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

Herbers, Jerome (SES) (OIG) Jerome.Herbers at VA.GOV
Tue Jul 22 13:21:51 UTC 2014


Drivel – and more than  a dribble.  

 

From: Harold Lehmann [mailto:lehmann at JHMI.EDU] 
Sent: Monday, July 21, 2014 8:27 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis & free
text vs coded data

 

At this year’s Academic Forum (AMIA), a number of schools demo’d their “EMRs
for education.” It’s very important work (how should we teach clinical
practice, when our brains are numbed by “a trash pile of duplication and
useless dribble”?)

 

Hmm, if we had a measure of diagnostic accuracy, goodness, we should be
tracking that accuracy in parallel to HIT adoption, and see if it goes up or
down. 

 

Those who think that “the story” is lost in the dribble would predict lower
accuracy.

Those who think the data are enough would predict higher (?).

 

Harold

 

  _____  

 

Developing an "Academic” EHR from the Vanderbilt Synthetic Derivative 

o Cynthia S. Gadd and Christoph U. Lehmann, Vanderbilt University 

 

2. Educational EHRs in a Virtual World 

o Susan Fenton, University of Texas 

 

3. Experiences with use in "academic" EHRs for Education of Informatics
Students 

o Saif Khairat, PhD, University of Minnesota, Institute for Health
Informatics 

 

4. Academic EHR as Simulation Environment for Interprofessional
Collaborative Team Simulation 

o Kellie Kramer-Jackman, University of Kansas Medical Center 

 

5. A Data-Driven Education: Learning Medicine by Understanding Bias in
Large, De-identified EHR Databases 

o Vishal N. Patel, Case Western Reserve University 

 

6. Free and Fee: Adopting EHRs for the Classroom 

o Ryan Sandefer and David Marc, the College of St. Scholastica 

 

 

From: Georges Bordage <bordage at UIC.EDU>
Reply-To: Society to Improve Diagnosis in Medicine
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Georges Bordage <bordage at UIC.EDU>
Date: Monday, July 21, 2014 at 4:40 PM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG"
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] [EXTERNAL] [IMPROVEDX] Bayesian diagnosis & free
text vs coded data

 

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]
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  <mailto:lehmann at jhmi.edu> <lehmann at jhmi.edu>
Reply-To: Society to Improve Diagnosis in Medicine
<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Harold Lehmann
<mailto:lehmann at jhmi.edu> <lehmann at jhmi.edu>
Date: Sat, 19 Jul 2014 22:31:39 -0400
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<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:  <mailto:Michael.H.Kanter at KP.ORG> "Michael.H.Kanter at KP.ORG"
<mailto:Michael.H.Kanter at KP.ORG> <Michael.H.Kanter at KP.ORG>
Reply-To: Society to Improve Diagnosis in Medicine
<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>,  <mailto:Michael.H.Kanter at KP.ORG>
"Michael.H.Kanter at KP.ORG"  <mailto:Michael.H.Kanter at KP.ORG>
<Michael.H.Kanter at KP.ORG>
Date: Saturday, July 19, 2014 at 8:23 PM
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG"
<mailto: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

NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail,
you are prohibited from sharing, copying, or otherwise using or disclosing
its contents.  If you have received this e-mail in error, please notify the
sender immediately by reply e-mail and permanently delete this e-mail and
any attachments without reading, forwarding or saving them.  Thank you.




From:        "Graber, Mark"  <mailto:Mark.Graber at VA.GOV>
<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  <mailto:Lorri at zpm1.com> <Lorri at zpm1.com>
Reply-To: Society to Improve Diagnosis in Medicine
<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Lorri Zipperer
<mailto:Lorri at zpm1.com> <Lorri at zpm1.com>
Date: Thu, 17 Jul 2014 17:05:08 -0400
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<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  <mailto:Barbara at THECOMMONFIRE.COM>
<Barbara at THECOMMONFIRE.COM>
Reply-To: Society to Improve Diagnosis in Medicine
<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Barbara Balik
<mailto:Barbara at THECOMMONFIRE.COM> <Barbara at THECOMMONFIRE.COM>
Date: Tue, 15 Jul 2014 10:30:03 -0400
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
<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
Office: 505.797.8933

Common Fire Healthcare Consulting:
Partnering with healthcare leaders to forge quality and safety outcomes



<http://www.lsoft.com/resources/faq.asp#4A>

http://LIST.IMPROVEDIAGNOSIS.ORG/ <http://list.improvediagnosis.org/> (with
your password)

<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>

Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
for Improving Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
DX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1> "
target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
D1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1> </a> </p>



<http://www.lsoft.com/resources/faq.asp#4A>

http://LIST.IMPROVEDIAGNOSIS.ORG/ <http://list.improvediagnosis.org/> (with
your password)

<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>

Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
for Improving Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
DX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1> "
target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
D1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1> </a> </p>


________________________________


To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG



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/


________________________________


To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG


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/






Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
for Improving Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
DX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1"
target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
D1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1</a>
</p>






Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
for Improving Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a
href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVE
DX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1"
target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
D1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1</a>
</p>

The information in this e-mail is intended only for the person to whom it is
addressed. If you believe this e-mail was sent to you in error and the
e-mail contains patient information, please contact the Tufts Medical Center
HIPAA Hotline at (617) 636-4422. If the e-mail was sent to you in error but
does not contain patient information, please contact the sender and properly
dispose of the e-mail.

 

  _____  



To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1 or send email to:
IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 
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/

 

  _____  



To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1 

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX 


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/ 

 

  _____  



To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1 

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG



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/









HTML Version:
URL: <../attachments/20140722/20290bc6/attachment.html> ATTACHMENT:
Name: smime.p7s Type: application/pkcs7-signature Size: 11251 bytes Desc: not available URL: <../attachments/20140722/20290bc6/attachment.bin>


More information about the Test mailing list