Definition of Diagnosis Error

Tom Benzoni benzonit at GMAIL.COM
Mon Feb 13 16:35:38 UTC 2017


I would recommend a study:
Using the E(M)R's timing capability, record the time from opening of the
Decision Support Tool to pressing "Enter" or clicking "Accept."
The result may be interesting.
(Disclosure: I am an E(M)R active user. I use the decision support tool
alluded to by Dr. Palen.)
tom

On Mon, Feb 6, 2017 at 12:38 PM, Art Papier <apapier at visualdx.com> wrote:

> Ted, Yes, n=1 im very interested in data around ACR CDS.  Thanks Art
>
>
>
> *From:* Ted.E.Palen at KP.ORG [mailto:Ted.E.Palen at KP.ORG]
> *Sent:* Monday, February 06, 2017 11:23 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> In regard to the ACR-AC, I just led a step-wedge study of the roll-out of
> the ACR Select decision support software. This decision support tool is
> embedded in Epic and used at the point of ordering imaging studies. An
> appropriateness score (1-9) is shown for the radiology study that is
> ordered. It is based on the coded clinical indication(s).
>
> We are currently writing up our results for publication. I would be happy
> to share them if this group is interested.
>
>
> Ted E. Palen, PhD, MD
>
> Institute for Health Research
>
> Colorado Permanente Medical Group
>
> Denver, CO
>
> 303-614-1215 <(303)%20614-1215>
>
>
> On Feb 6, 2017, at 7:52 AM, Bruno, Michael <mbruno at PENNSTATEHEALTH.PSU.EDU
> <mbruno at pennstatehealth.psu.edu>> wrote:
>
> *Caution: *This email came from outside Kaiser Permanente. Do not open
> attachments or click on links if you do not recognize the sender.
> ------------------------------
>
> Good points, Michael.
>
>
>
> Our profession is impacted by several drivers leading to overdiagnosis,
> which I believe is a much bigger problem in terms of patient harm than is
> generally acknowledged (even in this forum).  I applaud you, Bob and Tom
> Benzoni, Albert Yu and others for bringing it up.
>
>
>
> Certainly one of those drivers is *defensive medicine*, which is itself
> greatly underestimated in terms of its importance.  Dr. Lenny Berlin has
> pointed out that defensive medicine, in which an excess of diagnostic tests
> are ordered to reduce physician anxiety rather than for the benefit of the
> patient, may have had its genesis in the malpractice crisis of the 1970’s
> but now has taken on a life of its own, passed along in the GME process to
> successive generations of physicians.  All of us who struggle at our home
> institutions – as I do – to get clinicians to move more toward
> evidence-based utilization of imaging has run into this, and it is a
> formidable problem.
>
>
>
> Another driver of overdiagnosis is, of course, the emphasis on *screening*
> of healthy populations – which is done in the hope that early detection
> will lead to better patient outcomes.  The two biggest examples in
> Radiology, of course, are mammography and lung cancer screening.  While the
> evidence to support the benefits of mass screening is relatively weak, the
> false-positive rate is fairly high.  Since pathology is not an exact
> science by any means, this becomes a perfect formula for overdiagnosis
> leading to overtreatment.  Even the biopsy itself can be classified as
> “patient harm” when the false-positive rate is very high relative to the
> true-positive rate of screening.  A very nice, recent book (2016) on the
> subject (in case anyone is interested) is Steven Hatch’s *Snowball in a
> Blizzard*, although if you have read Gilbert Welch’s book, *Overdiagnosed*,
> you have pretty much covered the same material.
>
>
>
> Overutilization of imaging for whatever reason (including for valid
> reasons, such as *patient demand*, or to *speed discharge from the ED* so
> that more patients can be served, or even because of *lack of physician
> confidence* in their own physical diagnosis, *etc*) is another major
> driver of overdiagnosis.  This is simply because many disease entities
> cannot reliably be discriminated from each other by imaging and because a
> larger volume of imaging studies being performed will produce a
> proportionately larger volume of false positives—all of which must be
> worked up in one way or another.  Unnecessary imaging is truly a Pandora’s
> box for patients, as studies will often raise more questions for a patient
> than they answer.
>
>
>
> Moving physicians toward evidence-based utilization of medical imaging,
> based on objective clinical criteria whenever possible – and perhaps having
> a more clear-eyed (skeptical?) approach to mass population screening with
> imaging would carry us a long way toward reducing the currently severe
> problem of overdiagnosis, in my opinion.
>
>
>
> One approach to this problem is to provide electronic “decision support”
> to clinicians that can be accessed seamlessly at the time a physician
> encounters a patient, in order to help them weigh the evidence and decide
> whether an imaging study would be appropriate.  The nonprofit American
