Definition of Diagnosis Error

Bob Latino blatino at RELIABILITY.COM
Tue Feb 7 17:41:41 UTC 2017


The fog is certainly clearing up for me, thank you for the clear description.

Such candid responses like this about reality on the front lines, identify some clearly actionable tasks to reduce the immediate risk of Dx Errors.  Does anyone know if any such discussions are taking place between influential groups like yourselves and the top E(M)R/EHS vendors?

As a software provider myself (on other types of software), I can clearly see the programmatic changes that would need to take place, in order to make your lives easier and your patient's safer.  It just takes courage and conviction to buck the system and face the facts (evidence).

I have feeling we all deal with this (Confirmation Bias), in situations like this.

In this case, the truth will cost more money initially (for the vendor who will pass it down to their customers) to modify a program and it will take some time to do so (although not holding up the current status quo).

If a cost/benefit analysis was done on demonstrating the current, overall costs of dealing with results of reported Dx Errors, I am guessing the ROI would be a no-brainer to move forward on implementing these fundamental, but impactful changes.  Is anyone aware of such business cases being made to justify such a recommendation?

[cid:image002.jpg at 01D2813F.5FDFA220]

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com
www.reliability.com
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From: Tom Benzoni [mailto:benzonit at gmail.com]
Sent: Tuesday, February 07, 2017 12:02 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org>; Bob Latino <blatino at reliability.com>
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error

Our current systems are from the 1970s.

Last you think me cynical: next time one of the major vendor's product come up on your screen, read the legalese. Study the copyright. Report back here.____

I think we used billing codes in lieu of diagnoses because we didn't have natural language processing years ago. Now, if I could write the diagnosis in natural language and have that follow the patient, billing could derive therefrom.

To follow this process historically, study T-Systems. (I have no connection to them.) See how they started as a billing sheet, then, as CMS put in place "count the body systems checked" (not necessarily examined...) to make a billing level, someone got the idea to eliminate the medical record, the patient's story, altogether. This saved money while making even more money by use of the check-box bill. This was subsequently made electronic.

The loss of this narrative makes sequential logic, so necessary in putting together a diagnosis (how things change over time) impossible.

tom


On Feb 7, 2017 6:58 AM, "Bob Latino" <blatino at reliability.com<mailto:blatino at reliability.com>> wrote:
This discussion puts the definition of Dx Error in a whole new light, to an unbiased, non-clinical observer.

When Dx Error statistics are reported and thus compiled nationally, are the 'Dx Errors' based on verdicts from resulting bad outcomes (where claims were filed), or based on how the Dx was initially coded in the E(M)R?

This discussion has certainly changed my impression of what is a Dx Error and what can be done now to start to prevent it (as Art and Ted note actionable, initial solutions below that can be very impactful in the short-term).

Thanks for the enlightenment.

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645<tel:(800)%20457-0645>
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
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From: Art Papier [mailto:apapier at VISUALDX.COM<mailto:apapier at VISUALDX.COM>]
Sent: Monday, February 06, 2017 9:28 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error

Yes you see billing descriptors for diagnoses in the EMR, but they are in the EMR because the only way your hospital will be reimbursed is to have diagnostic ICD-10 and procedural CPT codes for each encounter.  The hospital and EHR companies use the codes the payors require.  Fixing this is not a responsibility of the ONC which is focused on healthcare IT, but on the government and payors that set the reimbrusement rules.  As a group interesting in reducing diagnostic error, we should consider making a recommendation to CMS and the government agencies setting the reimbursement rules that a problem or chief complaint (eg. evaluation of anemia)  could be used along with a CPT code, not only a presumptive diagnosis with a CPT code. Would be an interesting discussion at DEM.

From: Thomas Benzoni [mailto:benzonit at GMAIL.COM]
Sent: Monday, February 06, 2017 8:57 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error

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<mailto: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<mailto: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<mailto: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> [mailto: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<mailto: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<tel:(303)%20614-1215>

On Jan 19, 2017, at 9:06 AM, Charlie Garland - The Innovation Outlet <cgarland at INNOVATIONOUTLET.BIZ<mailto: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<mailto:000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>>
Date: Wed, January 18, 2017 6:29 pm
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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<mailto:benzonit at GMAIL.COM>>
Date: Wed, January 18, 2017 11:17 am
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto: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.
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