Diagnostic Infrastructure

Alan Morris Alan.Morris at IMAIL.ORG
Sat Feb 6 16:41:48 UTC 2016


Yes – and it has worked in several settings.  The limits are unknown and not systematically studied.
Alan
From: Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>>
Date: Friday, February 5, 2016 at 10:22
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Diagnostic Infrastructure

I agree that well done real-time decision support is much more likely to make a difference that the current educational approaches.

Two thoughts about this.

First, I have often fantasized about the ‘magic button’ in my EHR. It would be available anywhere I was working on documenting assessment or doing active planning (meds, testing, orders) and would be termed ‘Other possibilities to consider?’  If I clicked it, it would present a list of other possible explanations for the historical and exam/lab findings in my note, listed in order or probability, with hot-links to more information. I know this is a fantasy for the foreseeable future, but that doesn’t mean we couldn’t be working on pieces of this.

Second, I have never forgotten a research project I did during a clinical pharmacology fellowship between third and fourth year. (Sadly, it was never published.) The goal was to see if education changed prescribing habits. We picked hypertension and randomized (as best we could but not well enough) physicians to the education or control groups. At the end, habits changed but it was not correlated AT ALL with education vs control.  It was correlated with younger age, group practices versus solo practice, which journals they reported reading. As I said, not well enough done (I was a third year med student) to publish, but the implication was that clinical improvement was more likely in those motivated enough to create an environment that supported change and young enough to be more flexible.

Finally, it seems to me that a rapid diagnostic test for something as rare as plague would have to have almost magical sensitivity and specificity to be useful as a routine.

Peter


On 2016.02.05, at 10:54 AM, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>> wrote:

Rob:
If by infrastructure you mean decision-support, then I agree.  If you mean education and the usual traditional means we have used, I think this will have little effect.  We just discussed a fatal case of plague in Medial grand Round.  There is no way to help clinicians, in the absence of an epidemic, to quickly diagnose plague.  It is too infrequent.  We could, however, introduce a rapid diagnostic test that might become routine, if it had a low enough false positive rate.

Decision support is the key to helping humans because of their limited cognitive ability.

Alan
Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Medical Director, Urban Central Region Pulmonary Function Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603<tel:801-507-4603>
Mobile Phone: 801-718-1283<tel:801-718-1283>


From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Robert Bell <rmsbell200 at YAHOO.COM<mailto:rmsbell200 at YAHOO.COM>>
Date: Thursday, February 4, 2016 at 23:02
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] Diagnostic Infrastructure

Thanks Helene,

I had not thought of journalists. but they are so important. The AMA quotes each day in their daily sendings many newspapers. It seems as this is one of the main ways that medical information is spread.

Rob Bell



Sent from my iPad

On Feb 4, 2016, at 2:13 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>> wrote:

Robert:
Thank you for posting that link. It brings up an excellent point as well for freelance journalist like me. I often have to go to extreme measures to get copies of full studies. Most journalists don't bother which is why consumer press coverage of medical news is often limited to what the press release says. Those of us who like to dig a little deeper lose the ability to do so in a timely fashion in contrast to the echo chamber of most press outlets.

Now I'm going to check out #ICanHazPDF which the article refers to as an end run around pay walls.

Best,
Helene

--
<http://hmepstein.com/>hmepstein.com<http://hmepstein.com/>
@hmepstein
Mobile: 914-522-2116

Sent from my iPhone



On Feb 4, 2016, at 3:36 PM, robert bell <<mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

To all on the list.

A friend kindly sent me this:  <http://www.brookings.edu/blogs/techtank/posts/2016/01/11-open-access-scientific-knowledge> http://www.brookings.edu/blogs/techtank/posts/2016/01/11-open-access-scientific-knowledge

It seems that much of the information that we see is obtained from Open Access information not from closed source Scientific Journals. Wikipedia editors are 47 percent more likely to use Open Source Journals for their information.

Consequently, the the public and probably also physicians are not getting the very best scientific information in a timely way.

This brings up the issue of what I will call the Diagnostic Medical Infrastructure.

If the infrastructure is not sound, information is not being distributed in the best way to physicians and the public to focus on evidence based medicine, physicians are missing a “raised" PSA test when someone has had a prostatectomy, and a large percentage of radiologists are missing an image of a "Gorilla” on an X-ray, and also a thousand and one other problems, particularly in the communication area, that in turn all lead to error, how can we hope to successfully first tackle diagnostic errors?

If the current diagnostic error rate on all patients is say 30% would it not be better to get this figure down before focussing on improving diagnoses as a whole? It may be possible to tackle the standard errors and diagnostic errors together in some way but surely some of the standard errors have to be dealt with first to save lives and injury.

Triaging some of these problems, correcting/improving them, could quickly start reducing the current diagnostic errors.

Should we first be focussing on the Diagnostic Medical Infrastructure?

Should our focus first be on the best ways to save lives and stop patient injury?

Robert M. Bell, M.D.




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