Diagnostic Infrastructure

Elias Peter pheski69 at GMAIL.COM
Thu Feb 11 01:11:24 UTC 2016


When I decided to give all my patients a copy of their office visit note (not supported by - though also not forbidden by - my institution, and without any infrastructure or tools) I soon discovered that the most effective way to make the note accurate (and minimize the requests for post facto corrections) was to do the office visit ‘out loud’ in a triangle configuration, with me entering data as we worked together.  I could narrate and the patient could both hear and see what I was documenting.  A number of good things happen when this is done:

Things are phrased objectively. (Tough to write ‘patient has no insight’ and say this out loud while the patient is watching and listening.) Instead, a purely descriptive phrasing is used. It took some practice, but did NOT result in leaving valid or important things out. (My motto has become, if it is important enough to put in the record, it is too important to hide it from the patient.)
I can test my understanding of what the patient said. (“Did I get that right?”)
When (not if) the patient and I disagree about things, I can enter both opinions, acknowledge that we disagree, and talk about how we deal with that. (I think of that as adult conversation.)
It is MUCH more complete and accurate than if I do documentation hours (or days) later, based on what I remember, what I hope I said or did, what I should have said or done. Ask someone to read you a moderately detailed and somewhat disorganized story for five minutes. Four hours later write it down as well as you can.  Then look at the original story. Then think about getting 20 such stories over 80 hours and that night recording them as a legal document on which the lives or patients will depend. Weep.)

Some things did NOT happen: 

I did not get lots of inappropriate questions from worried or confused patients.
I did not have to avoid conversations about inappropriate drug use, psychological issues, somatization, home or work stress. In fact, these conversation were easier to have.
I did not spend a significantly increased amount of time. Some things took longer, yes.  But some things took less time and some important efficiencies also helped.

So, from my perspective and based partly on literature and largely on N=1, doing notes collaboratively and transparently with patients is a readily available technique to improve the quality and accuracy of notes, reduce errors and prevent harm.

