Transfers/referrals

Yehia Y. Mishriki ymishriki at RCN.COM
Sat Jan 6 23:17:14 UTC 2018


I suspect that Lawrence Weed is rolling over in his grave. For thirty 
years he advocated that a comprehensive documentation of all patient 
historical and clinical data be systematically obtained prior to any 
physician becoming involved in any decision making. He believed that 
physicians had neither the breadth of knowledge nor the time to 
rationally construct a comprehensive, accurate differential diagnosis on 
any  patient. He did not believe in the "art of medicine" or of "medical 
intuition". He was not keen on guidelines or evidence based medicine 
which approached diagnosis and care based on data derived from a 
conglomeration of patients in medical studies and ignored the individual 
patient who could very easily be an outlier. I suspect that, were he 
able to, he would mandate that decision support systems be employed de 
facto and initially in every patient encounter.

After thirty five years of academic practice, I am inclined to agree 
with Dr. Weed's recommendations although my feelings are a bit hurt.

Yehia Y. Mishriki, MD, FACP

Professor of Medicine

Morsani School of Medicine

University of South Florida


On 1/5/2018 10:36 PM, Edward Hoffer wrote:
> Diagnostic decision support systems (DXplain, ISABEL and VisualDx are 
> the big three widely available) have been clearly proven to improve 
> the differential diagnosis when used. The problem is that physicians 
> as a whole do not recognize when they need help!
> I feel very strongly that the way forward is to use natural language 
> processing to pull key findings from the electronic records and feed 
> these into a decision support system. When an important diagnosis is 
> supported but has not been mentioned by the clinician, a reminder 
> should be sent.
> Would be glad to discuss this further off-line
> Ed
> Edward P Hoffer MD, FACP, FACC
> Associate Professor of Medicine, part-time, Harvard
>
> On Fri, Jan 5, 2018 at 9:11 PM, Amy Bergau <amy at xenergyhealth.com 
> <mailto:amy at xenergyhealth.com>> wrote:
>
>     This is a broad question, but opening up to the group; Evidence
>     has shown that the current EMR functionality is not helping
>     diagnosis.  What technology solutions could be developed to help
>     solve these issues? Is it an algorithm that accesses data from the
>     EMR? What are the best areas to target?
>
>     Amy M. Bergau
>     Founder, CEO
>     amy at xenergyhealth.com <mailto:amy at xenergyhealth.com>
>     312-965-9573 <tel:%28312%29%20965-9573>
>
>     On Fri, Jan 5, 2018 at 5:52 PM, robert bell
>     <0000000296e45ec4-dmarc-request at list.improvediagnosis.org
>     <mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>>
>     wrote:
>
>         Dear Tom,
>
>         Strong words. But much of what you say resonates.
>
>         What is the way forward?
>
>         What can we do as Physicians/HCPs to create change?
>
>         Can we borrow ideas from other countries?
>
>         How dependent are accurate diagnoses to a background of
>         dysfunction that seems to or may exist in many hospitals?
>
>         Do we leave it to patients? But how do they get the
>         information to understand that there is, or maybe, a problem.
>
>         Rob Bell, M.D.
>
>
>
>
>>         On Jan 5, 2018, at 8:35 AM, Tom Benzoni <benzonit at GMAIL.COM
>>         <mailto:benzonit at GMAIL.COM>> wrote:
>>
>>         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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