The Nature of Diagnosis

One of my fundamental thoughts about the diagnostic model in medicine is illustrated by this case from the week's NEJM titled The Deficient Diagnosis.  The authors' comment in the closing paragraph on "circuitous diagnostic route" could (should) be applied to many other clinical situations. That is, most diagnostic routes, except the very obvious are indeed circuitous. And it is this aspect of medical decision refinement that should (or so I think) eliminate the term "errors" from the mix.

Instructive, especially to us, is the child's prior presentation, and the ultimate necessity of coming through the ED to find the true path to a successful diagnostic "route."

Were there errors prior to acquisition of a clinically actionable entity?  I don't see them that way.  Or maybe "hell no!"  This is the nature of medicine, in general.

Compare to someone who arrives with chest pain and acute ST-T elevation. A no-brainer, so to speak. But throw into the mix someone whose EKG and two enzyme sets are  normal, scheduled for a stress-test in 72 hours, and dies of an acute MI in 40 hours. Error? I don't see it that way.  Safe-route?  Not for that patient.

So diagnosis is not static, but dynamic. Even in the NEJM case, once action ability is reached, is that the "final" diagnosis ? (Of course "final diagnosis" is a term we use but applies in most cases to the moment of discharge, highlighting its inherent temporal nature) .   How many times have diagnostic pathways forced our otherwise non-compliant minds into submission to diagnosis' dynamism? Take hypoglycemia --> poor insulin administration --> (wait) Addison's disease --> (wait again) Multiple endocrine adenopathy.  Or chest pain --> acute MI --> aortic dissection.  And on and on.

Diagnosis is not, and should not ever be, a static entity.  What are called "errors" therefore are indeed (expected?) steps off the fastest route.  (That route of course is faster if the patient comes to the ED !!).  I think it would serve the diagnostic error community (if there is one) well, and the emergency medicine community (to which we belong) well if this were better encountered theoretically.  Hence, if done, a path to actionable diagnosis is best served when the time-frame to it is the shortest possible. And the ED is the best site for that !!

Surviving “Migration” To a New System

Many Practices are faced with the necessity of changing their Electronic Health Records vendor for a variety of reasons. These may include hospital buy-outs, marginal usability and/or poor performance of present EHR, political reasons, interoperability problems, cost, support, expansion, consolidation, and ownership personal preferences.

Commonly, the administrators, clinicians, and technicians involved do not understand the vast complexity and huge potential costs of mid-stream changes trigger. Often, a major issue that arises is the generally encountered requirement that providers maintain records for at least 7 years.      

The Strategies for Switching or Merging EHRs by Shannon Firth makes many reasonable suggestions on how to approach this transition with wisdom. Here are some essentials that the author suggests you think about:

·         Ask: What data do you absolutely have to have in your new system and what's negotiable? One has to decide what data to mine actively and what just to store. You might decide to input data on active patients only, while placing the rest in an accessible database. While you do not want to load up the new system with data you will never use, you also want access to historical data in some cases, should patients reappear (which of course they often tend to do).

·         Consider: Will you choose to load data manually or digitally? Digital loading is extremely expensive. A commonly employed solution is to scan potentially needed old data into a server from which the new system can retrieve. A provider can then access and utilize the previous data. This tends to work for both paper and digital records. You might be safer trying to resist any urge to move all the data all at once. That becomes a mountainous task. Instead, you might be able scan key documents for regular patients when it gets closer to their next appointment. What should you do about problem lists and medications? One approach is to treat patient as if new to the practice, and update the system with a clean slate using the scanned documents as the basis for doing so. This may sound onerous at first, but consider a) problem lists and medication lists frequently become outdated and need a regular “spring cleaning” anyway, 2) you would do this for any new patient anyway and probably correct many erroneous data points in the process.

·         Think About: What data will be archived and how will you find it in a timely way? Have a coherent plan to archive all the data but do not use unless needed. You can then decide what to scan into the new EHR. Medication lists, problem lists, last complete history and physical, and pertinent lab and x-ray data are high on the list, especially for current active patients. Routine follow-up checks can be accessed through the database if necessary.

·         Ponder: Will you maintain your old system? If so, for how long and how much will it cost? What will be the cost to maintain access?  Will you have to pay your old vendor support and updates?.  All this will depend on your changed contract with the previous vendor, and and the price to maintain it on a server, yours (preferably) or theirs. Remember that sever costs are based on amount of data. The author recommended a year.

·         Give thought to: How will new data (laboratory tests, consults etc.) be received? In most cases, this should be done by accepting data into the new EHR automatically using HL7 standard interfaces.

