Definition of Diagnosis Error

Kohn, Michael Michael.Kohn at UCSF.EDU
Mon Feb 13 22:46:51 UTC 2017


Dear Colleagues,

I hope this decision support system isn’t going to create a cumbersome hoop for front-line clinicians to jump through prior to ordering an imaging study.  Decision support systems may be helpful, but the benefit must be balanced against alert fatigue and time constraints.   As an emergency physician, I am sensitive to any hint that I need a radiologist’s permission to order a test that is clinically indicated.  I often call a radiologist to ask for advice on test ordering, but this is a consultation, not a request for permission.  Remember, a normal test result may change my management decision.  For example, a normal CTA of the head and neck allows me to discharge a TIA patient from the ED.   A radiologist looking at the diagnostic yield of CTA in TIA patients may not understand that.

Best,

Michael



From: Tom Benzoni [mailto:benzonit at GMAIL.COM]
Sent: Monday, February 13, 2017 08:36
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Definition of Diagnosis Error
Importance: Low

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

On Feb 6, 2017, at 7:52 AM, Bruno, Michael <mbruno at PENNSTATEHEALTH.PSU.EDU<mailto: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<tel:(717)%20531-8703>  |   6 (717) 531-5737<tel:(717)%20531-5737>
• mbruno at pennstatehealth.psu.edu<mailto:mbruno at hmc.psu.edu>
<image002.png>

From: Kohn, Michael [mailto:Michael.Kohn at UCSF.EDU]
Sent: Sunday, February 05, 2017 1:30 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto:jgraedon at gmail.com>]
Sent: Sunday, February 05, 2017 5:32 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<mailto:blatino at RELIABILITY.COM>> wrote:
Is over-diagnosis considered a diagnostic error?

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: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Wednesday, January 18, 2017 6:23 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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<tel:(800)%20457-0645>
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://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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