Definition of Diagnosis Error

Edward Winslow edbjwinslow at GMAIL.COM
Mon Feb 6 20:31:36 UTC 2017


Art,
You are right on about problem lists and diagnoses.

In the light of your perspective as written, a "diagnosis" is rendered to
make a billing decision - forced on us a couple of decades ago, when
insurers would not pay/reimburse for a "symptom" (signs, symptoms and ill
defined diseases). Putting a "diagnosis" on a billing slip was important so
that a practice could remain fiscally solvent.

I would suggest that most of us believe that a "Diagnosis" is not for
billing purposes, but as a beginning of a road map to suggesting a
preferred course of action (treatment (invasive or non-invasive), or
observation or reassurance, ...). As many of the posters have said,
sometimes a diagnosis without other modifiers might suggest different
things to a patient or her/his physician (ductal carcinoma in situ comes to
mind).

Maybe rather than going to ONC we should go to billing intermediaries and
get them to lighten up on needing a "specific diagnosis" for billing. This,
by the way, preceded by a long way EMR or EHR utilization. It is NOT the
fault of the EHR, except that the EHR, in order to close the encounter,
requires a diagnosis. Maybe "bad code".

On Sun, Feb 5, 2017 at 12:29 PM, Art Papier <apapier at visualdx.com> wrote:

> Agree completely.  Our billing system requires a iCD-10 diagnosis, which
> encourages anchoring and the passing along of inaccurate diagnoses from
> clinician to clinician.  Almost all Problem lists actually seem in reality
> to be the past medical history and not true problem lists.  I say this
> because clinicians almost always see in the EHR, Problem Lists containing
> only diagnoses, not symptoms or problems.    A Problem such as “unexplained
> vomiting”, or “headache cause unknown”, etc.. is almost never seen in
> today’s problem lists.    Larry Weed wrote that a problem remains a symptom
> or complaint, until there is a “basis” for the diagnosis. Once there is a
> objective basis (confirmatory studies) or a cogent clinical argument in the
> note explaining the logic for the diagnosis, a complaint or symptom can be
> transformed into  a diagnosis.   If you cannot rationally defend the
> diagnosis, then it should not be written as a diagnosis, but as the
> presenting chief complaint.  For example, if the patient has a biopsy
> proven basal cell carcinoma,  you write basal cell carcinoma.  If you see a
> lesion that has no defining clinical characteristics, you describe the
> lesion on exam.  The problem would be written as  “non-healing ulcer of
> forehead” .   Once the pathology comes back, the problem becomes a
> diagnosis.  We have gone backwards over the past 50 years.  Many of our
> younger physicians, residents and students are unaware of the rationale
> behind the POMR.
>
>
>
> Art Papier MD
>
> Associate Professor of Dermatology and Medical Informatics
>
> CEO VisualDx
>
>
>
> *From:* Ted.E.Palen at KP.ORG [mailto:Ted.E.Palen at KP.ORG]
> *Sent:* Sunday, February 05, 2017 2:06 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> 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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> 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 for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
> To learn more about SIDM visit:
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>
>
> ------------------------------
>
>
>
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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 for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> ------------------------------
>
>
>
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>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
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>
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>



-- 
*Edward B, J. Winslow, MD, MBA*
Home 847 256-2475; Mobile 847 508-1442
edbjwinslow at gmail.com
winslowmedical.com

"The only thing new in the world is the history that you don't know"
       Harry S. Truman, 33rd President of US (1945-1953)


"... it can be argued that underinvestment in assessing the past is likely
to
lead to faulty estimates and erroneous prescriptions for future action."
        Eli Ginzberg, 1997






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


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