·         Spend time considering: What forms looked like in the old system (especially those for each visit) and how will they look in the new one. This will affect workflow dramatically. Too much change at one time, even if perceived by you as an improvement, is rarely well received. Gradual change is better. Try to pick an EHR that is end-user oriented, with excellent graphic interfaces, and easy navigation. The end-user will reward such efforts with increased satisfaction and potentially increased productivity.

·         Think through: What is the workflow for each type of visit and what forms are used? You might find it best to use a template driven system for quality control and consistency.

A transition of this sort is in no way an easy task, even in the slightest. An important goal, naturally, is to minimize pain and cost. Remember what we have discusses so far does not even begin to examine what many consider to be the more important, and trickier, transitions of practice management and billing.

The One-Two Punch of Ill-Considered EHR Decisions

Many articles published lately like “Dissatisfaction” leading to EHR replacement trend, discuss the chronic unhappiness and dissatisfaction of Electronic Health Record users. Weeping and gnashing of teeth over electronic record systems is pervasive, and the sources of pain are common and recurrent. 

Still, most every EHR issue that appears or re-appears can be boiled down to one of two root sources. Systems are unusable because of either absence of realistically usable clinical support, or lack of real-time billing functionality. Or both.

Key points from this article include:

·       Practice management has grown as a focus for systems. Whereas in the more distant past, documentation-even CPOE have held sway, the nitty-gritty of running the operation is now the number one priority for systems.

·       The number clinicians replacing their EHRs in any one year has increased 59 percent since 2014

·       Billing functionality is a strong need for EHR buyers. It is the top-requested functionality (45 percent) ahead of claims support (27 percent) and patient scheduling (23 percent).

·       Practice management includes, not surprisingly, management of a facility’s patient population.  Hence, 28 percent of buyers are looking for patient tracking capabilities: monitoring assessments, treatment plans, progress notes, etc.



A parallel and significant problem arises when a facility decides to replace their EHR: the replacement becomes a new bombshell that can bankrupt the facility doing the change.  Buyer’s “remorse” from Electronic Health Records replacement ranks up with car purchases and marriage. Well, maybe not marriage. But in all cases, an unfortunate and costly initial mistake is often compounded by a second mistake.

The key question to ask is whether the EHR can support both the provider and the business side of the practice. Either alone won’t work, and the absence of any one key part creates a vicious cycle. For example, even though the financial side may be given priority, but chronic dissatisfaction of the provider team leads to decreased productivity and further exacerbates any lingering financial woes.

Find an Electronic Health Record System that can support everyone.

Meditation (et al) May Help Slow Down Dementia

A recent article the Benefits of Yoga and Meditation for Alzheimer’s and Dementia stated that meditation may delay the onset of dementia by 7 years. (Note: Be careful not to drop the first “t” in meditation, as a co-author did, because the result, mediation, will actually accelerate dementia for an equivalent period of time.) Now 7 years does not seem like a lot unless you are already in the senior citizen group. Any reprieve from Alzheimer’s disease and dementia is well worth the effort.

Dementia, according to Wikipedia, is a broad category of brain diseases that cause long term, usually gradual, decrease in the ability to think and remember, of a degree great enough to affect a person's daily functioning. Alzheimer’s disease accounts for 60% to 70% of cases of dementia.^[1][2] It is a chronic neurodegenerative disease that usually starts slowly and gets worse over time.^[1][2]The most common early symptom is difficulty in remembering recent events (short-term memory loss). If you do not remember why you started reading this blog, you may be a candidate.

The article extolls the virtues of yoga and meditation for both the individual and caregiver to make life less stressful and more fulfilling. Basically it is saying that you have to exercise your brain and body to maintain your “youth”.

Practicing Yoga is an easy solution to avoid the sedentary state that will eventually kill you. There are many forms of exercise but you have to perform them religiously. Meditation is a way to control anger, compulsions, and exercise your brain. There is a role for puzzles, games and focused mindfulness.

Take a class and find out whether these strategies will work for you. Medical science allows us to live longer, but preferably in an awake and aware state.

Keep in mind that causes and cures for Alzheimer’s are popping up daily. In the exercise category Pilates or TRX is likely as effective as yoga.  Not to mention swimming, surfing, sailing, and other activities conducive to meditative presence.

And if you get into the supplement category, there are far too many, from omega oils, to various roots and herbs.  And then there are the toxins, take aluminum salts in some antacids.

It is sufficient to say that if you read this blog, and you remember any of it, you don’t have to worry for a while.

