Definition of Diagnosis

Bob Swerlick rswerli at GMAIL.COM
Sun Feb 5 21:23:43 UTC 2017


And the rationale for this is what????

Bob

On Sun, Feb 5, 2017 at 4:08 PM, Tom Benzoni <benzonit at gmail.com> wrote:

> If an ER uses possible, probable or other modifier demonstrating anything
> less than certainty, Medicare and other insurers will not reimburse for the
> visit.
> Thus, an ER diagnosis is to be considered "forced."
>
> On Sun, Feb 5, 2017 at 12:12 PM, Bob Swerlick <rswerli at gmail.com> wrote:
>
>> I think this perspective is spot on. Diagnoses are always provisional to
>> some degree but our billing processes are require us to commit to a
>> diagnosis before we should be committing.
>>
>> This functionality may already be present. Our EHR (Cerner Powerchart)
>> actually has modifiers regarding diagnoses - possible, probable, confirmed,
>> etc that come up when a diagnosis is selected for billing. No one uses them
>> (except me), probably because of training and time issues.
>>
>> Bob
>>
>> On Sun, Feb 5, 2017 at 9:55 AM, Twest54973 <000000040134e744-dmarc-reques
>> t at list.improvediagnosis.org> wrote:
>>
>>> This question is for the Board of Directors at SIDM:
>>>
>>> Can SIDM approach ONC at the federal level to ask ONC to make a formal
>>> comment about the dynamic aspects of the dx process as we have previously
>>> described in prior emails and then start a conversation with the EMR vendor
>>> community to have them modify their platforms to incorporate the evolving
>>> nature of any given dx?
>>>
>>> ADDING prelimary/presumed/confirmed  codes for ICD-11 (i dont know when
>>> that will be done) with the WHO would be a whole different process ...
>>>
>>> Tom
>>>
>>> Thomas Westover MD
>>> Cooper Medical School
>>>
>>>
>>> Sent from my iPhone
>>>
>>> On Feb 5, 2017, at 2:06 AM, Ted.E.Palen at KP.ORG wrote:
>>>
>>> Great conversation
>>> I often cannot make a diagnosis the first time I see a patient. In fact
>>> it may take many visits, testing, and cogitation to arrive at the diagnosis
>>> that fits all the facts and even then it may be wrong.
>>> Early on in this process I am often frustrated by the need to "code" a
>>> diagnosis. Early on I may not know the diagnosis but if forced to code on
>>> it may often be in error. I sometimes resort to just coding the most
>>> pertinent symptoms (but the business people do not like that). It would be
>>> much better if our coding systems would allow for coding "preliminary" or
>>> "working" or "presumed" and finally "confirmed." But alas we are not, we
>>> are not allowed a coding system that is clinically relevant but rather the
>>> owners of the system profit from a coding billing system. Until this
>>> changes we will be forced to use inadequate means to document (and hence an
>>> inadequate means to measure) diagnostic reasoning.
>>>
>>> Ted E. Palen, PhD, MD
>>> Institute for Health Research
>>> Colorado Permanente Medical Group
>>> Denver, CO
>>> 303-614-1215 <(303)%20614-1215>
>>>
>>> On Jan 19, 2017, at 9:06 AM, Charlie Garland - The Innovation Outlet <
>>> cgarland at INNOVATIONOUTLET.BIZ <cgarland at innovationoutlet.biz>> wrote:
>>>
>>> *Caution: *This email came from outside Kaiser Permanente. Do not open
>>> attachments or click on links if you do not recognize the sender.
>>> ------------------------------
>>> Tom, I understand your perspective and you make an excellent point.
>>> That said, it's all the more reason to collectively include that very
>>> perspective in any "standard" definition of Dx Error.  I heartily agree
>>> with the *dynamic *nature of the Dx process, and that explicitly
>>> including something akin to a "confidence interval" is not only
>>> appropriate, but would facilitate any physician's dilemma in having to make
>>> an either-or choice between a right and a wrong answer (e.g. one option
>>> would be to add a "confidence interval" field into the EMR, which could
>>> serve as a trigger/forcing strategy; I'm sure there are others).
>>>
>>> Some would tend to simply stick with the definition that we've currently
>>> been handed by IOM, seemingly suggesting "if it ain't broke, don't fix it."
>>>  Well, have a look at the outcomes data.  *It's broke*.
>>>
>>> While I would still advocate for a conscious recognition of the concept
>>> of "completeness" (i.e. don't stop exploring, just because you've found one
>>> answer), I do believe you're onto something very interesting and worth us
>>> all re-thinking.
>>>
>>> Charlie
>>> =================================================
>>>
>>> Charlie Garland
>>> Senior Fellow of HITLAB <http://www.hitlab.org> (Healthcare Innovation
>>> & Technology Laboratory @ Columbia University Medical Center)
>>>
>>> -------- Original Message --------
>>> Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
>>> From: Twest54973
>>> <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
>>> Date: Wed, January 18, 2017 6:29 pm
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>>
>>> Dr Garland
>>>
>>> I must respectfully disagree ...
>>>
>>> Because EVERY dx a clinician makes is inherently an incomplete
>>> hypothesis that is not "completed" until the pt is followed serially over
>>> time to evaluate the pts response to a proposed therapeutic intervention(s)
>>>
>>> Diagnoses are not static objects : they  evolve over time by definition
>>>
>>> Perhaps It would be more relevant and truthful (and perhaps more easily
