[EXTERNAL] [IMPROVEDX] Bayesian diagnosis & free text vs coded data

Georges Bordage bordage at UIC.EDU
Mon Jul 21 20:40:23 UTC 2014


A couple of years ago I was at Vanderbilt and they developped a parallel 
electronic medical record for teaching purposes.
I have not heard how it has progressed  since.  Georges B.

On 7/21/2014 11:45 AM, Pauker, Stephen wrote:
> Here in lies the problem.
>
> The medical record should be/was a tool for reasoning also, but has 
> become a tool primarily for billing.
>
> I frankly doubt that most emrs do much for communication. The key 
> facts are often lost in a trash pile of duplication and useless dribble.
>
> Steve
>
>
>
>
> Stephen Pauker, MD, MACP, ABMH
> Professor of Medicine and Psychiatry
> Sent with Good (www.good.com)
>
>
> -----Original Message-----
> *From: *Eta S Berner [eberner at UAB.EDU <mailto:eberner at UAB.EDU>]
> *Sent: *Monday, July 21, 2014 12:35 PM Eastern Standard Time
> *To: *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject: *Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis & 
> free text vs coded data
>
> A main purpose of the EHR is to provide documentation and 
> communication of key findings and the clinician's assessment of the 
> meaning of the findings.  I would assume that the story as it unfolds, 
> as Mark says, can assist the physician in reaching a diagnosis, but 
> how much of that "story" is really needed for documentation and 
> communication?
>
> *********************************************
> Eta S. Berner, Ed.D.
> Professor, Health Informatics
> Director, Center for Health Informatics for Patient Safety/Quality
> Department of Health Services Administration
> School of Health Professions
> Professor, Department of Medical Education
> School of Medicine
> University of Alabama at Birmingham
> 1705 University Blvd. #590J
> Birmingham, AL 35294
> Phone: (205)975-8219
> Fax:       (205)975-6608
> Email:   eberner at uab.edu
>
>
> -----Original Message-----
> From: Graber, Mark [mailto:Mark.Graber at VA.GOV]
> Sent: Monday, July 21, 2014 9:23 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis & 
> free text vs coded data
>
> Harold raises an issue that we ultimately will need to address:  Is 
> diagnosis enhanced or degraded by a process like AHLTA's where data is 
> captured from pull down lists, as opposed to using free-text entries.
>
> We had this debate in the VA (where we use free text notes) when we 
> were considering merging with AHLTA (all pull down lists).  If the 
> pull down lists were somehow ever perfected and allowed more detailed 
> or more accurate selections, I guess these could ultimately 
> approximate free text.  Just seems to me that there is so much 
> information in HOW a patient tells his\jher story, and in what order, 
> and what gets associated with what.  All this rich data would be lost 
> in pull down lists, where everything has to fit a prescribed bucket.  
> I'll also acknowledge that many of the free-text notes created these 
> days are just horrible or frankly misleading, so there's a downside to 
> both approaches.
>
> A related question is whether using pull-down lists will facilitate 
> research into diagnostic quality, or whether you can approximate this 
> using text mining software to extract comparable data.
>
> ________________________________
> From: Harold Lehmann <lehmann at jhmi.edu>
> Reply-To: Society to Improve Diagnosis in Medicine 
> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Harold Lehmann <lehmann at jhmi.edu>
> Date: Sat, 19 Jul 2014 22:31:39 -0400
> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis
>
> If we ever get to have patient findings stored in an EHR in a 
> retrievable way (like the military's AHLTA system does, but in a 
> manner that physicians embrace), then those specific findings that the 
> physician should be using to arrive at a prior would in fact turn that 
> assessment into a true posterior probability. "Medicine in Denial," by 
> Larry and Lincoln Weed makes this point by advocating the "structured" 
> collection of patient data. (I don't think they advocate Bayesian 
> reasoning, but the result is the same.)
>
> Harold
>
> From: "Michael.H.Kanter at KP.ORG" <Michael.H.Kanter at KP.ORG>
> Reply-To: Society to Improve Diagnosis in Medicine 
> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "Michael.H.Kanter at KP.ORG" 
> <Michael.H.Kanter at KP.ORG>
> Date: Saturday, July 19, 2014 at 8:23 PM
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" 
> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis
>
> In my view, part of the problem with Bayesian approaches is that of 
> obtaining the prior probability.  Most examples attempt to use the 
> prevalence of the disease in the population giving the appearance of 
> it sounding scientific.  This is probably okay when screening 
> asymptomatic people for certain diseases where the physician actually 
> never sees individual patients but is instead looking at the 
> population.   Once the patient is seen by the physician, the prior 
> probability changes as not all patients are alike.