“Uberizing” Pre-Hospital Care

An Economic Toolkit for Identifying the Cost of Emergency Medical Services (EMS) Systems: Detailed Methodology of the EMS Cost Analysis Project (EMSCAP)

Medical Costs keep rising and are under a great deal of government, societal, and insurance company scrutiny. Rarely discussed in the medical cost debate the true cost versus effectiveness of prehospital care.

The entire fire-rescue paradigm has broad support from most constituents but there probably could be some evidence-based cuts. The article above gives some guidelines how this can be attempted.

An interesting phenomenon occurs every time a rescue is dispatched: a fire crew is simultaneously sent out to act as first responders. The rationale four quick response is to arrive within 4 minutes, start CPR, and defibrillate someone with reversible V-fib. Yet, the majority of calls do not need CPR, defibrillation, our even treatment; but at the same time, they cannot be simply left where they are, and therefore need transportation to a care facility. 

Such transports are not only extremely expensive, but also take valuable paramedics out of service to act pretty much as a taxi. Municipalities commonly encounter fire-rescue budget constraints, and many cities now instruct their paramedics to call for a private ambulance themselves when the need is strictly for transport. Of course, such vehicle and personnel shuffling is time-consuming and potentially more expensive.

A potential “out-of-the-box” solution is to take advantage of the Internet, social media, and companies like Uber and Lyft. In the future “Uber” may be used as the generic name for Internet driven transportation services.

Potential applications are:

1.      When a patient needs just transportation, “Uber” can be called by the fire rescue, paramedics, and or dispatch. A patient may even initiate the call.

2.      Cities and Fire Rescues can contract with “Uber” to send specific taxis with CPR-trained our even ACLS-trained drivers to transport patients who do not need a stretcher for transport.

3.      Certain cities are studying paging anybody within 6 blocks of a cardiac arrest victim who has volunteered as a CPR first responder. Specially trained “Uber” drivers that can commence CPR and attach and use the AED can extend this first level of care. Having backup of this type would gou a long way to alleviate community concern, and generally assure that every victim is reached in under 4 minutes

There is considerable potential for cost saving. Think of reductions in fire station construction, personnel, and equipment. All of this could be achieved with little reduction in quality. It’s time to take advantage of social media and include private infrastructure to aid the public good. Perhaps in the future, stories ouf babies being delivered by taxi-drivers will be replaced by a stories of heroic Uber drivers in that honored role.

Clinical Decision Support to Alleviate “Misdiagnosis”

The Institute of Medicine found that “most people will suffer from at least one wrong or delayed medical diagnosis during their lifetime, according to the latest data. Americans experience about 12 million diagnostic errors a year.”

“Conservatively, the report found that 5 percent of US adults who seek outpatient care will experience a diagnostic error. Further, such errors are thought to contribute to 10 percent of patient deaths and 17 percent of adverse events in hospitals.”

In the article Is Misdiagnosis Inevitable, the reality of misdiagnosis is discussed with potential solutions through clinical decision support from Electronic Health Records.

Unfortunately, the term misdiagnosis is misused to include everything under the sun. It neglects the concepts of over-diagnosis, overtreatment, irrelevant diagnosis, and mostly that people the majority of the time get better without treatment. “Tincture of Time” solves most problems while potential erroneous treatment plans can pose harm and drive the Medical-Industrial Complex to more and more.

Assuming that the missed diagnosis has clinical relevance (affects patients not statistics) , it would be important to reduce these errors.

Common factors causing problems are poor communication, inexperience of the various providers (providers is now generic for physicians, nurse practitioners , Physician assistants, and all other medical providers), pressure to see patients in a strict timeframe, minimizing test ordering, and finally unfortunately poor cognitive distillation of the present information by allowing acute on chronic biases to cloud judgement.

The IOM’s 1999 report said to “To Err Was Human”. Human beings probably have not evolved significantly since 1999 to fantasize that errors will not be made. The goal should be to limit critical errors by avoiding common recurrent mistakes.

The well-known ones are illegibility, allergic reaction, drug-drug interactions, lack of follow-up on abnormal tests that were ordered by someone, and systemic errors that create pressure to perform in unsafe environments. Consumerism and the public’s fantasy that everything can be figured out in 24 hours or less are also factors.

With respect to malpractice litigation, the acceptable miss rate on a patient in the United States is 0%. This cannot be achieved without endless unnecessary tests that may lead to unnecessary treatments that leave the patient in worse shape than the initial error.

