Definition of Diagnosis Error

Thomas Benzoni benzonit at GMAIL.COM
Tue Feb 7 01:57:19 UTC 2017


When I use our E(M)R, what I see for diagnoses, across 4 major vendors, are not diagnoses but billing code descriptors.
tom

Fearing no insult, asking for no crown, receive with indifference both flattery and slander, and do not argue with a fool. -Aleksandr Pushkin, poet, novelist, and playwright (6 Jun 1799-1837)

On Feb 6, 2017, at 16:54, Art Papier <apapier at VISUALDX.COM> wrote:

> Ted agree, not an intrinsic problem of EHR’s.  Really a problem created by fee for service medicine, and payors and CMS.  Pretty sure this has nothing to do with ONC.   The payors have to be convinced that a more rationale coding/billing/reimbursement system will lead to better care and lower costs.
>  
> From: Edward Winslow [mailto:edbjwinslow at GMAIL.COM] 
> Sent: Monday, February 06, 2017 3:32 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
>  
> 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
> 
> On Jan 19, 2017, at 9:06 AM, Charlie Garland - The Innovation Outlet <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 (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 (Healthcare Innovation & Technology Laboratory @ Columbia University Medical Center)
> Member of the Board of Trustees at Creative Education Foundation
> Developer of Cognitive Buoyancy ("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
> blatino at reliability.com
> www.reliability.com
> <image001.jpg>
>  
> 
> 
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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
> 
>  
>  
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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