> .  In true Bayesian statistics, the prior probability is a subjective 
> probability. (this is also one reason why many statisticians do not 
> feel Bayesian statistics are "scientific").  So, if a patient presents 
> with certain symptoms, the prior probability should ideally be 
> determined by the physician who uses all information about the patient 
> other than the various tests/symptoms that are used to modify the 
> prior probability to create a final conditional probability that the 
> patient has a disease given certain symptoms or test results.  This 
> then becomes an exercise in subjectivity where the physicians' 
> intuition, prior experience, and "gut feel" may and should be used in 
> determining prior probabilities.   Most advocates of a Bayesian 
> approach simply select a prior probability based on a few variables 
> and require that all physicians use that prior probability.  This is a 
> fundamental flaw, in my view.
>  In the example below (item 6) where Bayesian approaches may be 
> problematic due to failure to consider a rare disease, this  failure 
> to consider a rare disease can be viewed as simply using the wrong 
> prior probability for the more common disease.  Physicians who 
> consider the rare disease would have a much lower prior probability of 
> the non rare disease than those who do not consider the rare disease.
> Thus, the concept that a Bayesian approach is more objective may not 
> be correct.   One can force it to be objective by requiring use of a 
> certain prior probability but this then creates other potential errors 
> and in theory is less accurate because it may not consider variables 
> that are available to the physician seeing the patient but not in the 
> model.   Advocates of a Bayesian approach seem to forget that the 
> prior probability is generally not known but is merely a subjective 
> "guess".   So, comparing a Bayesian approach to the usual approaches 
> is something that would be real interesting to do yet, one must be 
> careful in defining exactly what a Bayesian approach means.
>
> Michael Kanter, M.D.
> Regional Medical Director of Quality & Clinical Analysis Southern 
> California Permanente Medical Group
> (626) 405-5722 (tie line 8+335)
> THRIVE By Getting Regular Exercise
>
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>
> From:        "Graber, Mark" <Mark.Graber at VA.GOV>
> To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Date:        07/19/2014 10:03 AM
> Subject:        Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis
> ________________________________
>
>
>
> I'd love to see the kind of comparative study Bimal is advocating.  
> One of the suggestions on how to improve diagnosis that seems like it 
> should work is exactly what Bimal is advocating: expanding the 
> differential diagnosis and weighing the options appropriately.  
> Hardeep's work found that in cases of dx error there was no 
> differential diagnosis listed 80% of the time.  Would this be an 
> antidote to dx error, as Jason Maude has suggested (Differential 
> diagnosis: The key to reducing diagnostic error?   DIAGNOSIS 2014; 
> 1:107-109).
>
> Just to make a point though:  The Ledley\Lusted approach was to use 
> the full range of conditional probability analysis in diagnosis, which 
> includes first deriving all the possible candidate diagnoses, then 
> weighing the evidence pro and con, and using tests to adjust 
> probabilities to narrow the list down..  It seems that when people 
> refer to Bayesian analysis these days they are referring to the 
> narrower usage of Bayes theorem to calculate the probability of a 
> SINGLE disease probability.  This focus on just one entity is exactly 
> the opposite of what Ledley\Lusted were advocating, and to the extent 
> that it discourages thinking about all the other diagnostic options, 
> could work against diagnostic accuracy.
>
>
> ________________________________
> From: Lorri Zipperer <Lorri at zpm1.com>
> Reply-To: Society to Improve Diagnosis in Medicine 
> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Lorri Zipperer <Lorri at zpm1.com>
> Date: Thu, 17 Jul 2014 17:05:08 -0400
> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [EXTERNAL] [IMPROVEDX] Bayesian diagnosis
>
> **** moderator forwarded ****
>
> -----Original Message-----
> From: Jain, Bimal P.,M.D. [mailto:BJAIN at PARTNERS.ORG 
> <mailto:BJAIN at PARTNERS.ORG> ]
> Sent: Wednesday, July 16, 2014 5:35 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; 'Graber, Mark'
> Subject: RE: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Patient-Provider 
> Communication and Diagnostic Error
>
> Great references. Here are some thoughts on a somewhat unrelated 
> topic-- Bayesian diagnosis.
>
> 1. Since Ledley and Lusted introduced a probabilistic (Bayesian) 
> approach to clinical diagnosis in 1959 (SCIENCE 1959), innumerable 
> books and papers have been written advocating its use in actual practice.