> College of Radiology (ACR) has invested quite a bit of volunteer physician
> effort and other resources to develop some guidelines, the *ACR
> Appropriateness Criteria*, and lately to develop deployable
> decision-support tools, such as the ACR’s R-Scan tool.  There is a need for
> more research in this area, both to develop better evidence and more
> guidelines where patient outcome is considered, and also to understand how
> better to deploy decision support so that it is accepted by physicians and
> is ultimately effective.  We are hoping to convene a research development
> and consensus conference this Fall in Hershey and hope that many SIDM
> members will attend (if we can get the funding to hold the meeting).
>
>
>
> All the best,
>
>
>
> *<image001.png>*
>
> *Michael A. Bruno, M.S., M.D., F.A.C.R.*
> Professor of Radiology & Medicine
>
> Vice Chair for Quality & Patient Safety
>
> Chief, Division of Emergency Radiology
>
> Penn State Milton S. Hershey Medical Center
> ( (717) 531-8703  |   6 (717) 531-5737
>
> *** mbruno at pennstatehealth.psu.edu <mbruno at hmc.psu.edu>
>
> <image002.png>
>
>
>
> *From:* Kohn, Michael [mailto:Michael.Kohn at UCSF.EDU
> <Michael.Kohn at UCSF.EDU>]
> *Sent:* Sunday, February 05, 2017 1:30 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> <IMPROVEDX at list.improvediagnosis.org>
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> Dear Colleagues,
>
> As per my prior post, I see two types of diagnostic error: 1) failing to
> provide effective treatment for something the patient has, and 2) treating
> unnecessarily for something the patient doesn't have.  If you believe tPA
> is effective treatment for acute stroke, then failing to provide it to a
> patient with a stroke is the first type of error, and providing it to a
> patient with a stroke mimic, such as a complicated migraine, is the second
> type of error.  Overdiagnosis is the second type of error.  Giving the
> wrong treatment combines (1) failing to treat with (2) treating
> unnecessarily.
>
> One correspondent correctly pointed out that these are actually treatment
> errors.  I am focused on incorrect decisions, not incorrect naming of a
> patient's illness.  With my narrower view, failing to apply the correct
> name to a benign, self-limited condition is not an error so long as you
> don't provide unnecessary and harmful treatment.  Also, failing to
> distinguish between two illnesses with the same effective treatment is not
> an error unless you fail to provide that treatment.  I am not one of those
> physicians who tries to please patients by applying a Greek name to their
> benign problem (cephalgia for headache), but this isn't necessarily an
> error.  Failing to identify an aneurysmal subarachnoid hemorrhage is an
> error because prompt referral for coiling can save the patient's life.
>
> One other point: all of this refers to patients who have symptoms, i.e.,
> they feel sick.  Screening of patients with no known symptoms of disease is
> a different matter.  That is primarily though not exclusively what H.
> Gilbert Welch was referring to in "Overdiagnosed: Making People Sick in the
> Pursuit of Health".
>
> Respectfully,
>
> Michael
>
> Michael A. Kohn, MD, MPP
>
>
>
> Chairman, Emergency Department
>
> Mills-Peninsula Medical Center
>
>
>
> Associate Professor
>
> UCSF Epidemiology and Biostatistics
>
> (Email created using voice recognition.  Please excuse transcription
> errors.)
> ------------------------------
>
> *From:* Joe Graedon [jgraedon at GMAIL.COM <jgraedon at gmail.com>]
> *Sent:* Sunday, February 05, 2017 5:32 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Definition of Diagnosis Error
>
> Bob,
>
>
>
> I think the IOM definition is comprehensive and helpful.
>
>
>
> Joe
>
> Sent from my iPad
>
>
> On Jan 18, 2017, at 8:54 AM, Bob Latino <blatino at RELIABILITY.COM> wrote:
>
> Is over-diagnosis considered a diagnostic error?
>
>
>
> *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.>
>
>
>
> *From:* Bob Latino [mailto:blatino at RELIABILITY.COM
> <blatino at RELIABILITY.COM>]
> *Sent:* Wednesday, January 18, 2017 6:23 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [IMPROVEDX] Definition of Diagnosis Error
>
>
>
> 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
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>
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
> ------------------------------
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
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>
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>
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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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>
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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 to Improve Diagnosis in Medicine


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