January 9, 2016

Turning to the Problems Inherent in Getting to the Right Diagnosis

Late in 2015, the National Academy of Medicine (formerly, the Institute of Medicine a/k/a the IOM) generated an important follow-up report to their earlier To Err is Human: Building a Safer Health System.  Their 2015 report is entitled Improving Diagnosis in Health Care. The report starts out acknowledging that, in spite of its importance to the value of care, the diagnostic process remains a rarely studied subject.

Errors in diagnoses remains a significant problem. The report cited some study data that concluded:

  • Diagnosis errors contribute to around 10% of all deaths
  • 17% of adverse events in a hospital setting had diagnosis errors
  • An analysis of malpractice claims indicated that diagnosis errors were the leading type of paid claim

As significant as this problem is, the authors, Erin P. Balogh, et. al., found that there was limited research on this topic. The authors identified 3 themes that repeat in their findings on what inhibits study in this area of medical practice. Those themes are

  1. Data is sparse
    1. Few reliable measures exist
    2. Errors are identified only in retrospect
  2. Patients play a big role in the diagnosis, and often are not adequately factored in
  3. Reaching a diagnosis is typically a collaborative process, and support for such collaboration remains a challenge in healthcare

The study produced the following 8 goals that they believe can lead to improvement in the diagnosis process and reduce diagnostic errors.

  1. Facilitate more effective teamwork in the diagnostic process among health careprofessionals, patients, and their families
  2. Enhance health care professional education and training in the diagnostic process
  3. Ensure that health information technologies support patients and health care professionals in the diagnostic process
  4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
  5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses
  7. Design a payment and care delivery environment that supports the diagnostic process
  8. Provide dedicated funding for research on the diagnostic process and diagnostic errors

What I find especially encouraging is that these goals reveal the systemic nature of the challenge in improving diagnoses. We need to make progress on a number of fronts. Like so much in the health care system, the challenges flow from the fact that healthcare is a team sport. And, as the first goal makes clear, central to the team is the (engaged) patient.

In all settings, the bedrock for effective team work is participant engagement and respect, backed up by effective communications. While not listed as a goal, the study rightly touches on the need for healthcare entities to become continuously learning organizations. Being able to learn from one’s mistakes, in healthcare, requires overcoming cultural barriers, achieving some simultaneous changes in how liability is addressed, and understanding what it means to be accountable in our complex healthcare system.

Not surprisingly, Goal number 3, Ensure that health information technologies support patients and health care professionals in the diagnostic process, clearly asserts that HIT must play a significant role. In addition, closer examination of the report details on Goals 1, 2, 4, 5, 6, and 7 reveals the need for new or enhanced HIT applications to meet those goals as well. Some examples of those related HIT applications or enhancements are [I acknowledge having elaborated on a few of these items to make them a bit clearer]:

  • Technologies (Portals/PHRs) that allow patients (1) to contribute valuable input to diagnoses, and (2) enable patients to provide feedback on diagnoses
  • Technologies that enable close collaboration amongst practitioners – electronic data exchange and interoperability were mentioned as an exceptionally high priority within the HIT realm
  • Within the educational/training settings, a need to include HIT applications that are typically used to support diagnosis within the live clinical setting
  • Move on from the present focus of EHR clinical documentation, which is mostly data that supports billing, to presenting and recording data that supports the diagnosis process
  • EHRs, Radiological, and Laboratory applications all must do a better job at focusing on the diagnosis process and providing better capabilities for tracking the evolution of a patient diagnosis and incorporating second opinions.
  • PHRs can play a stronger role in engaging the patient in the diagnosis process. The report also touched on the emerging opportunities and special challenges in incorporating mHealth-based data.
  • Radiological and Laboratory applications need good access to clinical information that resides in EHRs
  • Identification and tracking of performance measures specific to the diagnostic process
  • Expand the concept of entity-specific, and national, registries for never events to include diagnostic errors. Envision applications that can systematically gather relevant clinical data on diagnoses from clinical & other applications so to enable systematic analysis, feedback, and workflow improvement for the diagnosis process
  • Improved patient access to clinical documentation for the purpose of identifying and correcting diagnosis errors
  • More consistent use of human factors engineering and ergonomics to identify application design flaws that actually are contributing to diagnosis errors
  • Systematically leveraging and communicating the knowledge of the professional liability insurance carriers regarding diagnosis errors

I believe that the National Academy of Medicine with its Improving Diagnosis in Health Care report has done a good job of helping all of us think about the web of HIT applications and how it can be enhanced to improve one of the most important tasks in healthcare – getting the right diagnosis for a patient as quickly as possible. It will take years of effort, moving on multiple fronts. The good news is that what is being recommended is not blue sky, just very complicated.

A worthy challenge indeed.


April 10, 2015

Standards-Based Interoperability Is Finally Being Candidly Addressed

Filed under: CHERT,Data standards,EHR Record Portability,EMRs,HIEs,Interoperability — HankMayers @ 9:29 pm

It appears that National Coordinator DeSilva has laid down the gauntlet over the obstacles that the software industry has often (tho not universally) placed in the way of true, open standards, interoperability. In the ONC’s own words from their report to Congress, Health Information Blocking:
“While many stakeholders are committed to achieving this vision, current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use. Indeed, complaints and other evidence described in this report suggest that some persons and entities are interfering with the exchange or use of electronic health information in ways that frustrate the goals of the HITECH Act and undermine broader health care reforms. These concerns likely will become more pronounced as both expectations and the technological capabilities for electronic health information exchange continue to evolve and mature.”

And the former Coordinator Mostashari tweeted substantial agreement later today when he said:
“The second interoperability challenge that is really top of mind for these practices, in many cases, that they have spent years inputting data in to the systems that they have paid for, and now, to get their own data out of these systems, they are having to pay the vendor $5,000 to $10,000 for an interface. We’re covering that cost, but it’s outrageous. What we really want is basically the CCDA that they, for certification purposes, are supposed to be producing anyway.”

It has generally been understood that leadership has been quiet on this major problem because of its complexity, and the need for the solutions industry to truly get behind electronic medical records. Well, after $28 billion in EHR Incentive Funds (and untold billions by others to address electronic records needs for sectors of healthcare that were not eligible for HITECH funds), it is safe to assert that the market is no longer in its infancy. There are important elements in the healthcare information highway that must no longer be ignored, and agnostic interoperability is one of them.

This is precisely the thrust of the remarkable letter of January 21, 2015 wherein 22 medical specialty boards and the AMA said enough was enough to the National Coordinator and the Secretary of HHS. One of their major complaints was the absence of any meaningful (my intentional wording) agnostic interoperability readily available by federally certified medical records systems.

The S&I Wiki and HL7 have made great progress in providing agnostic interoperability concepts and standards. We now need the political will and the sense of common purpose to designate those standards that the industry must use to gain CHERT (now, HIT Certification Program) certification on the matter of interoperability. While there is still ways to go to reach our ultimate interoperability goal(s), we can set a starting point with what we have now, and incrementally reach where we need to be.

This is one of those areas where we must place aside our national zest for competition, and cooperatively build that which we all must ultimately share.

I am going to be very interested in the buzz at HIMSS15 in Chicago next week.

Comments, anyone?

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