The DDx and the (possible) contribution of the EHR to its demise

David L Meyers dm0015 at COMCAST.NET
Mon Feb 11 19:12:59 UTC 2019


The annual meeting of the Health Information Management Services Society (HIMSS) is taking place this week <https://www.himssconference.org <https://www.himssconference.org/>>. I suspect some listserv subscribers might be attending the meeting, and, if so, could raise this matter at an appropriate forum and report back to us.


David
David L Meyers, MD FACEP
Society to Improve Diagnosis in Medicine
Listserv Moderator/Board member
www.improvediagnosis.org
Save the Dates: Diagnostic Error in Medicine Conference (DEM2019), November 10-13, 2019 at Hyatt Regency Washington, DC (Capitol Hill)
AusDEM2019, April 28-30, 2019; Melbourne, Aus







> On Feb 11, 2019, at 1:29 PM, Edward Hoffer <ehoffer at GMAIL.COM> wrote:
> 
> Jason's suggestion is an excellent one.  If a differential (or "rule-out") were REQUIRED, then a) we would have the beginnings of measurable/quantifiable items to use for evaluation and b)the person creating the differential just might have that "Aha" moment and consider an alternative from the list.
> Ed
> Edward P Hoffer MD
> MGH Lab of Computer Science, co-creator DXplain
> 
> On Mon, Feb 11, 2019 at 1:15 PM Jason Maude <jason.maude at isabelhealthcare.com <mailto:jason.maude at isabelhealthcare.com>> wrote:
> This circles us back to the differential diagnosis which is a great trigger to make us stop and think and then, perhaps, realise that we may be wrong. However, it would have to be required for every patient and recorded in the notes to be able to play the role of a trigger. If that happened then it could easily become  a measure!
> 
>  
> 
> Regards
> 
> Jason
> 
>  
> 
> Jason Maude
> 
> Founder and CEO Isabel Healthcare
> Tel: +44 1428 644886
> Tel: +1 703 879 1890
> www.isabelhealthcare.com <http://www.isabelhealthcare.com/>
>  
> 
>  
> 
>  
> 
> From: Gerrit Jager <gerrit.jager at PLANET.NL <mailto:gerrit.jager at PLANET.NL>>
> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Gerrit Jager <gerrit.jager at PLANET.NL <mailto:gerrit.jager at PLANET.NL>>
> Date: Saturday, 9 February 2019 at 17:16
> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
> Subject: Re: [IMPROVEDX] Kahneman interview - putting a premium on error detection
> 
>  
> 
> I fully agree with Mike, but I like to add another category; the no-fault errors. The sensitivity of a diagnostic test is almost never 100%, e.g. a chest X-ray has too little spatial resolution to detect small nodules and in most patients missing them is an unavoidable misdiagnosis related to the limitations of the test. But abandon chest X-ray and perform CT in every patient is not the alternative. 
> (It is a different story when the selection of an imaging test is inappropriate.)
> 
> So the message is that we should always be aware and prepared that we may be wrong and be willing to reconsider a diagnosis.  
> 
> This is not easy as excellently described by Kathryn Schultz in her book “Being Wrong, adventures in the margin of error”.  She explains why we are so bad at imaging that we are mistaken. 
> 
> Gerrit Jager
> 
> Op 07-02-19 15:59, Bruno, Michael <mbruno at PENNSTATEHEALTH.PSU.EDU <http://mbruno@pennstatehealth.psu.edu/>> schreef:
> 
> Thanks, Nelson,
>  
> Yes, I agree—process changes, but also cognitive changes and an accommodation to our basic human biology.  I like to think of errors as falling into three categories: (1) those which are due to faults in our work processes, (2) t hose which are due to faults in our thinking, and (3) those which occur simply because of how we are made.  Each of these will be amenable to different solutions—but only error detection after the fact addresses all three.
>  
> While there are a few diagnoses which, if missed, lead to immediate and irreparable harm, most do not.  If we learn to be inclined to expect, search for, and rapidly detect errors we will prevent harm MOST of the time.  In our experience in radiology, we do on regular occasion detect errors which have been present for several hours, such as when a finding is missed overnight but picked up on re-review in the morning.  In virtually all of these, patient harm was averted by correcting the diagnosis a few hours later.
>  
> All the best,
> 
> Mike
> 
>  
> 
> From: Nelson Toussaint [mailto:ntoussaint at tamarac.com <mailto:ntoussaint at tamarac.com>] 
> Sent: Thursday, February 07, 2019 8:36 AM
> To: 'Society to Improve Diagnosis in Medicine'; Bruno, Michael
> Subject: Kahneman interview - putting a premium on error detection
> 
> 
>  
> 
> February 7, 2019
> 8:16 AM
> 
> Michael
> 
> In Aerospace, it is anticipated that this behavior will occur.  Equipment will fail and people will make mistakes!  So, a concept of Accommodation is built into the process to counteract those faults that could lead to serious harm.  In some cases you can detect the errors and in some the consequences are in play before you can confirm a detection.  So where real harm can appear, the Accommodation needs to be somewhat active before/as the fault occurs.
>  
> An example is the Ground Proximity Warning System, which estimates if the airplane may soon fly into terrain (navigation fault of the pilot or equipment).  This is only a warning and the pilot must take an action to change course.
>  