>
> 2. However, this does not seem to have happened to any great extent in 
> last
> 55 years. For example, CPCs in NEJM continue to be discussed in a 
> manner that is not Bayesian. Also discussions about diagnosis in 
> clinical problem solving exercises on actual patients published in 
> journals do not employ a Bayesian approach. In the occasional patient 
> in whom it is employed, it does not come out looking too good as it 
> seems to suggest an erroneous diagnosis (Pauker, NEJM 1992).
>
> 3. There is no published evidence it is superior to the usual method 
> of diagnosis in actual practice which is about 85 percent accurate 
> (Graber BMJ 2013). There are no head to head trials which demonstrate 
> superiority of Bayesian over usual method of diagnosis.
>
> 4. It is ironic, in this day and age of evidence based medicine, 
> Bayesian diagnosis continues to be advocated without any evidence for 
> its superiority.
> If it were a treatment, this issue would have been settled a long time 
> back by a controlled trial.
>
> 5. In all studies on diagnostic errors (Gordon Schiff, Hardeep Singh, 
> Mark Graber), the method of diagnosis has not been identified as a 
> source of diagnostic error. How would switching to a Bayesian approach 
> reduce error?
>
> 6. One of the major causes of errors found in these studies is a 
> failure to suspect a disease in patients with atypical presentations. 
> This error has potential to increase with a Bayesian approach in which 
> a low pretest probability may be interpreted as low plausibility or 
> low pretest evidence leading to ruling out a disease without testing.
>
> 7. A Bayesian approach appears attractive, it seems, due to 
> consistency and elegance of underlying Bayes theorem which it 
> employs.But reliance solely on mathematical criteria without 
> observation can be misleading as seen from the well known example of 
> planetary orbits. For over two thousand years, planetary orbits were 
> believed to be circular due to mathematical beauty and elegance of a 
> circle as a geometrical figure. This belief was found to be erroneous 
> when Kepler observed positions of Mars and calculated its orbit to be 
> elliptical.
>
> 8. I believe we need to have observational evidence of some sort, 
> probably from a controlled trial, to decide if Bayesian diagnosis is 
> superior to usual diagnosis or not. Only if it is found to be superior 
> can it be recommended for widespread use.
>
> Bimal
>
> Bimal Jain MD
> NorthShore Medical Center
> Lynn MA 01904
>
> -----Original Message-----
> From: Graber, Mark [mailto:Mark.Graber at VA.GOV 
> <mailto:Mark.Graber at VA.GOV> ]
> Sent: Tuesday, July 15, 2014 5:54 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Patient-Provider 
> Communication and Diagnostic Error
>
> Barbara - Thanks for asking a GREAT question.  I think we all know the
> answer.   The bad news is that I don't think you'll find a paper that
> clearly links effective communication with improved diagnostic accuracy.
> The reason is that so far we don't have a good way to actually measure 
> diagnostic accuracy.  We really need that tool to start making 
> progress in studying diagnostic accuracy and error.  David Sofen (Palo 
> Alto Foundation Medical Group) and I have discussed this exact issue a 
> couple of times, and the possibility of looking to see if there is 
> correlation between communication style and diagnostic accuracy just 
> amongst all the physicians in a large practice.  Hopefully he will 
> weigh in on his own as well.
>
>
> The good news is that there is PLENTY of INDIRECT evidence to support 
> the relationship between effective communication and diagnostic quality:
>
> 1)   Communication breakdowns are a common cause of diagnostic error.
> (Graber et al.  Diagnostic Error in Internal Medicine.  Arch Int Med 
> (2005).
> 165:1493-99).  Hardeep Singh also has a series of publications on 
> diagnostic errors arising from breakdowns in lab communications, which 
> is a related issue.
>
> 2)  As Charlene Weir points out, there is evidence that the diagnosis
> emerges from the history alone in the majority of cases.    (Peterson MC,
> Holbrook JH, Von Hales D, et al. Contributions of the history, 
> physical examination, and laboratory investigation in making medical 
> diagnoses. The Western Journal of Medicine. BMJ 1992;156:163-5.  
> Wahner-Roedler DL, Chaliki SS, Bauer BA, et al. Who makes the 
> diagnosis? The role of clinical skills and diagnostic test results. J 
> Eval Clin Pract 2007;13:321-5.)  There is also a famous Osler quote on 
> this:  "Listen to your patient, he is telling you the diagnosis".