Peter Elias, MD

> On 2016.02.09, at 8:53 AM, Julianne Nemes Walsh <nemeswalsh at GMAIL.COM> wrote:
> 
> Recently, Beth Israel in Boston completed a pilot study allowing patients access to all notes.  Their "open notes" project found at least 25% of the patients felt their history was incorrectly obtained by the provider.  This is an area where patients will become active contributors to improving the accuracy of diagnosis.  It is worth pursuing at every level, primary and specialist care.  
> 
> On Mon, Feb 8, 2016 at 2:17 PM, Grubenhoff, Joe <Joe.Grubenhoff at childrenscolorado.org <mailto:Joe.Grubenhoff at childrenscolorado.org>> wrote:
> Don't just do something, stand there...sometimes the best medicine we can practice.
> 
> Joe Grubenhoff, MD| Assistant Professor of Pediatrics 
> Section of Emergency Medicine | University of Colorado
> Children's Hospital Colorado
> 13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO 80045 | Phone: (303) 724-2581 <tel:%28303%29%20724-2581> | Fax: (720) 777-7317 <tel:%28720%29%20777-7317>
> joe.grubenhoff at childrenscolorado.org <mailto:joe.grubenhoff at childrenscolorado.org>
> 
> Connect with Children's Hospital Colorado on Facebook and Twitter
> 
> 
> For a child’s sake…
>                 We are a caring community called to honor the sacred trust of our patients, families and each other through
>                 humble expertise, generous service and boundless creativity.
> …This is the moment.
> 
> 
> -----Original Message-----
> From: Tom Benzoni [mailto:benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>]
> Sent: Monday, February 08, 2016 9:22 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> Subject: Re: [IMPROVEDX] Diagnostic Infrastructure
> 
> If you are to avoid systematic bias, you must include errors in guidelines.
> E.g., recall steroids in spinal cord injury.
> Big names: NIH, CDC put out big pronouncements. (references available)
> Then: Standard of care (Beneficial)
> Now: Standard of Non-care (Harmful)
> So it is honest to remember that inertia can also be safe practice.
> 
> While we're discussing errors:
> Errors start with letting small slips pass (broken window theory.) I.e., ER's don't get to choose who they treat and so must master all fields AND they act as backups to all specialties (thus being the specialist's specialist.) However, there is much data that most patients on PPIs don't have the disease for which they are being treated and most antibacterial agents are prescribed for people with viral illnesses.
> This type of heuristic, writing a script for a treatment which is not needed, represents a much bigger source of diagnostic error because it is foundational. This is what happened in Ebola/Duncan.
> 
> As I teach my residents. "It's awful hard for your patient to get better on your treatment for a disease which they don't have." Or, more crudely, you can give me (60 y.o. male) a prescription for OCP (oral contraceptives) and, even if I'm non-adherent, I'll still not get pregnant.
> 
> tom benzoni
> Des Moines
> 
> On Mon, Feb 8, 2016 at 8:54 AM, Jason Maude <jason.maude at isabelhealthcare.com <mailto:jason.maude at isabelhealthcare.com>> wrote:
> > Mike
> > Many thanks for highlighting this story. I would love to compile a
> > compendium of similar stories such as Semmelweis and hand washing,
> > Lister and antiseptics, Laennec and the stethoscope, Barry Marshall and hpylori.
> > The average adoption time must be more than a generation!
> > Please let me know of any other notable ones to add to the list.
> >
> > Regards
> > Jason
> >
> > Jason Maude
> > Founder and CEO Isabel Healthcare
> > Tel: +1 703 879 1890 <tel:%2B1%20703%20879%201890>
> > www.isabelhealthcare.com <http://www.isabelhealthcare.com/>
> >
> > From: "Bruno, Michael" <mbruno at HMC.PSU.EDU <mailto:mbruno at HMC.PSU.EDU>>
> > Reply-To: Society to Improve Diagnosis in Medicine
> > <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, "Bruno, Michael"
> > <mbruno at HMC.PSU.EDU <mailto:mbruno at HMC.PSU.EDU>>
> > Date: Friday, 5 February 2016 20:32
> > 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 think this sort of thing has been a problem throughout history.  For
> > example, consider the classic “history of medicine” story of Scurvy
> > and Vitamin C from the 18th Century:
> >
> >
> >
> > “…the first attempt to give scientific basis for the cause of this
> > disease was by a ship's surgeon in the British Royal Navy, James Lind.
> > While at sea in May 1747, Lind provided some crew members with two
> > oranges and one lemon per day, while others were given cider, vinegar,
> > sulfuric acid or seawater, along with their normal rations. In the
> > history of science this is considered to be the first occurrence of a
> > controlled experiment comparing results on two populations of a factor
> > applied to one group only with all other factors the same. The results
> > conclusively showed that citrus fruits prevented the disease. Lind
> > published his work in 1753 in his Treatise on the Scurvy1…
> >
> >
> >
> > But doctors, as a group, generally refused to accept Lind’s results,
> > and most clung to out-moded and unproven ideas about Scurvy, such as
> > the idea it could be prevented by drinking acid solutions.
> >
> >
> >
> > “…They considered that scurvy was a disease of internal putrefaction
> > brought on by faulty digestion caused by the naval diet. Although this
> > basic idea was given different emphases by successive theorists, the
> > remedies they advocated (and which the navy accepted) amounted to
> > little more than the consumption of ‘fizzy drinks’ to activate the
