disappointed

John Brush jebrush at ME.COM
Sun Sep 27 05:48:13 UTC 2015


	I agree with Art Papier about problem lists. I think that better use of the problem list is one of 2 things that could have immediate impact on improving diagnosis in medicine.
	Both Art and I trained at University of Vermont under Larry Weed. We were taught that a problem list should be dynamic. Problem statements can be provisional, temporary, active, permanent, inactive, or resolved. And the problem statement can change form day to day, becoming more specific as the diagnostic process proceeds. For example, “shortness of breath” can become “congestive heart failure” and then become “acute systolic heart failure” as new information is added and the diagnosis is re-evaluated through iterative hypothesis testing.
	I think we need to be much more attentive to the logic, syntax and semantics of problems statements so that they are as clear and unambiguous as possible. And having a complete list of evolving provisional problem statements can sometimes cause the practitioner to recognize a constellation of problems that unify into a single diagnosis. 
	By the way, the other thing that will improve diagnosis is using likelihood ratios as a tool to teach trainees how to place the proper weight on clinical cues.
John

John E. Brush, Jr., M.D., FACC
Professor of Medicine
Eastern Virginia Medical School
Sentara Cardiology Specialists
844 Kempsville Road, Suite 204
Norfolk, VA 23502
757-261-0700
Cell: 757-477-1990
jebrush at me.com



On Sep 25, 2015, at 4:42 AM, Art Papier MD <apapier at LOGICALIMAGES.COM> wrote:

This area of what and how an assessment is made and charted is an area
that the SIDM community should work with AMDIS (CMIO)/AMIA communtiy to
issue a recommendation as soon as possible.  Too often clinicians
expediently write a thin assessment and expediently put in an ICD
tentative diagnosis that erroroneously becomes THE diagnosis.  In my
clinic yesterday afternoon we saw a patient that had a single dystrophic
nail and distal finger edema.  The problem had been going on for years. 
The patient had previosuly been treated for onychomycosis.  During the
visit i noticed she was constantly manipulating the finger as we talked. 
We had a discussion that her problem might be due to this unconcious
habit.  She agreed.  The plan that was recommended was to do a fungal
culture, and for her to keep the finger bandaged and to not manipulate or
rub or touch that distal finger, then to come back in a couple months.  We
use Epic, Our residents chart and i review the notes at the end of clinic
or within 24 hours.  Yesterday late i reviewed the note for the patient. 
The assessment was one word "onychomycosis".  I sent the resident a note
through the EHR system that the assessment was not simply onychomycosis
and asked her to change the note to reflect what we discussed.  The
resident used an ICD 110.1  which means "onychomycosis".  How often do
physicians use the expedient ICD?  I know i typically do not enforce
preceision with it, (it takes too much time) We desperately need a code
that says NYD (or equivalent)  so that we do not expediently place one of
the diagnoses that is in the differential, but is NOT with certainty the
diagnosis.  Furthermore a good assessment will explain the "basis" for the
diagnosis.  I rarely see these in a note, even when the diagnosis is
tentative. Since many patients are not seeing the same physician in
follow-up in some care situations, having an accurate note becomes even
more important in preventing diagnostic error.   Larry Weed has written
about what a good note is and the idea of having a "basis" for a
diagnosis.  The ICD and CPT billing system has a systemic flaw in what it
encourages,  which is imprecision and expedience.  We desperately need for
our community to come together with the informatics community and the
ONC/HHS to create a coding system that encourages to note in the EHR that
we are not sure yet when we do not have a basis for the diagnosis.

PS For those that watched the IOM presentation.  A question was read from
the podium alledgedly emailed in by Larry Weed about the role of computers
and decision support systems in fixing diagnostic error.  I spoke with
Larry this week.  Interestingly he did not watch the IOM presentation and
was quite puzzled and a bit upset that someone would email in and
represent themselves as him.  He asked "Why would someone do that?" That's
a good question!

Best Art Papier MD
Asssociate Professor of Dermatology and Medical Informatics University of
Rochester, CEO VisualDx