>
> 3  There is substantial evidence that high levels of patient 
> satisfaction (typically reflecting communication) correlate with 
> improved health outcomes in general. Articles that David sent me 
> address this point:
>
> §  Doyle, C., Lennox, L., & Bell, D. (2013). "A systematic review of 
> evidence on the links between patient experience and clinical safety 
> and effectiveness." BMJ Open, 3. Available at 
> http://bmjopen.bmj.com/content/3/1/e001570.full 
> <http://bmjopen.bmj.com/content/3/1/e001570.full> . This study finds 
> consistent positive associations among patient experience, patient 
> safety, and clinical effectiveness for a wide range of disease areas, 
> settings, outcome measures, and study designs. It finds that patient 
> experience is positively associated with clinical effectiveness and 
> patient safety, and the results support the case for the inclusion of 
> patient experience as one of the central pillars of quality in health 
> care.
>
> §  Boulding, W., Glickman, S. W., Manary, M. P., Schulman, K. A., & 
> Staelin, R. (2011). "Relationship between patient satisfaction with 
> inpatient care and hospital readmission within 30 days", American 
> Journal of Managed Care, 17(1), 41-48. Focusing on three common 
> ailments-heart attack, heart failure and pneumonia-the authors 
> measured 30-day readmission rates at roughly 2,500 hospitals and found 
> that patient satisfaction scores were more closely linked with 
> high-quality hospital care than clinical performance measures.
> Hospitals that scored highly on patient satisfaction with discharge 
> planning also tended to have the lowest number of patients return 
> within a month for all three specified ailments. Overall, high patient 
> satisfaction scores were more closely linked to a hospital's low 
> readmission rates than a solid showing on clinical performance measures.
>
> §  Glickman, S. W., Boulding, W., Manary, M., Staelin, R., Roe, M. T., 
> Wolosin, R. J., et al. (2010). "Patient satisfaction and its 
> relationship with clinical quality and inpatient mortality in acute 
> myocardial infarction", Cardiovascular Quality and Outcomes, 3(2), 
> 188-195. Hospitals use patient satisfaction surveys to assess their 
> quality of care. The objective of this study was to determine whether 
> patient satisfaction is associated with adherence to practice 
> guidelines and outcomes for acute myocardial infarction and to 
> identify the key drivers of patient satisfaction. The authors found 
> that higher patient satisfaction is associated with improved guideline 
> adherence and lower inpatient mortality rates, suggesting that 
> patients are good discriminators of the type of care they receive. 
> Thus, patients' satisfaction with their care provides important 
> incremental information on the quality of acute myocardial infarction 
> care.
>
> §  Isaac, T., Zaslavsky, A. M., Cleary, P. D., & Landon, B. E. (2010). 
> "The relationship between patients' perception of care and measures of 
> hospital quality and safety", Health Services Research, 45(4), 
> 1024-1040. The overall rating of the hospital and willingness to 
> recommend the hospital had strong relationships with technical 
> performance in all medical conditions and surgical care. The authors 
> found that better patient experiences for each measure domain were 
> associated with lower decubitus ulcer rates, and for at least some 
> domains with each of the other assessed complications, such as 
> infections due to medical care.
>
> §  Jha, A. K., Orav, E. J., Zheng, J., & Epstein, A. M. (2008). "Patients'
> perception of hospital care in the United States", New England Journal 
> of Medicine, 359, 1921-1931. This study assessed the performance of 
> hospitals across multiple domains of patients' experiences and found a 
> positive relationship between patients' experiences and the quality of 
> clinical care.
> The authors found that patients who received care in hospitals with a 
> high ratio of nurses to patient-days reported somewhat better 
> experiences than those who received care in hospitals with a lower 
> ratio, and hospitals that performed well on the HCAHPS survey provided 
> a higher quality of care across all measures of clinical quality than 
> did those that did not perform well on the survey.
>
>
> Mark L Graber MD FACP
> President, SIDM
> Sr Fellow, RTI International
>
>
>
> ________________________________
> From: Barbara Balik <Barbara at THECOMMONFIRE.COM>
> Reply-To: Society to Improve Diagnosis in Medicine 
> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Barbara Balik 
> <Barbara at THECOMMONFIRE.COM>
> Date: Tue, 15 Jul 2014 10:30:03 -0400
> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [EXTERNAL] [IMPROVEDX] Patient-Provider Communication and 
> Diagnostic Error
>
> I am looking for citations that link effective patient-provider 
> communication and improvement in diagnosis accuracy.
>
> Effective communication from the patient's view is often described as 
> an effective listener, understanding the patient's story, and 
> respecting values and choices
>
> I appreciate any help
>
>
>
> Barbara Balik, RN, EdD
>
> Balik.Barbara at gmail.com
> www.thecommonfire.com <www.thecommonfire.com> 
> <http://www.thecommonfire.com 
> <http://www.thecommonfire.com%20%3Chttp://www.thecommonfire.com/> > >
>
> Cell: 651.249.9237
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