[No SPF Record] Re: [IMPROVEDX] Transfers/referrals

Shojania, Dr. Kaveh Kaveh.Shojania at SUNNYBROOK.CA
Wed Jan 10 13:50:37 UTC 2018


Sorry to potentially post a distracting tangent, but regarding the mantra "you can't manage what you can't measure,"  I can’t help mentioning a fascinating JAMA blog post from two years ago pointing out that Demming apparently never said “If you can’t measure it, you can’t manage it” https://newsatjama.jama.com/2016/01/13/jama-forum-if-you-cant-measure-performance-can-you-improve-it/

As the writer goes on to state, It’s not just a case of misattributed quote or slight nuance:  Deming actually wrote more or less the opposite, namely that  “It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth”.

Again, I know this is not the main point here, but I feel this is an underappreciated point throughout the quality improvement field/community, so just wanted to share this little piece of history

-kgs
Kaveh G. Shojania, MD
Professor and Vice Chair, Quality & Innovation
Department of Medicine
Director, University of Toronto
Centre for Quality Improvement and Patient Safety (www.cquips.ca<http://www.cquips.ca/>)

Sunnybrook Health Sciences Centre
Room H468, 2075 Bayview Avenue
Toronto, Ontario M4N 3M5

Editor-in-chief, BMJ Quality & Safety

From: Amy Bergau [mailto:amy at XENERGYHEALTH.COM]
Sent: Tuesday, January 09, 2018 9:16 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

I am a huge fan of the mantra "you can't manage what you can't measure."

There are adoption models with varying amount of success that track progress along a continuum in healthcare.  The HIMSS EMR Adoption Model is one that has been widely accepted although that scoring model and methodology couldn't be applied here since the first five stages are an algorithm run on IT installation data .  However, there are other models that have been constructed to measure success in other areas, such as Continuity of Care, Data Analytics, etc. that factor in the more human component of care.

It's a tall order, but would there be value in the creation of a Diagnostic Excellence Model- essentially an assessment/survey that encompasses everything from the most basic elements of diagnostics to the more complex?

It's design and development would involve whiteboarding every aspect of diagnostic error (cognitive, systemic, process, etc.) and then assess based on the model. This assessment could be a score, but my vision is less punitive, and more along the lines of a green/yellow/red for each diagnostic category.  For example, an IDS may do a great job with closing the loop with lab communications via MyChart as it contains discreet data that the patient can "easily" understand, but when it comes to a 5 page radiology report, this is more complex, even the physicians dont have time to read through it.

Examples above are very basic, but with the advent of AI and Machine Learning, can we run something on top of the EMR?

A

Amy M. Bergau
Founder, CEO
amy at xenergyhealth.com<mailto:amy at xenergyhealth.com>
312-965-9573

On Tue, Jan 9, 2018 at 7:09 PM, Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>> wrote:
We’ll have to agree to disagree on the lumping/splitting of this topic.

Some PSOs do provide reports on diagnostic error—this tends to be in system-specific PSOs (that is, those PSOs that are run by a hospital system and that serves only the facilities within that system). This is because those organizations tend to have a common EHR platform that the PSO has access to, and those PSOs then can do surveillance: “runs” through the EHR to pick up certain types of missed/incorrect diagnoses. Unfortunately, the lessons learned then tends to remain within the individual system.

PSOs that receive information through voluntary spontaneous reports typically have not yet developed specific taxonomies suitable to the area. Someone needs to do this. And I’d distinguish between a taxonomy of medical error and a practical taxonomy for information gathering through voluntary reports, as the latter requires a parsimonious approach to avoid overwhelming the reporter and inhibiting reporting. For spontaneous reporting, a taxonomy is only as good as the reporters’ use of it—if they don’t understand it, answer the questions incorrectly, or don’t answer the questions at all, the taxonomy is worthless for analysis.

Laboratory medicine and radiology are areas where I believe PSOs are doing significant specialized work on errors. They tend to have specialized taxonomies for their respective specialties—taxonomies that would not work for other providers. For example, Itri, J. N., & Krishnaraj, A. (2012). Do we need a National incident reporting system for medical imaging? Journal of the American College of Radiology, 9(5), 329–335. http://doi.org/10.1016/j.jacr.2011.11.015.

