Challenges and Opportunities in the Pursuit Challenges and Opportunities in the Pursuit of Better Diagnostic Performanceof Better Diagnostic Performance

Kerm Henriksen, PhDHuman Factors Advisor for Patient Safety

Diagnostic Error in Medicine: 5th International ConferenceBaltimore, MD – November 12, 2012

Gordy’s Eight Questions

1 What are the levers to move the agenda and practices forward?2 What is your org. doing on the Dx error front?3 Where are your (personal/org.) ideas for improving diagnosis and

decreasing errors?4 What are the reform and policy implications of over-testing and over-

diagnosis?5 In your view, what works; what doesn’t work?6 Where does EMR/HIT fit into your vision & practices?7 What are the pitfalls in various policy approaches (discouraging patients’

presenting, less phys. time w/ patients, delegation to non-MD staff, limiting tests)?

8 Who should “own” the diagnostic error problem – MDs or their HCOs?

3

What Past Conferences What Past Conferences Have Taught UsHave Taught Us

Reaching a diagnosis too quickly Reaching a diagnosis too quickly (premature closure) is like falling in love (premature closure) is like falling in love with the first puppy you see with the first puppy you see Graber, 2007Graber, 2007

Dual process theory with its Sys1 and Dual process theory with its Sys1 and Sys2 processes has provided a Sys2 processes has provided a decision-making frameworkdecision-making framework

A rich palette of cognitive, perceptual, A rich palette of cognitive, perceptual, affective and system components are affective and system components are involvedinvolved

Reporting systems haven’t captured Dx Reporting systems haven’t captured Dx errorserrors

Decision support might help but “not if Decision support might help but “not if I’m behind schedule and I’m behind I’m behind schedule and I’m behind schedule 80% of the time” schedule 80% of the time” Sittig et al., 2006Sittig et al., 2006

What Makes AddressingWhat Makes Addressing Diagnostic Error Difficult Diagnostic Error Difficult

Volume-based medical practice not very conducive to Sys 2, analytical inquiry ; most practice conducive to Sys 1, intuitive approach

Double-edged nature of the use of cognitive heuristics represents a paradox.

Cognitive biases and system flaws typically treated as separate entities; yet they are often interactive.

Administrators cede diagnostic issues to physicians; physicians cede system issues to administration . Who owns the problem?

Lack of a feedback mechanism to calibrate performance. In the absence of disconfirming information, “we’re doing fine here” is the mindset

What has AHRQ been doing What has AHRQ been doing on the Dx Error Front?on the Dx Error Front?

Two Small Conference GrantsTwo Small Conference Grants Three Large Conference GrantsThree Large Conference Grants Special Emphasis Notice (SEN)Special Emphasis Notice (SEN) Investigator-initiated Grants Investigator-initiated Grants Decision Support and Health IT GrantsDecision Support and Health IT Grants ACTION-contracted Task OrdersACTION-contracted Task Orders Efforts to Measure and Track Dx Error for National Healthcare Efforts to Measure and Track Dx Error for National Healthcare

Quality and Disparities ReportsQuality and Disparities Reports

How do EMRs and Health ITHow do EMRs and Health IT fit into your vision? fit into your vision?

Purported BenefitsPurported Benefits

Information is the lifeblood of Information is the lifeblood of health carehealth care

With IT, providers can make With IT, providers can make better decisions, avoid better decisions, avoid duplication of tests and duplication of tests and procedures, and prevent procedures, and prevent unwanted medication unwanted medication interactionsinteractions

PCMHs and patient PCMHs and patient engagement more easily engagement more easily realizedrealized

In-home monitoring allows In-home monitoring allows tracking of patient vitals and tracking of patient vitals and activity activity

ConcernsConcerns

Lack of system Lack of system standardization and standardization and interoperability can limit data interoperability can limit data sharingsharing

No central repository to No central repository to collect/analyze IT-related collect/analyze IT-related safety glitchessafety glitches

Most systems are vendor Most systems are vendor inspired; user needs, inspired; user needs, workflow, and usability workflow, and usability issues have been neglectedissues have been neglected

Data entry/retrieval and Data entry/retrieval and awkward interfaces are issuesawkward interfaces are issues

How do EMRs and Health ITHow do EMRs and Health IT fit into your vision? fit into your vision?

