Fwd: Coverys report on diagnostic errors

Tom Benzoni benzonit at GMAIL.COM
Thu Mar 22 19:24:26 UTC 2018


A thought which may not be as off beat as it seems at first glance:
What if the bedside clinician adopted the radiology/pathology model and did
not make a diagnosis but created a differential.
This could follow the patient until it is whittled down to a final one.

There are structural problems with this concept which are driven by the
payment model; insurers often require a diagnosis to approve payment. This
later factor may be one of the external drivers of errors.

Tom

On Thursday, March 22, 2018, Jackson, Brian <brian.jackson at aruplab.com>
wrote:

> I think the main opportunity here is in the word “Team”.  Healthcare
> desperately needs better diagnostic teamwork.  I don’t mean to imply that
> it’s always bad everywhere.  But radiology and pathology have become
> structurally less integrated into care team decisionmaking over the years.
> Bob Wachter has a great chapter on the radiology problem in his book The
> Digital Doctor, and suggests that healthcare information systems are at
> least part of the problem.  Mike Laposata is a pathologist (actually
> department chair) down at UT Galveston, and has done a lot of work
> developing pathology-centered diagnostic management teams.  Essentially
> he’s had to create his own workflow and communication mechanisms that go
> around certain aspects of the EHR.
>
>
>
> Having said all that, you might be on to something.  Categorizing into 5
> grades of risk might be more feasible than trying to cram everything into 2
> (normal versus abnormal).  And maybe this would help the clinician to
> prioritize his/her review time.  The gatekeeper will need to be the
> treating clinician; pathologists and radiologists don’t have enough context
> and are too far from the patient to make those decisions.
>
>
>
> --Brian
>
> *From:* Nelson Toussaint [mailto:ntoussaint at tamarac.com]
> *Sent:* Thursday, March 22, 2018 7:32 AM
> *To:* 'Society to Improve Diagnosis in Medicine'; Jackson, Brian
> *Subject:* [Marketing] RE: [IMPROVEDX] [Marketing] Re: [IMPROVEDX] Fwd:
> Coverys report on diagnostic errors
>
>
>
>
>
>
>
> March 22, 2018
>
> 8:50 AM
>
> *Brian*
>
>
>
> I am a retired Aerospace Executive that has done a lot of work in the Safe
> Flight arena.  When an analyst does a review of potential failures of a
> system, they are required to categorize them into 5 areas related to flight
> safety (according to his/her knowledge and experience):
>
>
>
> A  Catastrophic
>
> B  Hazardous
>
> C  Major
>
> D  Minor
>
> E  No Effect on flight safety
>
>
>
> It is then the responsibility of the design/operations *Team* to review
> the critical cases and respolve issues.  Sometimes this results in
> reclassification because the analyst did not have full understanding of the
> system and secondary functions; sometimes it requires accommodating the
> fault; sometimes it requires redesign to eliminate the failure.
>
>
>
> The data is often very volumous, so it becomes important to focus on the
> critical (to flight safety) issues.
>
>
>
> Most importantly, there is a high level gate keeper that determines which
> of the A, B, C faults are permitted (after Team resolution).  The
> gatekeeper must put his/her signature on the conclusion report, which
> explains why those remaining are tolerable - taken very seriously because
> if any of these cause a Catastrophic situation, it comes right back to the
> gatekeeper.  (Obviously, nothing in category A is allowed to remain).
>
>
>
> Although this strategy does not prevent every incident, it cleans up
> hundreds of them.
>
>
>
> Could a strategy of this nature be applied to supporting functions?  As
> you mentioned, the analyst could structure the feedback in categories and
> then it becomes the responsibility of the clinician Team to determine
> criticallity to a particular patient.
>
>
>
> I do not know where the gatekeeper is in the medical field?
>
>
>
>    Nelson Toussaint
>
>
>
> TAMARAC LLC
>
> 860-844-0199
>
> ntoussaint at tamarac.com
>
>
>
> *From:* Jackson, Brian [mailto:brian.jackson at ARUPLAB.COM
> <brian.jackson at ARUPLAB.COM>]
> *Sent:* Wednesday, March 21, 2018 3:02 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] [Marketing] Re: [IMPROVEDX] Fwd: Coverys
> report on diagnostic errors
>
>
>
> That request comes up all the time, but I personally don’t think it can
> work.  It’s just really hard to figure out what sorts of cases could be
> safely labelled as “no followup needed”.  A risk management mindset would
> likely lead to almost every case being labelled as “followup needed”,
