5/17/2014 www.knowurture.com 1

HEALTHCARE INDUSTRY LANDSCAPE

Presented by:

Madhukar Kalsapura

Founder & Chief

Ramnath Sundaram

Co-Founder & Chief – Finance & Operations

Shankar Bijapur

Co-Founder & Director – Medical Services

Shally Arora

Co-Founder & Chief - Communications

ERRORS OF DIAGNOSIS – ENORMITY OF THE PROBLEM

25/17/2014 www.knowurture.com

WHAT IS DIAGNOSTIC ERROR?

Diagnostic error can be defined as a diagnosis that is missed, wronged or delayed, that may be detected by

a subsequent definitive test or finding.

The ensuing harm results from the delay or failure to treat a condition present when the working diagnosis

was wrong or unknown, or from treatment provided for a condition not actually present.

35/17/2014 www.knowurture.com

DIAGNOSTIC ERRORS MORE COMMON, COSTLY & HARMFUL THAN TREATMENT MISTAKES

“Overall, diagnostic errors

have been under

appreciated & under

recognized because they’re

difficult to measure & keep

track of owing to the frequent

gap between the time the

error occurs & when it’s

detected,” Newman-Toker

says. “These are frequent

problems that have played

second fiddle to medical &

surgical errors, which areevident more immediately.”

Experts have often downplayed the scope of diagnostic errors not because they

were unaware of the problem, but “because they were afraid to open up a can of

worms they couldn’t close.” He adds: “Progress has been made confronting other

types of patient harm, but there’s probably not going to be a magic-bullet solution

for diagnostic errors because they are more complex and diverse than on this

issue if we’re going to successfully tackle it.” other patient safety issues. We’re

going to need a lot more people focusing their efforts

They found that of the 350,706 paid claims, diagnostic errors were the leading

type (28.6%) and accounted for the highest proportion of total payments (35.2 %).

Diagnostic errors resulted in death or disability almost twice as often as other

error categories.

The human toll of mistaken diagnoses is likely much greater than his team’s

review showed, Newman-Toker says, because the data they used covers only

cases with the most severe consequences of diagnostic error. There are many

others that occur daily that result in costly patient inconvenience and suffering, he

says. One estimate suggests that when patients see a doctor for a new problem,

the average diagnostic error rate may be as high as 15 %.

They also found that more diagnostic error claims were rooted in outpatient care

than inpatient care, (68.8 % vs. 31.2 %) but inpatient diagnostic errors were more

likely to be lethal (48.4 percent vs. 36.9 percent). The majority of diagnostic errors

were missed diagnoses rather than delayed or wrong ones.

45/17/2014 www.knowurture.com

DIAGNOSTIC ERRORS & MEDICAL ERRORS AMONG TOP 10 KILLERS

http://www.technologyreview.com/news/518871/we-need-a-moores-law-for-medicine/

http://www.technologyreview.com/news/518876/the-costly-paradox-of-health-care-technology/

Diagnostic errors are fundamentally obscure, health care organizations have

not viewed them as a system problem, and physicians responsible for

making medical decisions seldom perceive their own error rates as

problematic. The safety of modem health care can be improved if these

three issues are understood and addressed.

timesofindia.indiatimes.com/india/Medical-errors-in-top-10-killers-WHO/articleshow/8032059.cms

http://www.ncbi.nlm.nih.gov/pubmed/15791770

Although there is no Indian data available on this topic, WHO lists it among the

top 10 killers in the world. While a British National Health System survey in

2009 reported that 15% of its patients were misdiagnosed.

The Indian government has woken up to the concept. It set up the National

Initiative on Patient Safety in the All-India Institute of Medical Sciences a

couple of years back.

Medical errors in top 10 killers: WHO

Diagnostic errors in medicine: a case of neglect.

5/17/2014 www.knowurture.com 5

DIAGNOSTIC ERRORS ARE THE MOST COMMON MEDICAL MISTAKE

http://healthland.time.com/2013/04/24/diagnostic-errors-are-more-common-and-harmful-for-patients/

The reason that medication mistakes and surgical errors have been confronted first is related to the fact that

diagnoses are less objective, and more subjective. Determining whether a doctor’s assessment of what is

making a patient sick is a combination of art and science, which makes diagnoses more uncertain than

treatment.

Another force may be driving the escalating number of tests, and their costs — doctors may rely on them to

safeguard against malpractice suits and litigation. But Newman-Toker says this justification falls flat. “Of course

there is to some extent a trade-off between ordering more diagnostic tests and accepting more diagnostic errors.