As currently designed, EMRs and Health IT often As currently designed, EMRs and Health IT often add another layer of complexityadd another layer of complexity

The shortcomings need continued attention; vendors The shortcomings need continued attention; vendors and HCOs need to work together on design, and HCOs need to work together on design, implementation and use issuesimplementation and use issues

Users should be involved at the earliest stages of Users should be involved at the earliest stages of designdesign

It’s not just the technology. IT needs to be aligned It’s not just the technology. IT needs to be aligned with the needs of the greater socio-technical system – with the needs of the greater socio-technical system – the organizations, people, and clinical processes that the organizations, people, and clinical processes that interact and depend on it.interact and depend on it.

Improvement is a steady, incremental process.Improvement is a steady, incremental process.

Recent Literature Reviews Find Few Outcome Studies

System-related interventions System-related interventions ( (Singh et al., 2012))

Our literature review of system-related interventions to Our literature review of system-related interventions to reduce diagnostic error . . . yielded very few empirical reduce diagnostic error . . . yielded very few empirical outcome studies. . . Our findings highlight a large gap outcome studies. . . Our findings highlight a large gap between suggested interventions and those that have between suggested interventions and those that have been operationalised and evaluated empirically.been operationalised and evaluated empirically.

Cognitive interventionsCognitive interventions (Graber et al., 2012)(Graber et al., 2012)

We found that most interventions . . . were simply We found that most interventions . . . were simply ideas or suggestions. Many of these are well ideas or suggestions. Many of these are well conceptualised and widely endorsed, and seem ripe to conceptualised and widely endorsed, and seem ripe to be tested in experimental and real-world clinical be tested in experimental and real-world clinical settings . . . Our findings also affirm that the science of settings . . . Our findings also affirm that the science of outcome measurement in this area is underdeveloped. outcome measurement in this area is underdeveloped.

Progression of Progression of Patient Safety InitiativesPatient Safety Initiatives

Stage 1Stage 1: identify problem areas, raise : identify problem areas, raise awareness, build capacity and cultureawareness, build capacity and culture

Stage 2Stage 2: develop innovative measures and : develop innovative measures and approaches, demonstrate viable practices, approaches, demonstrate viable practices, implementimplement

Stage 3Stage 3: disseminate, create spread: disseminate, create spread Stage 4Stage 4: sustain by integrating into the fabric : sustain by integrating into the fabric

and infrastructure of workand infrastructure of work

Hospitals Slash Central Line Infections . . .(Could there be an equivalent headline for Dx Error?)

CUSP for CLABSI Infection prevention

evidence-based practices Frontline use of checklists Unit-wide patient safety

culture Local leader champion Engaging/educating team Collecting performance &

outcome measures Partnership alignments

(JHU, AHA, HRET, AHRQ) National spread (>1000

ICUs; 41% reduction, 500 lives saved & $36 M costs avoided)

CUSP for Dx Error What should be targeted? What should

never happen? Is there an evidence-base? What tools are available? Is there a strong culture for patient safety? Who’s the local champion? Who owns the

problem? What teams need to be engaged? How is diagnostic performance measured? What partners need to be aligned? When would we be ready for a national roll-

out?

