impossible.
> But without the ability to measure diagnostic errors, all attempts to
> lessen numbers will be undertaken without knowing whether we are actually
> moving the needle or creating unintended problems. We have stories and
> stories are great for get attention and conveying a message. The next steps
> will require actual measurements and data  (ideally both numerators and
> denominators) of what is happening to patients.
>
>
>
> There are many different contexts where diagnostic errors may occur and
> different parties who might become aware that diagnostic error has possibly
> happened. Each of us brings very different life and clinical experiences to
> this discussion. The experience of the ED physicians is very different from
> that of the primary care doc, the patient with their own personal
> experience and presenting symptom complex v. the physician who has seen a
> sea of patients with a similar symptom complex, the hospital intensivist v.
> the community dermatologist. All likely experience, observe, commit
> diagnostic errors but there the similarities end. No single approach will
> work.
>
>
>
> Perhaps we need not only a definition of diagnostic error but also a
> taxonomy of diagnostic circumstances:
>
>
>
> Inpatient v. outpatient
>
> Acute disease v. chronic disease
>
> Symptomatic disease v. asymptomatic (pre-disease) state
>
> Life threatening v. non-life threatening (high stakes v. lower stakes)
>
> Time constrained vs. not as time constrained
>
>
>
> The tools we use under these different circumstances will be very
> different and the ability to measure will also depend on different clinical
> contexts.
>
>
>
> Bob
>
>
>
>
>
> Robert A. Swerlick, MD
>
> Alicia Leizman Stonecipher Chair of Dermatology
>
> Professor and Chairman, Department of Dermatology
>
> Emory University School of Medicine
>
> 404-727-3669
>    ------------------------------
>
> *From:* Xavier Prida [dr.xavier.prida at gmail.com]
> *Sent:* Sunday, April 27, 2014 2:06 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
> Art,
>
>       Superb elucidation of the need for combinatorial approaches.
>
>
>
> And, would agree that decision trees/algorithms(of which any database and
> software system would be comprised) require plasticity and "bailouts" to
> allow for detection of, as you astutely described , atypical presentations
> of common diseases(illness) as well as unknown and unrecognized(to the
> examiner) hallmarks of either rare or common diseases(illness). Therefore,
> one would not "be lead down the garden path" or distracted by "red
> herrings".
>
> The cognitive skill to which you refer is "chunking"- the ability to
> aggregate, organize all data input(history, physical findings, testing) and
> distill a short list or singular accurate diagnosis- can be inherent
> extension of training, education, and experience with or without decision
> support tools.
>
>
>
> Also, telemedicine allows for "wisdom of the crowd"- collective cognition.
>
>
>
> Xavier
>
>
>
>
>
>
>
> On Sun, Apr 27, 2014 at 12:48 PM, Art Papier MD <apapier at logicalimages.com>
> wrote:
>
> Xavier,
>
> System 1 thinking occurs well or not well depending on the level of
> expertise.  It is all in the cortex of the decision-maker, can they
> automatically recognize the pattern with a high degree of accuracy?
> Alternatively does someone who is not an expert, think they know the
> pattern, and automatically make a judgment and prematurely close on the
> wrong diagnosis?    Additionally, there is the possibility that the
> decision-maker was trained incorrectly and actually spends quite a bit of
> time thinking about the diagnosis (system 2), but comes to the wrong
> conclusion despite the strong effort.  Some clinicians just have the wrong
> understanding or knowledge of certain problems.
>
>
>
> What you describe is a potential remedy but in my over two decades of
> practicing medicine, I have never seen a clinician or resident use a
> decision tree. Logically a tree can cause a user to go down a path based on
> one confounding factor.  Combinatorial approaches just make more sense for
> complex decision making.   The decision making challenge of recognizing
> visual patterns is often very different than an internal medicine problem
> that requires exhaustive history, thorough physical exam and a thoughtful
> assessment.  It is as Malcolm Gladwell describes a “blink” moment.
>
>
>
> Not all chief complaints and problem domains are created equal.
