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January 16, 2015 11:00 PM

Physicians blame patient 'treadmill' for missed calls

Sabriya Rice
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    For a physician to deliver an accurate diagnosis, it requires time for thoughtful consideration of a patient's symptoms.

    But time is one element physicians say they don't have these days as they scramble to maximize patient throughput, an unfortunate side effect of a payment system still dominated by fee-for-service medicine.

    The growing constraints on physician time have emerged as a major cause of missed or wrong diagnoses, experts say. And those errors account for about 1 in 6 incidents of system-induced patient harm, which causes more than 100,000 deaths a year, according to some estimates.

    While the U.S. patient-safety movement has focused enormous attention on medical errors over the past few decades, diagnostic errors have received less attention from practitioners, the research community or patient-safety advocates. The extent of the problem is hard to assess as missed diagnoses remain a largely unreported phenomenon.

    The Institute of Medicine, which first called attention to the extent of the patient-safety problem, barely mentioned diagnostic errors in its historic 1999 To Err Is Human report. But now it is finally tackling the issue.

    The IOM will issue a report this year that will raise a red flag over the issue and give advocates the intellectual firepower needed to get more resources focused on this cause of patient harm.

    One out of every 20 U.S. adults could be misdiagnosed during outpatient visits, and about half of those errors could prove to be harmful, according to recent estimates. “Everybody assumed we were doing OK, but the facts are very different,” said

    Dr. Mark Graber, founder and president of the Society to Improve Diagnosis in Medicine and a member of the IOM committee writing the upcoming report. Missed diagnoses “are probably one of the most common patient-safety problems. But virtually nobody is working on it,” he said.

    About 12 million U.S. adults every year experience a diagnostic mistake. But little is understood about the factors leading to those incorrect, delayed or missed diagnoses. The factors can include lapses in clinical judgments by the physicians or a breakdown in communication between providers.

    One needn't look far to understand why missed diagnoses are rarely reported. Physicians are reluctant to report their mistakes because of fear of litigation. Major medical malpractice cases with big settlements sometimes arisde from missed diagnoses.

    Also, there is no widely accepted definition of what constitutes a diagnostic error. This represents a challenge for researchers who want to study the problem.

    But in the few studies that have looked at the issue, high caseloads and rushed schedules are a recurring theme. At Maine Medical Center, a part of MaineHealth in Portland, the hospital's patient-safety officer and clinical educator initiated a pilot project that ran from January to July 2011 where internal and family medicine, critical-care and emergency room doctors voluntarily shared examples of diagnostic mistakes.

    Over the six-month period, the team found 36 instances where diseases such as cancer, stroke and pneumonia were either missed, misdiagnosed or not identified in a timely fashion. “Just about every time you talk to clinicians involved in diagnostic errors, it seems like time and volume is an issue,” said Dr. Robert Trowbridge, an internal medicine physician who teaches clinical reasoning at Maine Medical Center.

    When time or resources are limited, all people including physicians rely on mental shortcuts or heuristics, an abbreviated way of thinking. That can lead physicians to make quick assumptions and introduce cognitive bias. This not only increases the likelihood of missing disease warning signs, but leads to poorer quality decisions.

    Though expediting decisions may not always cause a problem, “it will inevitably fail some patients,” said Dr. Patrick Croskerry, an emergency medicine professor who directs the critical thinking program at Dalhousie University in Halifax, Nova Scotia. He is also on the IOM committee. “The normal checks and balances built into the decisionmaking process may not be executed.”

    Dr. Gordon Schiff, who practices general internal medicine at Brigham and Women's Hospital in Boston, often worries about time. He said that he may have only 15 minutes with patients, and within that time, only three minutes is spent ruminating on the information obtained.

    “I wish I had 22 minutes for every patient to stroke my beard and think about what the patient's condition could be,” Schiff said. “But a lot of that opportunity is being squeezed out of the encounters.”

    The fee-for-service reimbursement system, where physicians are paid a set price for every encounter, gets a large share of the blame. It leads to what some call the “treadmill effect,” where providers feel the need to squeeze in every possible patient to get the reimbursement needed to cover overhead costs.

    While the nation is gradually transitioning toward rewarding value instead of volume, most clinicians “have a foot in both canoes right now,” said Dr. Nirmal Joshi, chief medical officer of PinnacleHealth System, Harrisburg, Pa.

