Despite its title, “Improving Diagnosis in Health Care,” you have to dig deep into the Institute of Medicine's first-ever report on the problem of misdiagnosed patients to find proposals that will have an immediate impact on the problem.
In part, it's due to the failure of hospitals and physicians to systematically identify and catalog misdiagnoses when they occur. This violates the first dictum of any process-improvement program: You can't improve what you don't measure.
In part, it's due to the failure of government to fund adequate research on the nature and extent of the problem. The Agency for Healthcare Research and Quality this year for the first time will fund research on the topic.
And, in part, it's due to a lethargic attitude among providers, insurers and the public at large, which have been fed a steady diet in the media of stories about heroic doctors confronting hard-to-solve medical mysteries.
How many episodes of the “Scrubs” television series featured one of the 13% of stroke victims who visited an emergency department within the previous 30 days with pre-stroke symptoms but were sent home without proper diagnosis or treatment? That comes from a study by Johns Hopkins researchers that appeared last year in the journal Diagnosis.
Many of the maladies affecting humans do share common symptoms, making some level of misdiagnoses inevitable. But the extent of the problem is alarming.
According to the report, diagnostic errors contribute to 10% of all patient deaths and as many as 1 in 6 adverse hospital events. About 5% of adults who seek care each year experience a diagnosis error.
Hopefully, last week's IOM report will spur health system leaders to begin taking the problem seriously, much as the 1999 “To Err Is Human” report put patient safety on the national agenda (even as it largely ignored the issue of diagnosis error).
The report outlined admirable goals for improvement: better communication between patients and professionals; better training for physicians in diagnosis techniques; better electronic health records that go beyond documentation to aid in diagnosis; and a better reporting and liability system so providers can learn from their mistakes.
It's an ambitious policy agenda. But what can be done now at the point of care?
Here are a few things mentioned in the report: Hospitals need to find ways to bring together all the members of the medical team—the radiologists and pathologists, as well as the attending physician—when their different areas of expertise can contribute to an accurate diagnosis.
Collective wisdom usually leads to better results than dependence on a single point of reference, whether it is the interpretation of an image or lab test, or the line physician's professional judgment. Payment reform would help, of course. The report called for paying more for these group-cognitive sessions.
Technology can help. Given their track record on interoperability, it would be foolish to wait on electronic health-record vendors to figure out how their products could aid in diagnosis.
However, there are software products on the market that offer point-of-care help for physicians making diagnoses based on symptoms and test results. DXplain from Massachusetts General Hospital, which has been around for decades and has steadily improved, and the more recent Isabel from the U.K., are cutting-edge examples of technologies that have not received much traction in non-academic settings.
Hospitals should start identifying and studying diagnosis errors within their walls. They can begin by studying their medical liability claims, since diagnosis errors are the No. 1 cause of malpractice claims, accounting for twice as many lawsuits as other forms of medical error, according to a study published in Health Affairs. Understanding the source of the errors offers a start on tackling the process-improvement issues that will ultimately need to be addressed.
Medical-specialty societies also need to take on diagnosis errors within their ranks. They can use the Choosing Wisely campaign on eliminating unnecessary care as a model.
Each society should identify the five most common diagnosis errors within their specialty. They could develop tools and run education campaigns among their members. Maybe they should call it Diagnosing Wisely.