>
>
>
> A patient presented to my office several years ago  and said something
> like this to our RN “I was  out hunting and I bent over and my scalp got
> scraped and now it is not healing”, but she was quite good and presents the
> patient to me with a shortened version of what the patient was saying , and
> an assessment   “he was out hunting and was scraped…. but he has a basal
> cell carcinoma and we need to set up for a biopsy”…….  The idea is that
> diagnosing a basal cell carcinoma is often 100% physical exam, no history
> necessary…my nurse made the diagnosis in a blink of an eye, knowing that
> the physical exam finding trumped the history…  most patients, believe that
> they are well and create histories to tell themselves that problems are
> minor….non system 1 experts for skin diagnosis, typically over rely on
> history.   Alternatively a patient with fever and a rash, and the rash is a
> morbilliform or exanthematous eruption then you likely need detailed
> history, exposures hx, travel hx etc.  Do they have Dengue because they
> went to South America?  Do they have a drug reaction? Which one?  Can you
> remember the questions to ask related to the presenting problem?
>
>
>
> So there is a framing that goes on , with some problems solved totally on
> a system 1 level and others that will always require system 2.
>
>
>
> I come back to my initial assertion and Bob’s question.   Yes telemedicine
> would be helpful, but these problems are so common that there would not be
> enough experts to be on the other end……we have hybridized telemedicine with
> decision support.  The decision support creates a training effect whereby
> the expert sends the referring doc through the (store and forward)
> telemedicine system a link into diagnostic decision support .  It saves the
> consultant dermatologist a ton of time because they do not have to write a
> long message.  Then the referring doc receives this clickable link and sees
> how they could have searched the diagnostic decision support system.  It is
> a “teaching someone how to fish model, instead of always fishing for
> them”.  We are doing this already in California in LA county and the VA
> system with great success.
>
>
>
> I must point out that there are so many confounding factors that an
> algorithm, matrix or checklist cannot possible cover all the variants.  The
> beauty of well-designed databases and software allows one to capture
> variation and push that back to the user.    I stand by my assertion that
> variants of commons often cause diagnostic error, not just rare birds.
>
>
>
>
>
> Art Papier MD
>
> Chief Executive Officer
>
> 3445 Winton Place *.* Suite 240 *.* Rochester NY 14623
>
> (585) 427-2790 x230* .* apapier at logicalimages.com
>
> * www.visualdx.com <http://www.visualdx.com>*
>
> *www.skinsight.com <http://www.skinsight.com>*
>
> [image: Logical Images]
>
>
>
>
>
> *From:* Xavier Prida [mailto:dr.xavier.prida at gmail.com]
> *Sent:* Sunday, April 27, 2014 11:22 AM
> *To:* Society to Improve Diagnosis in Medicine; Art Papier MD
>
>
> *Subject:* Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
>
>
> Art,
>
>      As to your stated example(cellulitis vs. stasis dermatitis), in our
> paradigm this would be a Type 1 error- cognitive("I didn't know that").
>  The remedy would be a decision matrix that excluded diagnosis of
> cellulitis if bilateral in description and defer to a diagnostic pathway
> including lymphedema/stasis dermatitis, e. nodosum, etc.
>
>
>
> Xavier
>
>
>
> On Sat, Apr 26, 2014 at 5:21 PM, Art Papier MD <apapier at logicalimages.com>
> wrote:
>
> One of the common misperceptions is that diagnostic error always involves
> rare diagnoses and therefore is really hard to study, another is that
> prospective studies are not being performed.   Often very COMMON diagnoses
> are missed due to premature closure, over confidence and other cognitive
> reasons.  We looked at consecutive admissions for cellulitis at 2 major
> teaching centers and showed that on average 28% of patients admitted for
> cellulitis, did not have cellulitis
> http://www.ncbi.nlm.nih.gov/pubmed/21426867  (also presented a poster on
> this at DEM) a similar study in the UK showed the error rate to be 33%
> http://www.ncbi.nlm.nih.gov/pubmed/21564054   Incredibly there are many
> admissions for BILATERAL cellulitis in every city and town every day.  (for
> the non-physicians on the list, cellulitis is a soft tissue infection, that
> is 99.9% of the time only on one side of the body, usually the leg, but
> hands, arms and other body parts occur..but not bilateral!) Dermatologists
> have been grimacing, frowning, wringing their hands about this problem for
> decades.  Ask pretty much any general medical dermatologist and you will
> get
> the same puzzled response.  The academic dermatologists who cover the
> inpatient consultation services all look like they are going to have a
> seizure when you talk about this problem because it has been going on for
> decades.  We are unsure why so many clinicians cannot diagnosis
> lymphedema/stasis dermatitis in particular, but also common diseases like
> gout, zoster, erythema nodosum, lyme disease and many other diseases that
> are commonly called cellulitis.    Stasis dermatitis is the moist frequent
> condition mis-diagnosed as cellulitis.   This single diagnostic error area
> we estimate costs over 1.3 billion dollars in hospital admissions.  These
> are potentially fixable mistakes.  The human cost includes giving health
> people c. difficile or a life-threatening drug reaction such as Stevens
> Johnson Or TEN to a person that did not need antibiotics, nor
> hospitalization.   My hunch is there are many other problem areas where
> diagnosis is led by the good old fashioned physical exam where misdiagnosis
> thrives and is tolerated.  PS  Manoj-  admittedly this particular
> diagnostic
> problem area is centered in adult medicine.
