The Institute of Medicine's latest landmark report offers a number of suggestions for improving the care and systems we have in place as they relate to the problem of ill-defined and under-reported diagnostic errors.
The ambitious Institute of Medicine report on diagnostic errors released this week calls for nothing short of a "significant re-envisioning of the diagnostic process." Committee members have called the 450-page document the missing chapter of the IOM's oft-cited landmark report on medical errors, 1999's To Err is Human.
It has generated dramatic headlines, like this one from CBS News: Diagnostic errors put millions of people at risk.
Christine Goeschel |
But does the IOM's latest report have the same kind of gravitas that made "To Err is Human" a tipping point for healthcare?
It's hard to say. The 1999 publication fueled the patient safety movement and led to the creation of a world of new systems to prevent medical errors. Unlike medical errors, however, diagnostic errors are hard to identify, even harder to define, and not well reported.
Here's the definition the committee came up with: A diagnostic error is "the failure to
- Establish an accurate and timely explanation of the patient's health problem(s) or
- Communicate that explanation to the patient
A little further down in the report, a diagnostic error is described in non-committee speak: a "diagnosis is not accurate if it differs from the true condition a patient has (or does not have) or if it is imprecise and incomplete."
Unlike the medical errors report, this one does not seem aimed exclusively at hospitals, since most diagnostic errors occur in ambulatory settings. Still, hospitals have experience struggling with some of the fixes the committee recommends, such as increased intraoperability and out-of-court malpractice programs. So there are plenty of take-aways in the report for hospitals and health system, especially as they absorb more physician practices and offer more outpatient care.
IOM: Prevent Bad Diagnoses with Better Care Coordination
Christine Goeschel, a member of the committee and the assistant vice president for quality at the Baltimore-based health system MedStar Health, notes: "Most hospital and health care organizations should pay close attention to the report and explore the opportunities in it to improve the care and systems we have in place."
Here are a few key points:
1. Partner with the Patients, Families
While acknowledging that some patients simply want the doctor to tell them what they have, the committee notes that patients and their families "contribute valuable input that will facilitate an accurate and timely diagnosis."
So the report gives much space to patient engagement and two recommendations urge providers to "partner with patients and their families as diagnostic team members." To do that, providers need to educate patients about the diagnostic process. "Patients may be unfamiliar with the terminology related to the diagnostic process, such as a "differential diagnosis" or a "working diagnosis."
2. It Takes a Team of Professionals
The report notes that, in some cases, a single doctor delivers a diagnosis. Often, however, the diagnostic process can include "primary care clinicians, diagnostic testing healthcare professionals, and multiple specialists if different organ systems are suspected to be involved.
Those "diagnostic testing health care professionals" include pathologists and radiologists. The report notes that they are often seen as offering "support services" despite the importance of imaging and laboratory testing in diagnosis.
Mark Graber, MD |
The two "are critical to diagnosing patients' health problems, such as advising on the appropriate diagnostic testing for a particular patient and conveying the implications of the test results to treating health care professionals." And, they rarely make errors, according to said Mark Graber, MD, member of the committee and founder of the Society to Improve Diagnosis in Medicine.
3. Health Information Technology is a Blessing and a Curse
The report concludes that "health IT has the potential to impact the diagnostic process in both positive and negative ways." While helping some doctors who need to "know and apply vast amounts of information," poorly designed and implemented HIT systems can lead to misdiagnosis.
EHR 'Information Overload' Plagues Clinic Notes
"For instance, a confusing or cluttered user interface could contribute to errors in information integration and interpretation that result in errors in diagnosis. Poor integration of health IT tools into clinical workflow may create cognitive burdens for clinicians that take time away from clinical reasoning activities."
Then there's the issue of spotty interoperability, which can "limit or delay access to the data available for clinical decision-making. When health care systems do not exchange data, clinical information may be inaccurate or inadequate. "Sometimes, it's just better for members of the care team to talk face-to-face," Graber says.
4. Liability Can be a Barrier
As the report notes, misdiagnosis is the most common claim in malpractice suits, which is why providers might cringe at calls for better reporting. The committee decided to take a "pragmatic and aspirational approach" to deal with that problem and settled on recommending the use of so-called "Communication and Resolution Programs."
These program take many forms, including the "disclose, apologize and offer" approach. Under that system, a doctor will disclose an error to the patient or family, apologize, and then offer a cash settlement.
The committee endorses the Communication and Resolution Program approach because it creates "a transparent healthcare culture in which the early reporting of adverse events is the norm and is coupled with systems-based event analysis designed to understand the root causes of the event and to aid in the development of plans for preventing recurrences." One problem: while these programs are catching on, movement in this area has been slow.
5. Medical Errors Can be a Model for Change
The report consistently cites the "To Err is Human" report, but acknowledges that diagnostic errors are not the same as medical errors. For one, there is no reporting requirement for diagnostic errors and the committee doesn't recommend one.
Goeschel says that more research is needed to identify better metrics to measure and identify errors. However, she and Graber both say that hospitals can use the shift in patient safety system as a model to improve the accuracy of diagnoses.
"We've learned a lot about safety and we've learned how to analyze other kinds of error and we've learned that things can be improved," Graber says.
"There are fewer hospital acquired infections and fewer wrong side surgeries. The process of analysis and performance improvement—hospitals are pretty good at that. The hope is that they will be able to apply everything they've learned about patient safety to diagnostics."