One must remember that the concept of diagnosis itself derives from the diagnostic medical model:  symptomsà examination/testing à diagnosis à diagnosis-based treatment.  There are inherent flaws in that model, especially as the field of potential diagnostic entities grows in its complexity and possibilities.  Consider immunotherapy for carcinomas.  There, the diagnostic possibilities have expanded exponentially because of nuances in genome delineation. Many other subspecialties are following, each entity with its own specific therapeutic modality, and each with its own heavy price-tag.

What has (surprisingly) never been fully incorporated into the emergency medicine diagnostic model is the impact of time and extended clinical relationships.  That is, we discharge patients with a “diagnosis” which is not-uncommonly some vague re-interpretation of symptoms (e.g. “back pain,” “dizziness, vertigo”).  And the best outcome diagnostically, for us, is admission.  Why? Because, then the admitting physician is responsible for discovering the true nature of the disorder.  The next tier of outcome is arranged follow-up, in which a referral physician agrees to see the patient and continue the care as needed. A sub-tier to that is the more unreliable diagnostic plan of “return if worse” or better “return for a recheck” at a specified time. Finally there is the common discharge plan for diagnostic security:  “see your doctor if worse.” 

The experienced physician accepts that his diagnostic acumen is sometimes on, sometimes off target, and so builds a measure of time into diagnostic equation.  If done well, there is no such thing as misdiagnosis, there are potential diagnoses, there are working diagnosis, but there is no “final” diagnosis until confirmed by time and further evaluation.

What can be done to align these competing forces to allow the “lonely practitioner” to get the diagnosis right? Perhaps creating clinical decision support (CDS) tools in the Electronic Health Record through artificial intelligence (AI) may help. Effective employment of this may be a decade away, and may require buy-in from the tech industry, which seems decades ahead. As one ED physician recently said to his enterprise system that was trying to speak to him: “shut up…..you’re no Siri.” When present, good AI will hopefully function as a real-time consultant to the provider with propositions for differential diagnoses, treatment plans, legitimate warnings, notifications that the data inputted may suggest another serious diagnosis, the tests you never looked at are on page 21, and the nursing notes show major discrepancies with the provider’s input.

Bottom line, the system presently works quite well but can be significantly improved. Misdiagnosis should be a term only applied to situations that cause real harm to an actual patient, and only if the full-force of diagnostic acumen (and time) has been applied.  Accomplishing non-misdiagnosis is difficult in our current system, of course.  But thankfully most cases usually takes care of themselves. Preventive care actually may be the long term solution for serious all-to-common self-inflicted illnesses. If, that is, you can get patient buy-in.

Allowing the Patient to Input Data into the Electronic Health Record

In the article Medicine 3.0 Panelists Dissect Patient-Generated Data, a group discussed the possibility of the patient inputting their own data into the Electronic Health Record. These included objective data like blood glucose measurements, virtual assistant type tasks, and changing the doctor-patient relationship paradigm from paternal (maternal) to dynamic.

With the multiple apps being constantly developed it is foreseeable that patients can arrive in the office or on skype with all the data necessary in advance for a focused practitioner-patient interaction. Rather than let’s get an EKG; the EKG is already completed. This can affect all the blood work dramatically. This will dramatically save the patients time and expense.

The virtual assistant tasks are even more intriguing. The patient can be offered a problem-specific template to be filled out that asks all the pertinent data. The provider can quickly review and affirm the accuracy and quality of the data. They can then ask problem specific questions to solidify the diagnosis. Can patients answer these questions? They do now but verbally. They can also be asked about the research they have already done on the internet. If they cannot fill out the forms than office staff can call in advance and verify items like problem lists, medications, and allergies.

The last concern was the patient-provider relationship change. The consumer wants timely accurate answers, compassion, and to get the provider’s expertise. The paradigm of rushing through multiple questions that usually have been already asked several times already could become a thoughtful interaction.

Two big unaddressed issues here are privacy and doctor time.  Privacy can no longer be secured, as evidenced by recent ransom-ware break-ns. The potential for hacking into a system goes along with having a system. Patients, at this point need to be informed that a facility will do everything possible to provide IT security, but cannot guarantee it.  It a patient types information into a system where security has been guaranteed, and it is hacked, the facility can wind up on the adverse side of a courtroom.

And then there is our old friend, time. How many doctors do you know (maybe you?) that really have the time to read all their patients’ blah-blah-blah.  True there is important information potentially there, but a downside will be that many patients will have free-hand at the keyboard, and take it.  Then what?

In conclusion: Look for major changes in workflow and data collection in the near future. This can be a positive development. Compliance may be improved and not understanding what the provider said may diminish.