[EXTERNAL] Re: [IMPROVEDX] stroke misdiagnosis ... Washington Post [CB]

Graber, Mark Mark.Graber at VA.GOV
Sat Jun 28 15:01:39 UTC 2014

Thanks David for all the details.  There is so much to like in your approach.  I've copied the listserv in the hopes that others might be inspired to give it all a try.  Regarding that, what advice would you give practices that wanted to adopt your system?   I'm hearing that PKC isn't even available any more, or at least the system you're using.

From: David Hallbert <david.hallbert at gmail.com>
Date: Thu, 26 Jun 2014 05:17:29 -0400
To: "mark.graber at va.gov" <mark.graber at va.gov>
Subject: Re: [EXTERNAL] Re: [IMPROVEDX] stroke misdiagnosis ... Washington Post [CB]

   We may be sufficiently off the topic of better diagnosing stroke in young patients that I'm replying directly to you.  You decide.  This is in answer to your last answer to me:
    Mark, quality diagnosis takes time but it doesn't have to take up MY time.  It doesn't take me long to review a painstakingly put together questionnaire that a patient has spent time filling out online before the office visit (this forms the crux of the HPI and all the ROS, too).  They also update the fam/soc/surg hx--and billing info online.  My time is spent in promoting the relationship with the patient, digging deeper on a few points to refine the HPI (while my scribe types into the EMR) and together with the patient deciding on a diagnosis and plan (and billing code)--with the help of the computer CDSS.  I'm off to the next patient while the scribe (or collaborative nurse) finishes up.  Not much more time than any other PCP, but the tool vastly improves the depth of inquiry, completeness and quality of the visit.  We even schedule the next visit before the patient leaves the exam room and they leave with a completed office note (printers in each room) every time.  (the checkout is eliminated)
 I don't believe we're unique from what I gather from other listserves.  But too many of my brethren don't BELIEVE they can do this or their organizations don't think they can afford to make the necessary investments in training and improvements .  In "The Innovator's Prescription" by Christianson is a hint of what may happen to those organizations.
   Good luck waiting for the reimbursement system to change!

This all gave me an idea for another listserve topic though.  "What if the XPRIZE people were to create a contest for the best design of a primary care system that significantly improved quality of care (both iterative and sequential), was affordable and scalable in the US healthcare system?  Include parameters"  What would that contest look like?.

On Wed, Jun 25, 2014 at 12:10 PM, Graber, Mark <Mark.Graber at va.gov> wrote:
Thanks David for the follow-up input on using the PKC's.  I want to come work in YOUR practice !  Love the focus on quality  - great direction, and I hope the Weaver article gets attention.  One aspect troubles me:  Quality diagnosis takes time, and reimbursement for primary care services isn't based on quality, its based on time.  Seems to me like the most important thing we could ever do to promote diagnostic quality is to revise the reimbursement system.

Thanks for contributing to our listserv discussions.


Mark L Graber, MD FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook School of Medicine
Founder and President, Society to Improve Diagnosis in Medicine
Phone:   919 990-8497 <tel:919%20990-8497>

From: David Hallbert <david.hallbert at gmail.com>
Date: Tue, 24 Jun 2014 22:17:51 -0400
To: "mark.graber at va.gov" <mark.graber at va.gov>
Subject: Re: [EXTERNAL] Re: [IMPROVEDX] stroke misdiagnosis ... Washington Post [CB]

Seeking High Reliability in primary care: Leadership, Tools, and Organization

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