> > digestive system, the most extreme of which was the regular
> > consumption of ‘elixir of vitriol’ – sulphuric acid taken with spirits
> > and barley water and laced with spices. In 1764, a new variant
> > appeared. Advocated by Dr David McBride and Sir John Pringle, Surgeon
> > General of the Army and later President of the Royal Society, this idea was that scurvy was the result of a lack of ‘fixed air’
> > in the tissues which could be prevented by drinking infusions of malt
> > and wort whose fermentation within the body would stimulate digestion
> > and restore the missing gases…”
> >
> >
> >
> > As a direct result of stubborn and wrong-headed physician
> > intransigence,
> >
> >
> >
> > “…it was 1795 before the British navy adopted lemons or lime as
> > standard issue at sea.”
> >
> >
> >
> > No telling how many sailors were condemned to suffer and die horribly
> > from Scurvy in the 45 year delay between 1753, when Lind’s results
> > were first published, and 1795, when the British navy began to
> > provision ships with citrus fruits!?!  Certainly more died from scurvy
> > than died from actual combat.  45 years!!  That is even worse than our
> > modern FDA delays the dissemination of proven treatments and technologies.
> >
> >
> >
> > Have a great weekend, all!
> >
> >
> >
> > Mike
> >
> >
> >
> >
> >
> > References:
> > http://www.bbc.co.uk/history/british/empire_seapower/captaincook_scurv <http://www.bbc.co.uk/history/british/empire_seapower/captaincook_scurv>
> > y_01.shtml,
> >
> >
> >
> > https://dash.harvard.edu/bitstream/handle/1/8852139/Mayberry.html?sequ <https://dash.harvard.edu/bitstream/handle/1/8852139/Mayberry.html?sequ>
> > ence=2
> >
> >
> >
> > https://en.wikipedia.org/wiki/Scurvy <https://en.wikipedia.org/wiki/Scurvy>
> >
> >
> >
> > and
> >
> >
> >
> > http://www.healthaliciousness.com/articles/lind-scurvy-vitamin-C.php <http://www.healthaliciousness.com/articles/lind-scurvy-vitamin-C.php>
> >
> >
> >
> >
> >
> >
> >
> > From: Robert Bell
> > [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>]
> > Sent: Friday, February 05, 2016 1:08 AM
> > To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> > Subject: Re: [IMPROVEDX] Diagnostic Infrastructure
> >
> >
> >
> > Excellent points Peggy,
> >
> >
> >
> > The acceptance of new treatments is far too slow. I think it took
> > about 10 years in the US  for H.  pylori to be fully acepted as a the
> > cause of peptic ulceration and that antibiotics were the cure.
> >
> >
> > Rob
> > Sent from my iPad
> >
> >
> > On Feb 4, 2016, at 2:23 PM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM <mailto:peggyzuckerman at GMAIL.COM>>
> > wrote:
> >
> > How do we get the error rate down when there is such diverse range of
> > issues that cause such error?  We can certainly approach those known
> > errors in a linear fashion, but that will have little impact in the
> > near term, except in those cases.
> >
> >
> >
> > Just as Bell has pointed out that neither doctors nor patients are
> > getting the best possible information in a timely manner, that problem
> > is not limited to Wikipedia or OpenSource documents.  A great deal of
> > focus has been made on the difficulty of replicating clinical trial
> > studies, of the shifts in the reported outcomes away from the initial
> > goals of those studies, and of studies which are sadly incomplete of
> > the data which would give clinicians greater and more reliable
> > guidance in treatment.  Then there is the issue of the acceptance of
> > change which might derive from those studies, said by some require at
> > least 14 years for 50% of the clinicians incorporating even new guidelines in their practices.
> >
> >
> >
> > Rather than focusing on one topic or type of error, there must be a
> > cultural change in the diagnostic process.  Part of that--and there
> > are a myriad of parts--is permitting and encouraging patients to
> > receive and read their complete medical records.  Following that is
> > the need for patients to correct the errors in those records, and to
> > be able to share them freely with other family members or providers.
> >
> >
> >
> > There also needs to be a way for a misdiagnosis or concern for such to
> > be reviewed by a responsible party.  The sheer number of patients who
> > are treated for something which they do not have, and at the expense
> > in time, life and limb, is staggering.  However, imagine the resources
> > to be freed up when they are not dispersed incorrectly and with
> > greater long-term cost.  We all will benefit from approaching this as
> > cultural shift, as significant in society as was the civil rights and womens' movements.
> >
> >
> >
> > Peggy
> >
> >
> >
> > This while thinking as a board member of the Society for Participatory
> > Medicine (participatorymedicine.org <http://participatorymedicine.org/>),as well as patient advocate.
> >
> >
> >
> >
> >
> >
> > Peggy Zuckerman
> > www.peggyRCC.com <http://www.peggyrcc.com/>
> >
> >
> >
> > On Thu, Feb 4, 2016 at 12:36 PM, robert bell
> > <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-s <http://www.brookings.edu/blogs/techtank/posts/2016/01/11-open-access-s>
> > cientific-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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> > Moderator:David Meyers, Board Member, Society for Improving Diagnosis
> > in Medicine
> >
> > To learn more about SIDM visit:
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> >
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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