Transfers/referrals

robert bell rmsbell200 at YAHOO.COM
Sun Jan 7 18:57:51 UTC 2018


Dear all,

It is said that of the errors in medicine two thirds are standard errors while one third are diagnostic (does anyone know where those figures came from?).

It this is true then the next question would seem to be what is the impact of standard errors (from computers, hand offs, medication, laboratory and radiology errors, etc., etc.) on diagnostic errors. Is it a  small of large figure? Are there  any estimates?

Then the question arises should we as a community/organization be dealing in someway with all errors and not solely diagnostic. 

In fact, if the standard errors significantly effect diagnoses, will we be able to easily prove that any diagnostic approach is worthwhile?

Will historical analyses work? How would you compensate for standard error rates being different in different hospitals and HC facilities.

Do we need to know the level of effect of standard errors on diagnostic errors in different facilities? 

Robert Bell, M.D. 

 
> On Jan 6, 2018, at 4:17 PM, Yehia Y. Mishriki <ymishriki at RCN.COM> wrote:
> 
> 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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>> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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