Proposed Checklists to Reduce Diagnostic Error

Schiff & Leape, 2012

Essential data elements Don’t miss diagnoses Red-flag symptoms Potential drug causes Required referral(s) Patient follow-up instructions

and plan

Ely, Graber, & Croskerry, 2011

General checklist (medical history, focused physical exam, tests for differentiating initial hypotheses, time-out, and follow-up)

Differential diagnosis checklists (for prompting a comprehensive list of causes underlying pt’s complaint)

Cognitive forcing function checklists (requiring error-prone diagnoses to consider other possibilities thereby possibly precluding premature diagnoses)

Checklists Come with Checklists Come with ChallengesChallenges

It’s not all about the checklist. Evidence-based practices, It’s not all about the checklist. Evidence-based practices, patient safety culture, teamwork, leadership commitment, patient safety culture, teamwork, leadership commitment, measurement , implementation issues all need alignment. measurement , implementation issues all need alignment.

Checklists do not guarantee safety (subject to cognitive Checklists do not guarantee safety (subject to cognitive drift; performed in perfunctory manner; minimal drift; performed in perfunctory manner; minimal compliance)compliance)

Most successful so far with discrete, observable tasks; Most successful so far with discrete, observable tasks; diagnostic perceiving, thinking, interpreting are less diagnostic perceiving, thinking, interpreting are less observable; do these mental activities have a discernable observable; do these mental activities have a discernable start- and end-point for which a checklist could be used? start- and end-point for which a checklist could be used?

Some diagnostic pursuits can be characterized as “wicked Some diagnostic pursuits can be characterized as “wicked problems” – no true or false end-result; actions taken lead problems” – no true or false end-result; actions taken lead to new problems; uncertainty not reduced, but magnified. to new problems; uncertainty not reduced, but magnified. Are checklists appropriate here?Are checklists appropriate here?

What works; What works; what doesn’t what doesn’t

What doesn’tWhat doesn’t Expecting quick improvements, Expecting quick improvements,

simple fixessimple fixes Ignoring contextual, Ignoring contextual,

organizational and cultural organizational and cultural factorsfactors

Relying on knowledge in the Relying on knowledge in the headhead

Rushing into control group Rushing into control group comparisons before comparisons before intervention is fully developedintervention is fully developed

Treating cognitive-based and Treating cognitive-based and system-related errors as system-related errors as separate research campsseparate research camps

Raising awareness onlyRaising awareness only

What doesWhat does Balanced and flexible approach for the long Balanced and flexible approach for the long

termterm Viewing tools and technology as part of larger Viewing tools and technology as part of larger

socio-technical system socio-technical system Put knowledge in the worldPut knowledge in the world Spend more effort on development and Spend more effort on development and

efficacyefficacy Recognize that humans with their biases and Recognize that humans with their biases and

flawed systems are not going to disappear; flawed systems are not going to disappear; both will continue to impact the diagnostic both will continue to impact the diagnostic processprocess

Growing the evidence-base and Growing the evidence-base and implementation strategiesimplementation strategies

What Works in Industry

A Systems Engineering Approach for Dx Error Problem analysis High-level design Detailed design Develop rapid prototypes Small-group trials Revise and improve Large-group trials Revise and improve final intervention Full-dress rehearsal of integrated intervention Test in simulated setting Adapt and implement in clinical setting

Who owns the Dx error problem – MDs or their HCOs?

Administrators cede diagnostic matters to physicians

Physicians, in turn, cede systems problems to administration

Both views are short-sightedBoth “own” the problem and could benefit from learning about the reciprocal influences and interactions that exist between imperfect humans and their imperfect work environments.

What are the Levers that Move the Agenda Forward?

Less Costs Greater Access Better Quality

Current reform debate focuses predominately on costs, recognizes the pressures increased access will produce, and appears uncertain about the impact quality initiatives will have. Yet the Affordable Care Act provides a vision we can have all three.

Will there be less testing, less face time w/ docs, and greater use of assistants? With any system change, something is gained, something is lost. Health consequences are unknown.

Some Encouraging SignsSome Encouraging Signs

Pioneering work of early advocates starting to get its due.

Diagnostic error and patient safety closely linked; reducing harm to patients on the national radar screen

Healthcare reform places greater expectations on reducing costs via quality and safety improvement

Calls for accountability and P4P movement should serve as a catalyst for improving diagnostic performance

Enjoy the Conference!