> I'm seconding Brian Jackson's suggestion to move towards attaching levels
> of certainty to each diagnosis.  I'm especially fond of the "NYD" label
> Sam Campbell had on his list of the 10 best things to have happened in the
> field of emergency medicine in Canada.   NYD = not yet diagnoses.  This
> would alert the next person in the chain to keep thinking !   If we only
> had an ICD-10 code for that …..
> 
> On Sep 24, 2015, at 10:32 AM, Jackson, Brian <brian.jackson at aruplab.com>
> wrote:
> 
> We might want to be careful about this one.  From a research perspective,
> analyzing time to diagnosis would indeed be interesting and productive.
> But if in the process we give regulators, payors and attorneys new ways to
> punish delays at an individual physician level, it could amplify premature
> closure and overdiagnosis.
> 
> A suggestion others have brought up, and I suspect this needs to be pushed
> more aggressively, is the concept of explicitly labeling diagnoses with
> their level of certainty, e.g. as tentative or working diagnoses where
> appropriate.  Sometimes empiric therapy is the best way to proceed.  When
> empiric therapy fails, it doesn’t necessarily mean the diagnostic process
> failed, i.e. that a diagnostic error occurred.
> 
> Many of the complications introduced by both medicolegal and quality
> improvement efforts come from treating diagnosis as a black and white
> situation.  As much as I like the current news coverage of the IOM report,
> it’s reinforcing that black/white perspective.
> 
> --Brian Jackson
> 
> From: robert bell
> [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
> Sent: Wednesday, September 23, 2015 3:25 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] disappointed
> 
> But our foot is in the door.
> 
> Also, as we get more information on Time to Diagnosis, it would seem that
> there could be a kind of “standard time to diagnosis,” for less common
> diseases/conditions that could be adjusted from time to time as we get
> more proficient (e.g. for myasthenia gravis), perhaps even adjusted in
> some way for the medical sophistication of the medical center in question!
> 
> Do we need to talk about standards for what is a delayed diagnosis?  Or
> maybe that has already been discussed.
> 
> Just publishing a list of the common conditions we THINK are diseases of
> delayed diagnosis would be a start.
> 
> Rob Bell, M.D.
> 
> 
> On Sep 23, 2015, at 11:19 AM, Michael Grossman <Michael.Grossman at MIHS.ORG
> <mailto:Michael.Grossman at MIHS.ORG>> wrote:
> 
> I agree with your assessment. The IOM sometimes seems to fall short of
> expectations. Their relatively recent report on Graduate Medical Education
> was disappointing.
> The fact that multiple news agencies are running with this story may lead
> to some misunderstandings , especially on the nature of "delayed
> diagnoses".
> Michael Grossman, MD MACP
> 
> -----Original Message-----
> From: Robert L Wears, MD, MS, PhD [mailto:wears at UFL.EDU
> <mailto:wears at UFL.EDU>]
> Sent: Wednesday, September 23, 2015 9:31 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: [IMPROVEDX] disappointed
> 
> Great that misdiagnosis and related failures are getting attention, but
> ...
> 
> This is a disappointing effort; a naïve, keyhole view of a complex
> problem.
> 
> I count 82 mentions of 'error' in the first 15 pages (~5.5 per page), 753
> in the entire document.
> 
> Lots of discussion about biases (78 mentions) but important issues that
> challenge the focus on 'error', such as hindsight bias, or outcome bias,
> are never mentioned even once.
> 
> This restriction to a very narrow framing of the problem is unlikely to
> lead to progress.
> 
> bob
> 
> 
> 
> Robert L Wears, MD, MS, PhD
> University of Florida              Imperial College London
> wears at ufl.edu <mailto:wears at ufl.edu>
> r.wears at imperial.ac.uk <mailto:r.wears at imperial.ac.uk>
> 1-904-244-4405 (ass't)            +44 (0)791 015 2219
> Nothing matters very much, and very few things matter at all.
>                                                 ---Balfour
> 
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 
> <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: David Meyers, Board Member, Society to Improve 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=IMPROVEDX&A=1
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>"
> target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1%3c/a>>
> </p>
> 
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 
> <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: David Meyers, Board Member, Society to Improve 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=IMPROVEDX&A=1
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>"
> target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1%3c/a>>
> </p>
> 
> Robert M. Bell, M.D., Ph.C.
> P.O. Box 3668
> West Sedona, AZ  86340-3668
> USA
> Tel: Fax: 928 203-4517
> 
> 
> 
> 
> 
> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> <mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>
> 
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/ <http://www.improvediagnosis.org/>
> -------------------------------------------------------------------
> The information transmitted by this e-mail and any included
> attachments are from ARUP Laboratories and are intended only for the
> recipient. The information contained in this message is confidential
> and may constitute inside or non-public information under
> international, federal, or state securities laws, or protected health
> information and is intended only for the use of the recipient.
> Unauthorized forwarding, printing, copying, distributing, or use of
> such information is strictly prohibited and may be unlawful. If you
> are not the intended recipient, please promptly delete this e-mail
> and notify the sender of the delivery error or you may call ARUP
> Laboratories Compliance Hot Line in Salt Lake City, Utah USA at (+1
> (800) 522-2787 ext. 2100
> 
> 
> 
> 
> To unsubscribe from IMPROVEDX: click the following link:
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
> 
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
> 
> 
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
> 
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
> 
> 
> 
> 
> 
> 
> 
> 
> Moderator: David Meyers, Board Member, Society to Improve 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=IMPROVEDX&A=1"
> target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
> </p>
> 


-- 
Art Papier MD
Chief Executive Officer
Logical Images Inc.,
Suite 240
3445 Winton Place
Rochester, NY 14623
apapier at visualdx.com
585-272-2640
www.visualdx.com
www.skinsight.com






Moderator: David Meyers, Board Member, Society to Improve 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=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


HTML Version:
URL: <../attachments/20150927/149146ef/attachment.html>


More information about the Test mailing list