> Early detection of diagnostic error is good; but it still may not be in time to limit the potential harm.  A more robust process would include methods where the "conclusions" are reviewed before a diagnosis is complete.  One that comes to mind is what many of us use quite often - "what does this seem like to you"; a discussoin amongst involved parties such as the attending physician - radiologist/pathologist – patient.  This Accommodation can serve to cause the “experts” to pause and reasses their findings.  It does not give a foolproof solution, but still allows the experts to continue to form the diagnosis.
>  
> This is just a thought, but it seems to me the process changes are the best way to attack this problem in order to get broad participation.  The trick will be how to modify the process without penalizing the many straight-forward cases.
>  
>  Nelson Toussaint
> 
> TAMARAC LLC
> 860-844-0199
> ntoussaint at tamarac.com <http://ntoussaint@tamarac.com/> <mailto:ntoussaint at tamarac.com <mailto:ntoussaint at tamarac.com>> 
> 
> 
> From: Bruno, Michael [mailto:mbruno at PENNSTATEHEALTH.PSU.EDU <mailto:mbruno at PENNSTATEHEALTH.PSU.EDU>] 
> Sent: Tuesday, February 05, 2019 12:41 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <http://IMPROVEDX@list.improvediagnosis.org/>
> Subject: Re: [IMPROVEDX] Kahneman interview - putting a premium on error detection
> 
> Yes, thanks, Art!  
>  
> It seems to me that while some errors are preventable, others may well be inevitable. The perceptual errors we were talking about at that session at DEM are probably biologically rooted (i.e., secondary to neurocognitive brain network functions) and are thus essentially outside of our conscious control. They are an example of an entire class of errors that flow from “how we are made,” our biology and our evolution, and so they will not respond to the usual interventions, such as cognitive de-biasing,  adult learning/CME, or even mindfulness. 
>  
> So it seems to me that, for these types of errors at least, there needs to be a premium placed on early error detection, so that errors can be more promptly detected and corrected before any patient harm is done.  That is the value of double-reading in radiology, and it may be an avenue where AI turns out to be particularly helpful in the years ahead.
>  
> All the best,
> 
> <image001.png>
> Michael A. Bruno, M.D., M.S., F.A.C.R.  
> Professor of Radiology & Medicine
> Vice Chair for Quality & Patient Safety
> Chief, Division of Emergency Radiology
> Penn State Milton S. Hershey Medical Center
> ( (717) 531-8703  |  6 (717) 531-5737
> * mbruno at pennstatehealth.psu.edu <http://mbruno@pennstatehealth.psu.edu/> <mailto:mbruno at pennstatehealth.psu.edu <mailto:mbruno at pennstatehealth.psu.edu>>  |  
> <image002.png>
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> From: Art Papier [mailto:apapier at VISUALDX.COM <mailto:apapier at VISUALDX.COM>] 
> Sent: Sunday, February 03, 2019 2:34 PM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <http://IMPROVEDX@list.improvediagnosis.org/>
> Subject: Re: [IMPROVEDX] Kahneman interview
> 
> Thanks for sharing!   Great interview with many fascinating threads, and some new thoughts on the randomness of error, and how all error is not due to cognitive bias.  Towards the conclusion we hear that Dr. Kahneman in not a believer in cognitive debiasing…. saying essentially we are too busy making errors to recognize that we are making errors.  He asserts we should be thinking about how we recognize other peoples errors.  In made me think of the session at DEM on perceptual errors in diagnostic imaging and the very positive role of second reads in radiology….whether by humans or AI to recognize errors.  Perhaps either co-decision making, or AI “second opinions” is an area we should all be further exploring.  
> Best
> Art
>  
> Art Papier MD
> CEO VisualDx
> Associate Professor of Dermatology and Medical Informatics
> University of Rochester College of Medicine
>  
> 
> 
>  
> From: Xavier Prida <dr.xavier.prida at GMAIL.COM <http://dr.xavier.prida@gmail.com/>> 
> Sent: Sunday, February 03, 2019 8:59 AM
> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <http://IMPROVEDX@list.improvediagnosis.org/>
> Subject: [IMPROVEDX] Kahneman interview
> 
> 
> On "thinking again"- not changing your mind, error, and bias - the latter two are not always linked.
> 
> 
> 
> https://onbeing.org/programs/daniel-kahneman-why-we-contradict-ourselves-and-confound-each-other-jan2019/ <https://onbeing.org/programs/daniel-kahneman-why-we-contradict-ourselves-and-confound-each-other-jan2019/><https://urldefense.proofpoint.com/v2/url?u=https-3A__onbeing.org_programs_daniel-2Dkahneman-2Dwhy-2Dwe-2Dcontradict-2Dourselves-2Dand-2Dconfound-2Deach-2Dother-2Djan2019_&d=DwMGaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=UrbAzwfML-iEIuCykgw2Fqn20pE6WrN96IDUMbiOHMs&s=3X_IjCf1rsQokLp5q2wzaZqF1pXrJky5MKUV2tVppnQ&e= <https://urldefense.proofpoint.com/v2/url?u=https-3A__onbeing.org_programs_daniel-2Dkahneman-2Dwhy-2Dwe-2Dcontradict-2Dourselves-2Dand-2Dconfound-2Deach-2Dother-2Djan2019_&d=DwMGaQ&c=_FmMnDvUH5queZcSmOuBzHZMbp7E7EwtGwv5cxxnTj0&r=XZJky8Jx0OuETXcWpBMhx9j_wSYpSZPDVXdInJ5O9gQ&m=UrbAzwfML-iEIuCykgw2Fqn20pE6WrN96IDUMbiOHMs&s=3X_IjCf1rsQokLp5q2wzaZqF1pXrJky5MKUV2tVppnQ&e=>> 
> 
> 
> 
> XEP
> 
> 
> 
> praesent superare odio (rise above)
> 
> 
> 
> Xavier E. Prida MD FACC FSCAI
> 
> Assistant Professor of Medicine
> 
> Program Director Cardiology Fellowship Training 
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> USF Morsani College of Medicine
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> Department of Cardiovascular Sciences
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> 
> 
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine
> 
> To learn more about SIDM visit:
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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