From: Powell, Melanie A [mailto:Melanie.A.Powell at medstar.net<mailto:Melanie.A.Powell at medstar.net>]
Sent: Tuesday, January 09, 2018 4:35 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>>
Subject: RE: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

Rory,

Love your post and agree with all of it. I would push back slightly on your previous post regarding the significance of lumping together all diagnostic error in medicine. I do think there's something to be achieved, as Amy Bergau mentioned, in understanding the "why" behind diagnostic error. Perhaps the cognitive processes are different in evaluating 5 days of nasal congestion vs. acute onset chest pain, but I think probably not. As you and Bob stated, looking back at historical data and case studies on proven wrong diagnoses can be enormously helpful and something that health systems, hospitals, clinics, and individual physicians should commit to doing on a regular basis.

Do any PSOs provide reports on diagnostic error as part of their updates/feedback to participating entities?

Melanie Powell, MD/MPH
Fellow, MedStar Institute for Quality and Safety
(c) 410-688-5216<tel:(410)%20688-5216>
Website: http://www.medstariqs.org/<https://urldefense.proofpoint.com/v2/url?u=http-3A__www.medstariqs.org_&d=DwMF-g&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=ZBuRFRAtJFGw864KrlIC64yBrCsgvKU5XuIMi2GvWAk&s=JQDvMpMXWLuNUoQl7v3i38NI3FTu5J7p5VDIZUoXmVM&e=>

________________________________
From: Rory Jaffe [rjaffe at CHPSO.ORG<mailto:rjaffe at CHPSO.ORG>]
Sent: Tuesday, January 09, 2018 6:41 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals
First a note—I spent the last year working part time for AHRQ to evaluate the patient safety organization program and also assess what AHRQ should do to better understand and collect information on diagnostic error—this position was stimulated by some of the recommendations from the NAM report on diagnostic error. However, these are my opinions only and do not represent the opinion of AHRQ or HHS.

Like with many other areas of interest in patient safety, no one information collection technique will cover the whole range of issues. Further, it is very difficult (nearly impossible) to get “denominators” with many of the collection techniques, particularly with what are termed “spontaneous reporting systems” (e.g., event reports). And our information collection needs will vary depending upon the type of error.

We really need are some population-level ideas of the importance of each major type of diagnostic issue, a “diagnosis” as to the factors involved in the issue, and workable plans to mitigate the issue.

Some ideas on collecting more information about the current state of diagnosis/misdiagnosis:
1. We need spontaneous reporting from physicians and other diagnosticians because this is the only way we can peek into their brains—this will require some amount of education (how can a person meaningfully report on something he or she doesn’t understand?), and some very simple data collection formats since there will be little appetite to fill out complex forms. In ambulatory care, there isn’t an established tradition of reporting errors and issues, unlike in hospitals. Even worse, physicians have a poor record of reporting issues even in hospitals. This probably should be focused on specific physician groups that are interested in participating—there’s going to have to be buy-in, a commitment to think about these issues, and a willingness to file a report whenever the physician is “surprised” by a diagnosis or recognizes an unnecessary delay in diagnosis. There are also significant legal barriers to this type of reporting as in most states medical groups do not have access to the legal protections that hospitals do when it comes to recording and analyzing reports of issues.
2. We need spontaneous reporting by patients—there’s some evidence that they may be the only source of a large portion of the misdiagnosis and delayed diagnosis issues. For example, if a patient bounces between two providers, the only one with knowledge as to the conflict between the two providers may be the patient him/herself.
3. We need more work on the simpler to detect stuff (e.g., lab/radiology misreads). By the way, there are initiatives already under way in some areas of radiology and laboratory medicine to do just that.
4. We need some more sophisticated and imaginative data mining for those issues that are amenable to that technique. For example, there’s been some work on diagnostic process where an organization looks at correct diagnoses (e.g., dissecting aneurysm) and then checks as to whether the correct diagnostic process was followed. This will bring out some latent errors quite effectively, even though it is not looking at mis-diagnosis per se. Cancer cases are also good for data mining, as cancer is one of those things that usually eventually gets diagnosed if it is a major cause of morbidity (as opposed to, for example, cardiac disease, which could result in a death without a prior diagnosis)—this is even easier in those states with cancer registries.