    Payment reform clearly has to be a part of the fix, said Dr. Reid Blackwelder, immediate past president of the American Academy of Family Physicians. One of the challenges in the fee-for-service system is that physicians practice what he calls “chart care” instead of patient care. “In the absence of payment reform, it's hard to tell physicians to have more time.”

    To tackle misdiagnoses, a few healthcare systems encourage physicians to open up about errors and the factors that caused them. They want to know what factors beyond time are leading to poor decisionmaking.

    They are being pushed by studies conducted by medical malpractice insurers, which can wind up making large payouts on cases that hinge on misdiagnoses. “Malpractice insurers are not letting us forget,” Schiff said. “It's costing them a lot of money.”

    A 2014 report by CRICO Strategies, a Cambridge, Mass.-based risk-management group, found that about 20% of 23,527 medical malpractice cases filed between 2008 and 2012 were related to diagnostic concerns. About 73% of the 4,705 diagnostic claims alleged lapses in clinical judgment, such as failure to order diagnostic tests, establish a differential diagnoses or give a referral.

    Better EHRs could help

    Some researchers say electronic health records could be used to identify patients who are at higher risk of being misdiagnosed. “Triggers can help us identify needles in a haystack by making the haystack smaller,” said Dr. Hardeep Singh, a patient-safety researcher at the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston.

    His study of primary-care physicians at a large VA facility and a large integrated private healthcare system found dozens of missed diagnoses of pneumonia, decompensated congestive heart failure, cancer and kidney infections. Most were related to lapses in the patient-practitioner encounter, such as failure to take a complete medical history or order recommended tests.

    Missing information or follow-ups could trigger a red flag in a properly formatted EHR, Singh said.

    Yet some physicians say EHRs are actually robbing them of the time to conduct more thoughtful diagnoses. Collecting data can actually cut into opportunities to observe the patient and ask questions about symptoms.

    PinnacleHealth's Joshi has been working to reduce distractions that encumber physicians' face-to-face interactions with patients. His system is switching from using more than five EHR platforms to only one. That should make it easier for clinicians to share a patient's medical history and test results.

    In addition, medical assistants and nurses now enter patient vital signs and other data before the clinician enters the room. Doctors are encouraged to face the patient and not the computer during visits, which makes the patient feel as if they have had more time with the doctor.

    “It will never be that doctors are completely free of time pressures,” Joshi said. “But we have to learn how to best manage our time given the pressures.”

    MH Strategies

    Measuring diagnostic errors: Lessons from MaineHealth

    Start a dialogue: MaineHealth started with conversations meant to get physicians talking about diagnostic errors

    Keep it simple: A four-question survey was added to an existing error-reporting system on clinical desktops

    Make the rounds: Diagnostic error reports spiked when a reporting champion was visible in the department

    Get/give feedback: Time limitations were often mentioned in subsequent conversations with physicians

    Measuring the problem

    Diagnosis, as much art as science, will remain difficult to improve without better data. While hospitals have developed solid systems for monitoring hospital-acquired infections and surgical errors, systems for tracking diagnostic mistakes barely exist.

    But first, clinicians must recognize that misdiagnosis is a problem. Dr. Joseph Meir, who misdiagnosed Thomas Eric Duncan, the first Ebola patient diagnosed in the U.S, told the Dallas Morning News that “it's very easy to make a diagnosis of any condition after the patient's medical evaluation confirms the final diagnosis. Unfortunately, such 20/20 hindsight is not available to medical professionals in real time.”

    Despite the challenges in measuring errors, Trowbridge at MaineHealth said his system includes a four-question survey on its error-reporting system and makes the questionnaire available on all clinical desktops. Physicians can write in the patient's medical record number, a brief description of what happened, and check boxes about whether the diagnosis was wrong, delayed or missed, and select the severity of the harm.

    The goal is to identify the scenarios that led to diagnostic errors so the patient-encounter processes can be re-engineered. That usually involves the entire medical team, not just the attending physician.

    The idea that diagnosis is “this heroic, lone ranger thing the doctor does with the doors closed in their office” is romantic and outdated, Schiff said. “This is not just a matter of the doctor thinking harder about the patient. It's putting systems in place that makes the whole diagnostic process more reliable.”

    Follow Sabriya Rice on Twitter: @sabriyarice

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