FW: [IMPROVEDX] AHRQ Grants for Diagnostic Error

Knapp, Lucy LKnapp at PEACEHEALTHLABS.ORG
Wed Apr 15 17:42:48 UTC 2015



From: Knapp, Lucy
Sent: Tuesday, April 14, 2015 4:01 PM
To: 'Grefe, Rosemary'
Subject: RE: [IMPROVEDX] AHRQ Grants for Diagnostic Error

Very true Rosemary. I really wish we were licensed in all states. That would prevent the high school graduates with too little training doing laboratory testing. I have a BS in medical technology and that is true of all the technologists working here. That is only because of the high standards of my employer. We are, and have been for over 40 years, a CAP accredited laboratory. Physician office labs are not. CAP accreditation has requirements for education and annual competency assessment for all technologists. I’m involved in that – each technologist must show that they are competent for every test they run. It’s a pretty heavy burden for most labs but it is important. In addition, CAP requires that when assays are brought into the laboratory, they are correlated with the prior method and the meet requirements for accuracy, precision, linearity, etc. Laboratories must run control samples at regular defined intervals and troubleshoot assays when they don’t pass. I have defined total allowable error for all the analytes performed in my department. This margin is used to insure that assay’s continue to perform as they should. The laboratory subscribes to regular proficiency testing sample (bought from CAP) for all analytes we report. These are blind samples which are tested and results sent back to the CAP – the CAP calculates means by peer group method and grades your results as acceptable or unacceptable. Unacceptable results are investigated by lab management (me for chemistry) and we must show what caused the problem and what we have done to prevent recurrence.

There is a testing cycle for each sample which at a minimum includes the pre analytical, analytical and post analytical phases. The pre analytical includes: Dr. considers patient needs and decides to order a test, order is entered in computer system or manual system, phlebotomist draws blood or collects other sample, lab processors or automated system processes the sample and presents it for testing. The analytical phase is the testing phase which may be manual or automated, this includes all the testing steps up to the release of a result. Post analytical phase covers the transmission of a result to the clinician AS WELL AS the thought processes involved in the interpretation of the result.  Many studies have shown and (my experience agrees) that most errors occur in the pre and post analytic phase. Where I feel we in the laboratory could do the most good is in “Dr. considers patient needs and decides to order a test” (is it the best test for the situation) and the thought processes involved in interpretation of the result and using the result for best advantage for the patient.

Laboratory medicine is exploding – especially with genetic tests – It is very difficult for laboratory folk such as myself to keep up. How can doctors be expected to keep up with the latest tests and all the nuances of the average hospital test menu? We are trained, let us help! All that is needed is a structure to support it.



Lucy

[Description: PHLlogo]

Lucy Knapp
Technical Specialist, Chemistry
Vancouver Laboratory

360-514-2732 Phone

lknapp at peacehealthlabs.org<mailto:lknapp at peacehealthlabs.org>
www.peacehealthlabs.org<http://www.peacehealthlabs.org/>
400 NE Mother Joseph Place
Vancouver,WA 98664

From: Grefe, Rosemary [mailto:RGrefe at childrensnational.org]
Sent: Tuesday, April 14, 2015 3:09 PM
To: Society to Improve Diagnosis in Medicine; Knapp, Lucy
Subject: RE: [IMPROVEDX] AHRQ Grants for Diagnostic Error

This is true but I’m talking to a more troubling problem which is how many diagnostic tests can be performed and reported on without any tracking tool or competency requirements.  Medical laboratory testing and radiology testing require structure, primarily due to CLIA, but how many other tests can be done by a wide assortment of staff who have varying degrees of training?  When you couple that with Lucy’s point about the lack of time spent on learning all about the tests that are relied on you can see how many data collection errors could go undetected.

Rosemary Grefe

From: Knapp, Lucy [mailto:LKnapp at PEACEHEALTHLABS.ORG]
Sent: Tuesday, April 14, 2015 4:22 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

As a Medical Technologist with 39 years of  experience – I heartily agree. The average medical technologist gets far more education in laboratory medicine than physicians do. Clinical Pathologists of course, get even more than we do. One of the problems in medicine today is the lack of training by physicians in laboratory tests – when to order and how to interpret. It is unfortunate. Many laboratories are attempting to fill the gap in various ways (Vanderbilt has Diagnostic management teams for various conditions). I would love to see something like that happen here – but money and staff are short for such things, and unfortunately getting shorter.

