Copyright 2014 MMIC • All rights reserved Error and … · diagnostic process • MMIC’s summer...

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Copyright 2014 MMIC • All rights reserved

Diagnostic error and the

changing health care

environment

Laurie Drill-Mellum, M.D., MPH

Chief Medical Officer

V.P. of Patient Safety Solutions

MMIC

Don Bauman

CEO, Isabel Healthcare


Agenda

• National landscape on diagnostic error

• Challenges of diagnosis

• What can be done today to minimize diagnostic error

• Review of diagnosis decision support tool

• Questions


Diagnostic error is dominating national health

care discussions

• Major yet unaddressed problem,

adds significant overhead and

costs

• Institute of Medicine developing

recommendations to reduce

diagnostic error (report due 2015)

• The Robert Wood Johnson

Foundation and the Urban

Institute publish brief – Placing

Diagnosis Errors on the Policy

Agenda – providing insight and

practical solutions

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care discussions

• National Patient Safety Foundation produces series of

webinars on reducing diagnostic error

• JAMA paper argues that health care organizations must

pay attention to diagnostic error:

• Diagnostic errors are common and harmful

• High-quality health care requires high-quality diagnosis

• Diagnostic errors are costly

• HCOs are well positioned to lead the way in reducing diagnostic

error



care discussions

• PIAA’s first issue in 2014

focuses on helping clinicians

avoid misdiagnosis

• CRICO’s 2014 Annual

Benchmarking Report focuses

on malpractice risks in the

diagnostic process

• MMIC’s summer 2014 Brink

focuses on diagnostic error

and solutions


Diagnostic error in malpractice claims

most frequent allegation behind surgical treatment and medical treatment

in total cost

#3

#1

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Getting it wrong

A hospital can be rewarded through

“pay-for-performance initiatives for giving all of its patients

diagnosed with heart failure, pneumonia and heart attack

the correct, evidence-based and prompt care …

… even if every one of the diagnoses was wrong.”

(Robert Wachter, 2010)


Rory Staunton … undiagnosed sepsis

Rory Staunton Foundation, http://rorystaunton.com/about-rory-staunton


Why improvement is possible just now

Better data

Better neuroscience

Better tools and systems

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Better data


Digging deeper, seeing more

• MMIC partners with

CRICO Strategies (2013)

• Harvard-based

• Leading with medical data

• Patient safety mission,1998

to extend beyond Harvard

• Created national comparative

benchmarking database


CRICO Strategies

Comparative Benchmarking System (CBS)

>300,000 claims ~30% of National Practitioner Data Base

Membership

Copyrighted by and used with permission of The Risk Management Foundation of the Harvard Medical Institutions, Inc., all rights reserved.

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$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

$800,000,000

$900,000,000

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Su

rgic

al

Tx

Med

ical

Tx

Dia

gn

os

is

Med

icati

on

OB

Safe

ty &

Sec

uri

ty

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es

the

sia

Pt

Mo

nit

ori

ng

IND

EM

NIT

Y P

AY

ME

NT

S

NU

MB

ER

OF

CA

SE

S

number of cases total incurred

Top major allegations across CBS

• CBS N=22,292 PL cases closed 1/1/08–12/31/12

4,519 cases (20%) 4,519 cases (20%)

$774 million (27%) $774 million (27%)

© 2014 CRICO Strategies, all rights reserved.

> $1 billion w/ expenses


Most diagnosis-related cases originate in ambulatory setting Outpatient + emergency department

© 2014 CRICO Strategies, all rights reserved.

0%

10%

20%

30%

40%

50%

60%

70%

2008 2009 2010 2011 2012

Perc

en

t o

f C

ases

Assert Year

ED Inpatient Outpatient

CBS N=4,184 PL cases asserted 1/1/2008–12/31/2012

Outpatient

57%

ED

16%

Inpatient

26%


Diagnosis claims are expensive Outpatient + emergency department

% of claims % of total costs

Medical Tx

26%

Diagnosis

24%

Diagnosis

37%

Medical Tx

14%

Surgical Tx

20%

Surgical Tx

21%

MMIC N=952 PL cases asserted 1/1/2008–12/31/2012

Medication

11%

Medication

10%

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• Problem noted, care sought

• History and physical conducted

• Patient assessed, symptoms evaluated

• Differential diagnosis established

• Diagnostic test(s) ordered

Assessment Failures

• Tests performed

• Tests interpreted

• Test results transmitted/received

Testing Failures

• Physician follows up with patient

• Referrals/consults

• Patient info communicated to care team

• Patient/providers establish follow-up plan

Follow-up Failures

Where diagnostic errors occur

58%

29%

46% *Claims can have more than one contributing factor.