We also need to revisit the definition of misdiagnosis—I’m sorry, I don’t like the NAM one too much. For example, it doesn’t address overdiagnosis at all (correct diagnosis, but meaningless or even harmful for the patient who receives it). And it focuses too much on the diagnosis rather than the treatment. Is settling on a specific diagnosis when faced with a problem as important as identifying the correct way forward (in terms of further evaluation and treatment plans)? We deal with lots of uncertainty, and it is how we navigate this, rather than whether we end up with nice labels for the patient, that seems the most important to me. And in terms of patient-centeredness, it is what the patient goes through (medical treatments, procedures, tests, etc.) that’s most important, not what labels the patient gets.


From: Amy Bergau [mailto:amy at xenergyhealth.com]
Sent: Monday, January 08, 2018 7:57 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org<mailto:IMPROVEDX at list.improvediagnosis.org>>; Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

What technology solution could be developed to document the cognitive process? What we are learning is that the "why" and how clinicians arrive at a diagnosis is an important and very integral component of diagnosis and the learning medicine continuum.

Amy M. Bergau
Founder, CEO
amy at xenergyhealth.com<mailto:amy at xenergyhealth.com>
312-965-9573<tel:(312)%20965-9573>

On Mon, Jan 8, 2018 at 6:03 PM, Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>> wrote:
And even then, methods of getting counts of diagnostic errors are very insensitive, unless your definition is very limited.

You can get pieces of the answer with some reasonable accuracy—e.g., pathology mis-reads, diagnostic errors resulting in malpractice suits. But getting the big picture? No, don’t think we have any idea. For example, see Graber, M. L. (2013). The incidence of diagnostic error in medicine. BMJ Quality & Safety, 22 Suppl 2(Suppl 2), ii21-ii27. http://doi.org/10.1136/bmjqs-2012-001615<https://urldefense.proofpoint.com/v2/url?u=http-3A__doi.org_10.1136_bmjqs-2D2012-2D001615&d=DwMGaQ&c=RvBXVp2Kc-itN3g6r3sN0QK_zL4whPpndVxj8-bJ04M&r=C42EOoK0usvan6uLAPOvpUNb_Jn8YFsH_X3utGQE6zc&m=sQZLbYf6nX8H4nNsGL_7Of7-lFIHdI2Es65RPoT5LII&s=iIa5NiqJeIPnaQFh9GuNYz3jFiqCglNZscwsvdBLEkU&e=>.

Clinicians in general do a poor job of documenting their cognitive work, so unless we actively solicit this information from physicians and their patients we’re not going to get anywhere close to an answer.

And then there’s the issue of what diagnostic errors do we care about counting? Misdiagnosing a viral URI as a bacterial infection is more a population health issue than an individual patient safety issue, but each time that happens we’re dealing with a diagnostic error. The implications of this type of error and the types of interventions needed are much different from, say, missed diagnoses of dissecting aneurysms in the ED.

With such a heterogeneous problem as diagnostic error, I’m not sure that counting and lumping all errors together to say, for example, “1/3 of all errors are diagnostic” is of any use.

From: Harry Burke [mailto:harry.burke at gmail.com<mailto:harry.burke at gmail.com>]
Sent: Monday, January 08, 2018 3:02 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>; Rory Jaffe <rjaffe at chpso.org<mailto:rjaffe at chpso.org>>
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

The incidence depends on how you define diagnostic errors and how you detect diagnostic errors.
Sent from my iPhone

On Jan 8, 2018, at 5:43 PM, Rory Jaffe <rjaffe at CHPSO.ORG<mailto:rjaffe at CHPSO.ORG>> wrote:
There are no reliable estimates of the incidence of diagnostic errors.

Rory

From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Sunday, January 07, 2018 10:58 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [No SPF Record] Re: [IMPROVEDX] Transfers/referrals

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.


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