Lucy

[Description: PHLlogo]

Lucy Knapp
Technical Specialist, Chemistry
Vancouver Laboratory

360-514-2732 Phone

lknapp at peacehealthlabs.org<mailto:lknapp at peacehealthlabs.org>
www.peacehealthlabs.org<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.peacehealthlabs.org_&d=BQMGaQ&c=Zoipt4Nmcnjorr_6TBHi1A&r=iMpVRgI4Jb8qPZsZHXUj0g&m=Tu-yH-iadS9iworH_u_a_SEQ9-k236yCa-iO7xTUqIE&s=JW8FuAYKX848WXWZ_oL4xN-WBaveMl44Mrd65MKQBlc&e=>
400 NE Mother Joseph Place
Vancouver,WA 98664

From: Vic Nicholls [mailto:nichollsvi2 at GMAIL.COM]
Sent: Tuesday, April 14, 2015 11:37 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

I had a gastroenterologist who finished his residency in 2012 tell me that my albumin would be low if I had malnutrition.

I referred him to the Minnesota Starvation Experiment and a few other articles. Albumin goes high in dehydration, also a problem in starvation.

I spent hours and hours going over research in medical libraries, books, etc. to get a fairly good grasp of some of the items. With all else in medical school, I have to wonder where they would find the time to review the information (on top of the overload already).

With all due respect, maybe there could be some lab techs or the like that could help doctors out with this? NP's or PA's as some sort of resource? It seems it would be better to have that then another thing that doctors have to keep up with.

Vic
On 4/14/2015 12:59 PM, Grefe, Rosemary wrote:
A while back I was reading an article that claimed over 60% of medical decisions are made off of diagnostic test results.  Our system has yet to ensure that those whose collect these results are actually well trained and know what pitfalls to look for.  If we start with bad data bad decisions could follow.

-Rosemary Grefe

From: Jackson, Brian [mailto:brian.jackson at ARUPLAB.COM]
Sent: Tuesday, April 14, 2015 11:31 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

There’s an important point in this thread that I want to call out.  Health insurance companies are NOT the right entity to play the main role in ensuring high quality care.  They’ve only stepped into that role because clinical care delivery entities (medical groups, hospitals, etc.) haven’t fully owned it.  And I suspect this is largely because of a misunderstanding of the role of professionalism.

Utilization reviewers working for insurers will never be in a good position to assess clinical quality because they’re organizationally too distant from the point of care.  What we need instead are more front-line leadership roles filled by experienced doctors who supervise their peers, reporting up to clinically-trained top-level leaders.  In an ideal world, insurance companies would play a subordinate role.  Or to paraphrase a VP at Intermountain Health Care (I forget his name), health insurers should own actuarial risk (who gets what diseases) and healthcare delivery systems should own medical risk (how much value is delivered to those patients).

--Brian Jackson


From: Phillip Benton [mailto:0000000697ec7b18-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Monday, April 13, 2015 3:23 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error

Rob & Mark,

Yes, theoretically the insurance carrier should be the primary filter, but most of the reviewer's who pre-certify (approve/turn down) surgery requested have little or no formal medical education, and operate strictly from a computer screen that lists what they will or will not approve for a certain diagnosis. Whether it is unnecessary or excessive at that point in time (with so little symptomatic disease, confirmed by appropriate studies) is outside their discretion.

'Second Opinion' also falls short of controlling inappropriate or unnecessary surgery (see L. Leape, attached). In small communities, friends may approve each other's cases without the insurors' knowledge. Some specialty societies, such as North American Spine Society, are working actively to establish 'surgical appropriateness criteria' to help apply the clinical practice guidelines its' dedicated guideline committees have worked so hard to formulate.

Many have written about this (Leape, Epstein, others) but no one yet has tried to take real action. Deyo & Mirza in 2010 described a 15-fold increase in complex surgery for spinal stenosis (as occured in my Power Point example) between 2002 and 2007.

The JC's Mission Statement extols 'Quality Care and Patient Safety' in hospitals it accredits, but it has not yet acknowledged or confronted the problem of  unnecessary or excessive surgery. When asked JC says they depend upon the hospitals QA committees to control this -- but there are no guidelines, no monitoring and no sanctions for cases such as that described in my Spinal Stenosis PowerPoint. I am preparing a presentation to The Joint Commission on this point and I may ask SIDM to weigh in.