Findings in MMIC diagnosis error claims

Less than aggressive pursuit of short-term / urgent presentations

• Failure to respond to repeated complaints

• Failure to generate a broader differential diagnosis

• Failure to obtain tests

• Failure to consult or refer

• Misinterpretation of diagnostic studies

• Lax use of “protocols” / best practices

Better neuroscience

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Exploring our thinking patterns


Thinking fast and slow

System 1

Intuitive

Fast

Automatic

Effortless

Implicit

Emotional

System 2

Analytical

Slower

Conscious

Effortful

Explicit

Logical

Illustration by David Plunkert


Common cognitive biases

• Anchoring bias – locking on to a diagnosis too

early and failing to adjust to new information

• Availability bias – thinking that a similar recent

presentation is happening in the present

situation

• Confirmation bias – looking for evidence to

support a pre-conceived opinion, rather than

looking for information to prove oneself wrong

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More biases

• Diagnosis momentum – accepting a previous

diagnosis without sufficient skepticism

• Overconfidence bias – over-reliance on one’s

own ability, intuition, and judgment

• Premature closure – similar to “confirmation

bias” but more “jumping to a conclusion”

• Search-satisfying bias – the “eureka” moment

that stops all further thought


Cognitive debiasing strategies

• Encourage decision makers to get more

information

• Encourage metacognition (thinking about your

thinking) and reflection

• Recognize personal biases

• Maintain a healthy skepticism – question

everything – “What else could this be?”

• Involve others – group decision-making can be

smarter

• Use clinician tools and checklists

Better tools and systems

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Potential solutions

Support practitioners

• Clinical decision support tools

• Consultation resources (prearranged)

• Clinical guidelines (embedded in EMR)

• CME targeted to known risk areas (cardiac, stroke,

fractures, sepsis)

• Stat radiology reads

• Triage education


Potential solutions

Create an integrated diagnostic community

for practitioners who may be isolated

• Video/Skype conferencing for clinical consults

• Telemedicine (remote radiology review)


System improvements

Focus on and invest in improving

the diagnostic process

• Data analysis / sharing (claims, adverse events, patient

complaints)

• Case studies (teaching abstracts)

• Educational forums: ambulatory M&M, grand rounds

• Practice collaborative (share issues, concerns, solutions)

• Culture of Safety survey

• Physician office / practice evaluations

• Proactive peer review (trends and triggers)

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Clinical decision support tools reviewed

Differential Diagnosis Generators: an Evaluation of

Currently Available Computer Programs William F. Bond, MD, MS, Linda M. Schwartz, MDE, Kevin R. Weaver, DO, Donald Levick, MD, MBA,

Michael Giuliano, MD, MEd, MHPE, and Mark L. Graber, MD

A Qualitative Review of Differential Diagnosis Generators

William F. Bond, MD, MS, Linda M. Schwartz, MDE, Kevin R. Weaver, DO, Donald Levick, MD, MBA,

Michael Giuliano, MD, MEd, MHPE, and Mark L. Graber, MD

Differential Diagnosis Generators: A Systematic Review of

Their Efficacy

Nicholas Riches, Maria Panagioti, Rahul Alam, Peter Bower, Stephen Campbell, Sudeh Cheraghi-Sohi


Clinical decision support …

one way to assist in mitigating diagnostic error

• Key is enabling access where and when it’s needed

– In the workflow, integrated with EMR

– Via mobile devices

– Stand-alone

• Broad disease coverage, all specialties

• Easy-to-use, simple, fast user interface


How does clinical decision support help?

• System receives basic information about the patient – age, gender, pregnancy status, travel history

– presenting clinical features (signs and symptoms, lab results, vitals, family history)

• System produces a list of diagnosis possibilities – Encourages clinician to consider multiple possibilities, avoid

premature closure, minimize bias

• User can link to evidence-based content about each disease/condition on list to further refine thinking about the differential diagnosis

Demo of clinical decision support system

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It might have made a difference for Rory


Diagnostic error – loss and opportunity

• Diagnostic error is costly and widespread

• Early, correct diagnosis drives cost-effective care

• Clinical decision support can help

– Broadens differential diagnosis, buys thinking time

– Improves appropriateness of care

– Increases capabilities of all clinicians

– Reduces litigation risk

– Enables greater use of existing knowledge resources

– Supports training and education


For more information

Laurie Drill-Mellum, M.D., MPH

[email protected]

www.isabelhealthcare.com

http://www.isabelhealthcare.com/



Copyright 2014 MMIC • All rights reserved Error and … · diagnostic process • MMIC’s summer...

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Transcript of Copyright 2014 MMIC • All rights reserved Error and … · diagnostic process • MMIC’s summer...