>>> measurable?) to classify diagnoses as preliminary, presumed, and
>>> probable/final as the clinician moves from less certainty to more certainty
>>> thru these three blurred stages  (as more data is gathered and the clinical
>>> course becomes more revealing )
>>>
>>> One could then compare the time course , appropriateness of testing
>>> strategies and accuracy between clinicians by each category
>>>
>>> Just a thought ...
>>>
>>> Tom Westover MD
>>> Cooper Medical School
>>> Camden NJ
>>>
>>>
>>>
>>> Sent from my iPhone
>>>
>>> On Jan 18, 2017, at 3:55 PM, Charlie Garland - The Innovation Outlet <
>>> cgarland at INNOVATIONOUTLET.BIZ> wrote:
>>>
>>> Great question, Bob.  But I would ask a follow-up question to yours...
>>>
>>> What qualifies something as being "SIDM-approved"?  Is this a result of
>>> a democratic vote?  If so, by all members, by a steering committee, and/or
>>> by some other group herein?  I recall that Mark Graber openly invited
>>> feedback from the audience at the Sep 2015 conference (just after the IOM
>>> report was published) on these definitions, and he got a few suggestions in
>>> real time, but I don't know what happened thereafter.
>>>
>>> One suggestion I have is to supplement these three dimensions (*wrong*,
>>> *missed*, and *delayed*) with that of *incomplete*.  Perhaps there is
>>> more, but in my mind, "incomplete" is a unique form of Dx error that is not
>>> necessarily captured by any of the other three.  One could argue that it's
>>> merely a form of missed Dx, but to lump it in to that category would lose a
>>> crucial nuance of the physician's cognitive process (e.g. it would tend to
>>> obscure an important cognitive bias at play in such cases).  There's much
>>> more than just this example, but for brevity sake, I'll end there.
>>>
>>> Happy to elaborate/discuss further for anyone's interests...
>>>
>>> CG
>>>
>>> =================================================
>>>
>>> Charlie Garland
>>>
>>> Senior Fellow of HITLAB <http://www.hitlab.org> (Healthcare Innovation
>>> & Technology Laboratory @ Columbia University Medical Center)
>>> Member of the Board of Trustees at Creative Education Foundation
>>> <http://www.creativeeducationfoundation.org/>
>>> Developer of Cognitive Buoyancy <http://www.cognitivebuoyancy.com/> ("The
>>> Trigger to Innovation")
>>>
>>>
>>>
>>>
>>>
>>> -------- Original Message --------
>>> Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
>>> From: Tom Benzoni <benzonit at GMAIL.COM>
>>> Date: Wed, January 18, 2017 11:17 am
>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>>
>>> There are too many flaws in the definition to give it credibility.
>>>
>>> Tom
>>>
>>> On Jan 18, 2017 8:33 AM, "Bob Latino" <blatino at reliability.com> wrote:
>>>
>>>> Is this IOM Definition of Diagnosis Error an accepted definition by
>>>> SIDM?
>>>>
>>>> What is Diagnostic Error?
>>>> The Institute of Medicine recently defined diagnostic error as the
>>>> failure to (a) establish an accurate and timely explanation of the
>>>> patient’s health problem(s) or (b) communicate that explanation to the
>>>> patient. Simply put, these are diagnoses that are missed altogether, wrong,
>>>> or should have been made much earlier.
>>>>
>>>> These categories overlap, but examples help illustrate some differences:
>>>> *A missed diagnosis *refers to a patient whose medical complaints are
>>>> never explained. Many patients with chronic fatigue, or chronic pain fall
>>>> into this category, as well as patients with more specific complaints that
>>>> are never accurately diagnosed.
>>>>
>>>> *A wrong diagnosis* occurs, for example, if a patient truly having a
>>>> heart attack is told their pain is from acid indigestion. The original
>>>> diagnosis is found to be incorrect because the true cause is discovered
>>>> later.
>>>>
>>>> *A delayed diagnosis* refers to a case where the diagnosis should have
>>>> been made earlier. Delayed diagnosis of cancer is by far the leading entity
>>>> in this category. A major problem in this regard is that there are very few
>>>> good guidelines on making a timely diagnosis, and many illnesses aren’t
>>>> suspected until symptoms persist, or worsen.
>>>>
>>>>
>>>> *Robert J. Latino, CEO*
>>>> Reliability Center, Inc.
>>>> 1.800.457.0645 <(800)%20457-0645>
>>>> blatino at reliability.com
>>>> www.reliability.com
>>>> <image001.jpg>
>>>> <https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>
>>>>
>>>> ------------------------------
>>>>
>>>>
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>>>> D1=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/
>>>
>>>
>>> ------------------------------
>>>
>>> Address messages to: IMPROVEDX@ <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>>
>>>
>>> ------------------------------
>>>
>>>
>>> To unsubscribe from IMPROVEDX: click the following link:
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>>> D1=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/
>>
>>
>>
>>
>> --
>> Bob Swerlick
>>
>> ------------------------------
>>
>>
>> To unsubscribe from IMPROVEDX: click the following link:
>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBE
>> D1=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/
>
>
>


-- 
Bob Swerlick






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


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