Phil Benton
Atlanta, GA


-----Original Message-----
From: robert bell <rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
To: IMPROVEDX <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Mon, Apr 13, 2015 2:32 pm
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error
Excellent point.

Where are the loyalties of the Joint Commission - are the mainly patient or hospital?  Who pays the JCs fees? I ask this as there seem to be 100s many areas where the JC could help reduce errors to a far greater extent. Accurate data collection could be a start.

Insurance carriers often are asking for approval for expensive procedures, operations, or drugs. Do they ever challenge a surgeons decision to perform an operation?  Are second opinions ever sought in those situations?  Could the Insurance Carriers be the filter that you ask for?

But let’s not forget ambulatory care diagnostic errors, which must be massive, when so many do not have the training to diagnose many of the conditions.

Rob Bell

On Apr 13, 2015, at 10:32 AM, pgbentonmd at aol.com<mailto:pgbentonmd at aol.com> wrote:

Rob, Mark and SIDM,

I would like to add another very important area in which "diagnostic" errors may cause massive and irreparable patient harm. I'm talking about not an error of diagnosis, but about the misapplication of surgical treatment indications for some diagnoses.. Currently there are no barriers to posting surgery that is inappropriate (viz unnecessary or excessive) for the underlying diagnosis.

 Patients usually have given their "informed" consent to the procedure because they trusted their physician. Most physicians are trustworthy, but some surgeons looking to enhance the surgical fee treat surgically all pathology seen on the diagnostic imaging, or do the surgery prematurely. Attached, anonymized, is one example.

What we really need is a diagnosis related "appropriateness criteria" screening system at the surgery scheduling desk that the OR nurses can understand and apply, that can trigger review of questionable case postings by senior surgeons with departmental administrative responsibility for quality of care. The Department Chair will also need timely backup consultation available from specialty society Practice Guidelines Committees when needed.

Hopefully Joint Commission will face the problem and  join this effort to ensure patient safety and quality care in America's accredited hospitals.

Phillip G. Benton, MD, JD
Atlanta, Georgia

-----Original Message-----
From: robert bell < rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>>
To: IMPROVEDX < IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Sent: Mon, Apr 13, 2015 11:33 am
Subject: Re: [IMPROVEDX] AHRQ Grants for Diagnostic Error
That was the point I was trying to make previously, and asking where most diagnostic errors are to be found.  In hospitals or in private specialty practice and primary care practice?

If it is thought that most diagnostic errors come from the latter, then funding should be be available there.

Rob Bell
On Apr 12, 2015, at 4:24 PM, Julianne Nemes Walsh < nemeswalsh at GMAIL.COM<mailto:nemeswalsh at GMAIL.COM>> wrote:

After reviewing the grant criteria, primary care practice groups that are not attached to a higher ed institution are not eligible.   Would love to see grant opportunities available to smaller settings to stimulate more diversified opportunities for all levels of providers interested in diagnostic error.

On Thu, Apr 9, 2015 at 9:52 PM, <graber.mark at gmail.com<mailto:graber.mark at gmail.com>> wrote:
This is a big day for our diagnostic safety community:  AHRQ has just issued the first-ever grant announcement that specifically targets “ Diagnostic Safety in Ambulatory Care”.  Both R01 (large grants) and R18 (small grants) will be funded under this initiative, which will be open annually until 2018.  With so many proposed, but untested interventions that have been raised, there’s many opportunities.  Go get ‘em !

Mark

Mark L Graber MD FACP
President, SIDM

Title:     Understanding and Improving Diagnostic Safety in Ambulatory Care: Strategies and Interventions

Deadline Date:  Standard due dates apply: January 25, May 25, and September 25.

For details, click on the link below:
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Robert M. Bell, M.D., Ph.C.
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Tel: Fax: 928 203-4517

I am changing my e-mail address to  rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>

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<Spinal_Stenosis.ppt_BASIC +.pptx>

Robert M. Bell, M.D., Ph.C.
P.O. Box 3668
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USA
Tel: Fax: 928 203-4517

I am changing my e-mail address to  rmsbell200 at yahoo.com<mailto:rmsbell200 at yahoo.com>

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