Transfers/referrals

Powell, Melanie A Melanie.A.Powell at MEDSTAR.NET
Sat Jan 6 02:33:15 UTC 2018


I second many of the thoughts below.

The problem with diagnostic error during handoffs is well documented and only serves to highlight the importance of continuing education around diagnostic error, standardized handoffs, universal EHR, engaging patients in reviewing problems lists, increasing patient access to their own electronic records, developing diagnostic teams inclusive of radiologists, pathologists, PCPs, ER docs, hospitalists, surgeons, etc. (all of whom have access to and feel empowered to edit the problem list in real time), and moving from a problem list as a reimbursement tool to a key part of the cognitive process around reducing diagnostic error.

Studies have also shown that only 25 percent of patients seen for follow up after hospitalization have a discharge summary, which prevents accurate problem list maintenance.

Medical decision making during and after the handoff process is being addressed by many organizations, including the Patient Safety Movement Foundation (https://patientsafetymovement.org/actionable-solutions/challenge-solutions/hand-off-communications/), the I-PASS study group (http://ipassstudygroup.com/home) - which has developed a patient and family centered tool to help with medical decision making during and after times of transition - and of course SIDM. ACGME involvement going forward will be crucial as well.

Melanie Powell, MD/MPH
Fellow, MedStar Institute for Quality and Safety
(c) 410-688-5216
Website: http://www.medstariqs.org/

________________________________
From: Tom Benzoni [benzonit at GMAIL.COM]
Sent: Friday, January 05, 2018 10:35 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Transfers/referrals

Front line thoughts, interdigitated:

On Thu, Jan 4, 2018 at 10:24 PM, robert bell <0000000296e45ec4-dmarc-request at list.improvediagnosis.org<mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
Is there a problem in medicine regarding diagnoses and other errors in medicine when a patient gets transferred from one Physician/HCP to another, in or out of hospital?

Some difficulties:

 *   One or more specialists are outside the computer system of the other.

We have 2 major systems in town using 2 different systems. We communicate by fax...which are hundreds of printed pages of indistinguishable babble. Their so much data I can't find information.

 *   When the physician/HCP does not usually comment on diagnoses and treatment of another, or even review what is happening to the patient on a daily basis. This even when they have access to the computer story.

While some think we have diagnoses in the computer system, what is actually presented is the terms used for billing; the terms used for diagnoses are markedly different. There no fora (like we once had in the doctors' lounge) for the disparate limited-filed physicians to meet/discuss.

 *   There is a culture of non-interference.

Each stick solely to their field, for sure. And with the demise of the primary care physician, we now have 5 blind men and an elephant.

 *   When there is an important error in the computer system that is immensely difficult to remove. E.g. “The patient has disseminated carcinoma,” when it is not true. The error repeats time an time again with differing results.

I have a button where I can cut and paste forward all past errors. However, I don't need to; this is done automatically for me, which increases reimbursement to the hospital.

 *   When there are many specialists involved in a patient’s care who are not talking to each other, directly, by phone or computer and watching the diagnoses and treatments unfold.
 *   Etc. etc.

One would ask what needs to be done? Are there barriers that need to be broken and new procedures adopted?

The solution is really simple; stop paying for it! The behaviors I see every day (or, tonight) are as lucrative as they are dysfunctional.
If the end-users had a vote and that vote was directly tied to $ to vendors, this behavior would cease within 24 hours.
There is a reason retailers have return policies; it's good for business and the vendors get feedback on the quality (or lack thereof) from the end-users. We do not have that in healthcare. And the pressure to change will diminish as newly minted physicians believe this dysfunction is normal.

Do we leave as is because it is complex?

No; can't. Interface engines can be written to unravel the Tower of Babel. Chat rooms can be opened. We have the technology; we lack the will. The pressure for change must come from the patient-side.

tom

Rob Bell, M.D.

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