Tuesday, November 29, 2011

Misdiagnosis - Checklists, Policy and Safety

This is perhaps one of the things which both patient and physicians have an opinion about and surprisingly it does align! Where is the breakdown? Patient safety? Cognitive errors? Policy approaches?

We keep reading a lot about medication errors/mistakes due to the malpractice suits. Surprisingly, the number of diagnostic errors is pretty high as well. A lot of these are attributed to the history of the patient, physician exams, assessment, the battery of tests, etc. The payment system and reimbursements add another layer of challenges. As a freshly minted MBA, I am inclined to think whether Six Sigma or similar variations of the tools/strategies used in business processes can be applied to healthcare practice settings. After all, it is about process excellence!

Actually, Dr. Don Berwick put this quite nicely: 'Genius diagnosticians make great stories, but they don't make great health care. The idea is to make accuracy reliable, not heroic.'

Everyone has their personal stories about their last visit to a doctor and unfortunately a lot are not that positive. Why is it so? Complexity of care? Misdiagnosis? or just broken workflow processes at the hospital/clinic leading to the experience!

QuantiaMD did a study with 6400 clinicians on this topic and the results were fascinating. Diagnostic error is defined as a diagnosis that is missed, wrong, or delayed, as detected by some subsequent definitive test or finding. The top diagnoses identified at greatest risk for diagnostic errors were:
  1. Pulmonary embolism
  2. Bipolar disorder
  3. Appendicitis 
  4. Breast cancer 
  5. Myocardial infarction 
  6. Infection 
  7. Lung cancer 
  8. Prostate cancer 
  9. Colorectal cancer 
  10. Heart failure
Here are some other stats that I think are interesting from the study and speak for themselves.
  • 47% of clinicians encounter misdiagnosis at their practice at least monthly (Tweet)
  • 64% of physicians say up to 10% of misdiagnoses they’ve seen have resulted in patient harm (Tweet)
  • 83% of physicians believe efforts to change the way physicians think will help reduce misdiagnosis (Tweet)
  • 75% of physicians believe computerized decision-support and artificial intelligence will help reduce misdiagnosis (Tweet
Dr. Stewart Segal mentioned about the importance of the human factor and how the community is drifting towards the art of practicing template medicine. The financial 'pressures' and reporting requirements are pushing physicians even further in this direction. The top three reasons that are strong contributing factors to diagnostic errors:
  1. Societal "zero tolerance" attitude toward any mistake a physician makes it a strong contributing factor to diagnostic error 
  2. Over-testing in order to mitigate malpractice risk
  3. Prescriptive, inflexible or inadequate care pathways or protocols
    Delays in proper care, re-admissions, etc. affect the healthcare system (patients included) in a major way. Patient safety is at the center of this and it is encouraging to see HHS considering the topic seriously. Pay for Performance or linking the compensation/reimbursements to the work quality/patient outcomes has already shown improvements in efficiency as well. EHRs can help a lot to identify and prevent breakdowns in the diagnostic process of care and perhaps even create something like diagnostic decision aids to assist clinicians. Patient perspective - I have found that patient education handouts are very useful for understanding the diagnosis and even asking appropriate questions to the doctor.

    Neither am I an authority on this topic nor a practicing physician however as an patient I believe that an essential part for diagnosis boils down to listening and talking to the patients. I encourage everyone to listen to this passionate TED talk 'A Doctor's Touch' by Abraham Verghese.

    I really like the simple and effective checklist approach by Atul Gawande. This is one step in the right direction and their are many success stories on why it works in the healthcare setting. The integration of technology and/or protocol approach will help minimize the misdiagnosis, yet the balance needs to be maintained. I can't help but think of hospital acquired infections while writing about this but I think it deserves a separate discussion post.

    Some of the interesting literature I came across, if you want to further read on this topic:
    Dr. Gordon Schiff and colleagues have done a study looking at diagnostic errors and recommend ideas for an error-free diagnosis. There is an interesting paper on 'Sleep Deprivation, Elective Surgical Procedures, and Informed Consent' in NEJM. Also, a couple of years back the Journal of American Medical Association published the commentary by Dr. Pronovost & Dr. Newman-Toker on 'Diagnostic Errors — The Next Frontier for Patient Safety.'

    And if you really fancy the topic, pick up the book by Dr. Jerome Groopman on 'How Doctor's Think' where he mentions the process many doctors follow for the likely diagnosis and the best treatment. Medical decision making is a combination of intuition (continuous improvement with experience) and rationalization (analytical mode of reasoning).

    Where do we go from here? Is EMR/PHR the answer? Should patients utilize technology to communicate and engage with doctors?  How about metrics like customer satisfaction and high quality care? From a physician standpoint, the central question remains whether diagnosis is an art or a science? The balance of this process will continue to evolve and hopefully so will the probability for even getting it right in the wrong patient.

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