In theory, if you ordered every possible test for every possible patient in every possible occasion, you would

probably break the health care piggy bank, but you would get the so-called right diagnosis in every case at the

limits of our current scientific knowledge,” he explains. “But no one believes it is good practice to obtain every

test on every patient in every situation. The best diagnosis is efficient and parsimonious as well as accurate.”

The threshold between such parsimonious testing to rule out certain conditions and hone in on a diagnosis and

excessive analysis, however, is a fuzzy one.

“The current fragmentation of our health care system makes these errors more likely,” says Dr. Richard

Anderson,

“Treatment starts with diagnosis. If you don’t get the diagnosis right, you can’t get the treatment right. And yet no

one is working on it,” says Newman-Toker.

http://www.ncbi.nlm.nih.gov/pubmed/12377672

This considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in

medicine:

"No-fault errors" occur when the disease is silent, presents atypically, or mimics something more

common. These errors will inevitably decline as medical science advances, new syndromes are

identified, and diseases can be detected more accurately or at earlier stages. These errors can never be

eradicated, unfortunately, because new diseases emerge, tests are never perfect, patients are

sometimes noncompliant, and physicians will inevitably, at times, choose the most likely diagnosis over

the correct one, illustrating the concept of necessary fallibility and the probabilistic nature of choosing a

diagnosis.

"System errors" play a role when diagnosis is delayed or missed because of latent imperfections in the

health care system. These errors can be reduced by system improvements, but can never be eliminated

because these improvements lag behind and degrade over time, and each new fix creates the

opportunity for novel errors. Tradeoffs also guarantee system errors will persist, when resources are just

shifted.

"Cognitive errors" reflect misdiagnosis from faulty data collection or interpretation, flawed reasoning, or

incomplete knowledge. The limitations of human processing and the inherent biases in using heuristics

guarantee that these errors will persist. Opportunities exist, however, for improving the cognitive aspect

of diagnosis by adopting system-level changes (e.g., second opinions, decision-support systems,

enhanced access to specialists) and by training designed to improve cognition or cognitive awareness.

Diagnostic error can be substantially reduced, but never eradicated.

REDUCING DIAGNOSTIC ERRORS IN MEDICINE: WHAT IS THE GOAL?

5/17/2014 www.knowurture.com 6

5/17/2014 www.knowurture.com 7

DIAGNOSTIC ERRORS – CENTRAL TO PATIENTS SAFETY STILL IN THE PERIPHERY OF

SAFETY RADAR

“At the 6th International

Conference on

Diagnostic Error in

Medicine Dr. Robert

Wachter gave a quick

history of patient safety

and quality

improvement but noted

that activity to reduce

diagnostic errors was

noticeably absent from

the movements'

timeline.

http://Diagnostic-errors-central-to-patient-safety-yet-still-in-the-peripheryhttp://www.modernhealthcare.com

Low-tech interventions may hold the answer, he said. These include instilling a

patient safety/quality improvement culture and promoting medical

professionalism. “That has turned out to have a lot of oomph to it—more than I

expected,” Wachter said. “Professionalism is a surprisingly powerful lever.”

“What should we do? I really don't know,” Wachter said. But before going to the

CMS for an answer, he suggested advocates should engage specialty boards,

the Joint Commission, the National Quality Forum, the Institute of Medicine, the

National Patient Safety Foundation, the Institute for Healthcare Improvement and

malpractice insurance carriers.

“CMS should be last, not first,” he said.

As one vivid example of how far we need to go, a hospital today could meet the

standards of a high-quality organization and be rewarded through public reporting

and pay-for-performance initiatives for giving all of its patients diagnosed with

heart failure, pneumonia, and heart attack the correct, evidence-based, and

prompt care – even if every one of the diagnoses was wrong.”

There may well come a day when a tool such as Isabel has been proven

sufficiently beneficial that having it as a structural proxy for diagnostic accuracy

(or at least for the commitment to improve diagnosis) would be a good idea. But

until that day arrives, I would be looking to other organizations to promote the

diagnosis agenda.

5/17/2014 www.knowurture.com 8

DIAGNOSTIC ERRORS & THEIR ROLE IN PATIENT SAFETY

“health IT has it’s own biases. Remember GIGO – garbage in, garbage out. A simple example is an over-reliance on

“template charting,” whether electronic or in paper form. Let’s say the patient tells the triage nurse “I’ve been vomiting

and my chest hurts.” If one chooses too early the template for “Vomiting,” “Gastroenteritis,” or “Abdominal Pain,” one

could easily lead oneself and others astray, causing them to overlook the fact that what the patient really meant to say at

triage was “I started having this heavy chest pain and have been vomiting ever since.” If the template is too focused, the

patient may well be discharged with an undiagnosed MI – or worse. http://www.kevinmd.com

Charles A. Pilcher

“Thinking errors” include:

Anchoring bias – locking on to a diagnosis too early and failing to adjust to

new information.

