New IOM Study Focuses on Improving Diagnosis in Healthcare
The Institute of Medicine’s (IOM’s) Committee on Diagnostic Error in Health Care has issued Improving Diagnosis in Health Care, a new study that was partially funded by The Doctors Company Foundation.
At the committee’s first meeting, Medical Director David B. Troxel, MD, presented data on the role of diagnostic error in his review of 7,438 claims closed by The Doctors Company from 2007–2013. Twenty-five percent of the claims were diagnosis related and involved misdiagnosis, delayed diagnosis, and failure to diagnose. Overall, 34 percent of nonsurgical specialty claims were diagnosis related (the most common allegation), and 14 percent of surgical specialty claims were diagnosis related (the third most common allegation).
The top five diagnoses for each of the 10 specialties involved commonly encountered conditions with well-known differential diagnoses. Half of the diagnoses were found repeatedly in different specialties; e.g., acute myocardial infarction appeared in emergency medicine, internal medicine, family medicine, hospital medicine, and cardiology. This finding suggests that factors other than knowledge deficiency play an important role. Factors may include the following:
- Failure to create a differential diagnosis.
- Impaired synthesis of diagnostic data from various sources (such as medical history, physical exam, diagnostic tests, consultations, etc.).
- Failure to order appropriate diagnostic tests.
- First-impression or intuition-based diagnosis.
- Narrowly focused diagnosis influenced by a known chronic illness.
- Context errors.
- Failure to follow diagnostic protocols.
- Human factors that include impaired judgment, fatigue, and distractions.
IOM Goals for Improving the Diagnostic Process
Of the eight IOM Goals for improving diagnosis and reducing diagnostic error, The Doctors Company is focusing its support on Goals 3 and 6.
Goal 3: Ensure that health information technologies support patients and health care professionals in the diagnostic process.
The free flow of information is critical for the diagnostic process, which occurs over time and involves multiple healthcare professionals in different healthcare settings. EHR interoperability across healthcare organizations and across lab and imaging information systems is essential to information integration.
We support the report’s recommendation that health IT vendors and the Office of the National Coordinator for Health Information Technology (ONC) work together with users to ensure that EHRs used in the diagnostic process
- demonstrate usability and facilitate the timely flow of information among healthcare professionals involved in the diagnostic process, and
- meet standards for interoperability across different EHR systems to support the flow of patient information across care settings to facilitate the diagnostic process.
We also support the recommendation that the Secretary of the U.S. Department of Health and Human Services (HHS) should
- require vendors to submit their products for independent evaluation and notify users about potential adverse effects on the diagnostic process, and
- permit the free exchange of information about real-time user experiences with EHR design that adversely affects the diagnostic process.
Goal 6: Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses.
Specifically, The Doctors Company supports the IOM recommendation that professional liability insurance carriers should collaborate with healthcare professionals on opportunities to improve diagnostic performance through education, training, and practice improvement.
For more than 25 years, we have performed and published internal analyses of our claims database—and we have encouraged external analyses by national medical specialty societies.
Our analyses are published in The Doctor’s Advocate (made available each quarter to our 77,000 members), posted to our website, and presented at meetings with national medical specialty societies and medical specialty advisory boards. Many of our studies are also published in peer-reviewed medical journals.
To download the full IOM report, go to www.nas.edu/improvingdiagnosis.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
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