>
> Art Papier MD
> Chief Executive Officer
> 3445 Winton Place . Suite 240 . Rochester NY 14623
> (585) 427-2790 x230 . apapier at logicalimages.com
>  www.visualdx.com
> www.skinsight.com
>
>
>
>
> -----Original Message-----
> From: Mittal, Manoj K [mailto:MITTAL at EMAIL.CHOP.EDU]
> Sent: Saturday, April 26, 2014 3:40 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
> Hi,
>
> Thanks for your input.
>
> I like Hardeep's framing of diagnostic errors as missed opportunities. It
> is
> important what labels we use.
>
> Retrospective studies to identify diagnostic errors are a good start. The
> problem of hindsight bias in these studies, however, may make front line
> clinicians resistant to accept their conclusions.
>
> I am a practicing PEM physician. Our practice has evolved to such an extent
> that new onset serious diseases (where improving diagnosis is most
> important
> as it can have a difference between life and death) have become very rare,
> be they serious sepsis/septic shock, bacterial meningitis (much less than 1
> in 1000 children presenting with febrile illness), brain tumor, renal
> failure, etc. that any test (historical information and physical exam
> findings) has a very low positive predictive value.
>
> We have to find a way to study diagnostic errors by prospective analysis of
> records. it is going to be difficult as all the records will have to be
> analyzed, but with the increasing use of EMRs and machine learning, it may
> become possible. The system could pick up suspect records that would be
> reviewed by the clinician's peers, who will decide if something was missed.
> The follow-up will show the truth.
>
> Thanks,
> Manoj Mittal, MD
> The Children's Hospital of Philadelphia
> ________________________________________
> From: Graber, Mark [Mark.Graber at VA.GOV]
> Sent: Saturday, April 26, 2014 2:00 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] [EXTERNAL] Re: [IMPROVEDX] quick ?
>
> I'd like to underline the comment from David Gordon that .... "Ultimately,
> this evolving science about how to improve diagnostic efficacy is going to
> have to balance the harm that can come by both under and over diagnosis".
>  I
> couldn't agree more.
>
> David was concerned that if we see an 'explosion' of research that focuses
> excessively on delayed and missed diagnoses, we will under-emphasize the
> harm from over-diagnosis.  I certainly acknowledge the costs and harm from
> over-diagnosis, but would argue that an explosion of studies on diagnostic
> error (under-diagnosis) is exactly what's needed right now to understand
> how
> to improve the efficiency and quality of diagnosis.
>
> If there is going to be any explosion (doubtful, given that the funding for
> dx error research is almost nil at the moment) my bet will be that this
> will
> come from the over-diagnosis community.  The evidence for this is number of
> abstracts submitted to the Overdiagnosis Conference (in the hundreds) vs
> the
> Diagnostic Error in Medicine conference (a few dozen).  And the reason is
> that it is so much easier to study over-diagnosis - all the data has
> already
> been collected, and the extra CT's and incidentaloma's have all been
> tallied.  Finding and studying under-diagnosis is much harder, for all the
> reasons everyone has described.  It may take months or years to know that a
> diagnosis was missed and in many cases we may never know at all.
>
>
>
>
>
>
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
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> --
>
> Xavier E. Prida MD FACC FSCAI
>
> 813 813 0721(H)
>
> 813 245 3143(C)
>
>
>
>
>
> --
>
> Xavier E. Prida MD FACC FSCAI
>
> 813 813 0721(H)
>
> 813 245 3143(C)
>
>
>  ------------------------------
>
>
>
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> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
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> for Improving Diagnosis in Medicine
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>
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>
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-- 
Xavier E. Prida MD FACC FSCAI
813 813 0721(H)
813 245 3143(C)








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