Availability bias – thinking that a similar recent presentation is happening

in the present situation.

Confirmation bias – looking for evidence to support a pre-conceived

opinion, rather than looking for information to prove oneself wrong.

Diagnosis momentum – accepting a previous diagnosis without sufficient

scepticism.

Overconfidence bias – Over-reliance on one’s own ability, intuition, and

judgment.

Premature closure – similar to “confirmation bias” but more “jumping to a

conclusion”

Search-satisfying bias – The “eureka” moment that stops all further thought.”

5/17/2014 www.knowurture.com 9

The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the

moment of truth arrived, and the room was silent with anticipation. At last he spoke. “Lymphoma with secondary

hemophagocytic syndrome,” he said. The crowd erupted in applause.

http://www.nytimes.com/2012/12/04

Dr. Gurpreet Dhaliwal

FOR SECOND OPINION, CONSULT A COMPUTER?

Isabel, the diagnostic program that Dr. Dhaliwal sometimes uses, was created

by Jason Maude, a former money manager in London, who named it for his

daughter. At age 3, Isabel came down with chickenpox and doctors failed to

spot a far more dangerous complication — necrotizing fasciitis, a flesh-eating

infection. By the time the disease was identified, Isabel had lost so much flesh

that at age 17 she is still having plastic surgery.

Mr. Maude said that while someone like Dr. Dhaliwal would probably have

thought of necrotizing fasciitis, his daughter’s doctors were so stuck in what is

called anchoring bias — in this case, Isabel’s simple chickenpox — they

couldn’t see beyond it. Had they entered her symptoms — high fever, vomiting,

skin rash — into a diagnostic program, Mr. Maude said, the problem would

probably have been identified.

5/17/2014 www.knowurture.com 10

FACTS

What is the cause of diagnostic error?

It’s multi-factorial and can present as a perfect storm of multiple factors lining up: 6 factors on average

were found per case of diagnostic error in an internal medicine study (Graber 2005).

Lack of physician knowledge is least often the problem. It is more often due to cognitive error, systems

errors including communication errors, and most common of all, the combination of cognitive and systems

errors (Graber 2005).

Is it the rare diagnosis that is the subject of diagnostic error?

No, it is the common diagnosis and the common killers: heart attack, cancer and stroke.

Overall, the top diagnosis in claims related to diagnostic error is breast cancer (PIAA Data Sharing Report

1985-2009).

Acute myocardial infarction is the top subject of diagnostic error in claims for the specialties of adult

primary care, emergency medicine and cardiology (PIAA Data Sharing Report 1985-2009).

Stroke is associated with diagnostic error 9% of the time (Newman-Toker et al 2008).

For family and general practice, the top diagnoses involved in diagnostic error in descending order were

myocardial infarction, breast cancer, appendicitis, colorectal cancer and lung cancer.

In a study of physician self-reported diagnostic errors, the diagnoses most often involved were pulmonary

embolism, drug reaction or overdose, lung cancer, colorectal cancer, acute coronary syndrome, breast

cancer and stroke (Schiff et al 2009).

Certain diagnoses like pulmonary embolism and aortic dissection may not be found until autopsy, but the

rate of autopsies performed in the US has declined steeply, so these and others are under-detected at an

unknown rate.

http://www.improvediagnosis.org

5/17/2014 www.knowurture.com 11

MYTHS ABOUT DIAGNOSTIC ERRORS

From a Patient’s Perspective

No news is good news.

My doctors are talking to one another.

My doctor is different.

Somebody is in charge of my diagnosis.

There is always an answer.

My hunches don't count as much as my

physician's.

I would be disloyal if I ask for a second opinion.

My insurance won't pay for a second opinion.

The more tests I have, the better.

Diagnosis errors won't happen to me.

•

From a Physician’s Perspective

It won't happen to me.

I can trust my intuition.

We know what they know & know what they don't

know.

I communicate effectively with my patients.

I'm a good listener.

Most diagnostic errors involve rare or uncommon

diseases.

I always make a complete differential diagnosis.

If I made a diagnostic error, I'd find out about it.

I speak with the Radiologist about important tests.

I have a reliable system to track requested tests.

http://www.improvediagnosis.org/?page=Myths

5/17/2014 www.knowurture.com 12

HEALTHCARE INDUSTRY LANDSCAPE

CONTACT

Madhukar Kalsapura

Founder & Chief

Madhukar@knowurture.com

+91 9845035436

Ramnath Sundaram

Co-Founder & Chief – Finance & Operations

Ramnath@knowurture.com

+91 9845147779

THANK YOU