> including ones with really minor findings.
>
>
>
> I agree that communication of diagnostic findings is a huge problem and
> opportunity.  I just don’t think that you can solve it by asking pathology
> and radiology (who notably don’t have all the info on the patients) to
> identify reports that can be safely be left unread.  It’s sort of the same
> problem as when clinicians only look at chemistry and hematology results
> that have high/low/critical flags.  This binary approach causes you to
> occasionally miss important findings, and it will never work reliably.
>
>
>
> Better, in my opinion, would be to work on the efficiency of the result
> review process.  It needs to be much faster and easier for a clinician to
> review ALL diagnostic results and decide which ones need to be read in
> greater detail.  The role of radiology and pathology is then to structure
> their results for maximum readability, with clear conclusions at the top,
> etc.  The role of IT/software is to make it much faster to scan results in
> bulk without lots of clicks, seeing what’s important, and then be able to
> easily zoom in on areas of interest.
>
>
>
> --Brian Jackson
>
>
>
> *From:* Tom Benzoni [mailto:benzonit at GMAIL.COM <benzonit at GMAIL.COM>]
> *Sent:* Wednesday, March 21, 2018 8:55 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [Marketing] Re: [IMPROVEDX] Fwd: Coverys report on diagnostic
> errors
>
>
>
> As technology has occasioned these errors (There was a time when Mark
> would pick up the phone and tell me my patient had an abnormality on CT.)
> so can it be programmed to help.
>
> *On any study mandating interpretation (Radiology and pathology come to
> mind, although there are many others) there is to be a mandatory field:
> "this study requires/does not require followup". This will activate a
> tickler cascade that is not stopped until action is taken.
>
> Coding this would be a minor undertaking.
>
> So why does it not exist?
>
> tom
>
>
>
> On Wed, Mar 21, 2018 at 9:29 AM, Mark Graber <
> Mark.Graber at improvediagnosis.org> wrote:
>
> And its not just America.  Here is a report on claims data (2000
> incidents) in Australia collected by Avant.  Diagnostic errors were the
> second leading cause for a claim in this compilation.  Cancer and
> cardiovascular conditions were the #1 and #2 problem areas, as in reports
> from the US.
>
>
>
> https://www.avant.org.au/diagnostic-error-claims/
> <https://clicktime.symantec.com/a/1/A5eH3PfTLnK2PKF1gyRwVPqtQToq_Cp99veTfjImm3Q=?d=bbEnrWSRZceP1deDrf6vYEoVEIa5mp1gro9RlgmkIvHgpCtnrpMmoqQnqLxGs6pBjCbxbXjSMCB25CUADY5UvvHsBlSwxuJ1B-qmOA_YnsYhLhl_WEkEhbkgwmyQMnrK5WJVf_2p8JTmA7f2DvtTQ33THcSFfdY8WM0a4Jjdma3lLSzTmtmwmQkct3RY4Cs8BFhyBjoMq98IbtZWIKwqlXpJBd7AMCv0qAxPlxQTMyaEoTbiJ7TaJ_EuJaZRkBsCu7h73VIAVaKdF-bB6hcHupnDdmJELr3KDlHPsO6_H7Jcy0mA6ccOc-doFfthgMifz2AMKnpYWRzqHyrZjfwATmxQ1aKOvQT6LiS0_d2WXdMxVbYHGa0y_UmnZIYHo2YWwvOocTN9tVs7QQf6HQz1QHS1uZXpDjK-U6EuVyNp76ONuRxx4ve3Df9Hg20tgzFOG38JL4h9RVdnBQ%3D%3D&u=https%3A%2F%2Fwww.avant.org.au%2Fdiagnostic-error-claims%2F>
>
>
>
>
>
> Mark L Graber MD FACP
>
> President, SIDM
>
> Senior Fellow, RTI International
>
> Professor Emeritus, Stony Brook University
>
>
>
>
>
>
>
>
>
> *From: *David L Meyers <dm0015 at COMCAST.NET>
> *Reply-To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>,
> David Meyers <dm0015 at comcast.net>
> *Date: *Tuesday, March 20, 2018 at 12:37 PM
> *To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject: *[IMPROVEDX] Fwd: Coverys report on diagnostic errors
>
>
>
> To the List, Coverys, the medical liability insurer has issued a report on
> diagnostic errors.  You can download the PDF here.
>
> https://coverys.com/PDFs/Coverys_Diagnostic_Accuracy_Report.aspx
> <https://clicktime.symantec.com/a/1/rRonm13cCh4U1ceRO5c6sa-7oSKsK9apz_lnaIx-Y6E=?d=bbEnrWSRZceP1deDrf6vYEoVEIa5mp1gro9RlgmkIvHgpCtnrpMmoqQnqLxGs6pBjCbxbXjSMCB25CUADY5UvvHsBlSwxuJ1B-qmOA_YnsYhLhl_WEkEhbkgwmyQMnrK5WJVf_2p8JTmA7f2DvtTQ33THcSFfdY8WM0a4Jjdma3lLSzTmtmwmQkct3RY4Cs8BFhyBjoMq98IbtZWIKwqlXpJBd7AMCv0qAxPlxQTMyaEoTbiJ7TaJ_EuJaZRkBsCu7h73VIAVaKdF-bB6hcHupnDdmJELr3KDlHPsO6_H7Jcy0mA6ccOc-doFfthgMifz2AMKnpYWRzqHyrZjfwATmxQ1aKOvQT6LiS0_d2WXdMxVbYHGa0y_UmnZIYHo2YWwvOocTN9tVs7QQf6HQz1QHS1uZXpDjK-U6EuVyNp76ONuRxx4ve3Df9Hg20tgzFOG38JL4h9RVdnBQ%3D%3D&u=https%3A%2F%2Fcoverys.com%2FPDFs%2FCoverys_Diagnostic_Accuracy_Report.aspx>
>
>
>
> Art Papier MD
>
> CEO VisualDx
>
> Associate Professor of Dermatology and Medical Informatics
>
> University of Rochester College of Medicine
>
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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