Challenges and Opportunities in the Pursuit of Better Diagnostic Performance

1. Challenges and Opportunities in the Pursuit of Better Diagnostic Performance Kerm Henriksen, PhD Human Factors Advisor for Patient Safety Diagnostic Error in Medicine: 5th International Conference Baltimore, MD – November 12, 2012

2. Gordy’s Eight Questions • What are the levers to move the agenda and practices forward? • What is your org. doing on the Dx error front? • Where are your (personal/org.) ideas for improving diagnosis and decreasing errors? • What are the reform and policy implications of over-testing and over-diagnosis? • In your view, what works; what doesn’t work? • Where does EMR/HIT fit into your vision & practices? • What are the pitfalls in various policy approaches (discouraging patients’ presenting, less phys. time w/ patients, delegation to non-MD staff, limiting tests)? • Who should “own” the diagnostic error problem – MDs or their HCOs?

3. What Past Conferences Have Taught Us • Reaching a diagnosis too quickly (premature closure) is like falling in love with the first puppy you see Graber, 2007 • Dual process theory with its Sys1 and Sys2 processes has provided a decision-making framework • A rich palette of cognitive, perceptual, affective and system components are involved • Reporting systems haven’t captured Dxerrors • Decision support might help but “not if I’m behind schedule and I’m behind schedule 80% of the time” Sittiget al., 2006

4. What Makes Addressing 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

5. What has AHRQ been doing on the Dx Error Front? • Two Small Conference Grants • Three Large Conference Grants • Special Emphasis Notice (SEN) • Investigator-initiated Grants • Decision Support and Health IT Grants • ACTION-contracted Task Orders • Efforts to Measure and Track Dx Error for National Healthcare Quality and Disparities Reports

6. How do EMRs and Health IT fit into your vision? Purported Benefits Concerns Lack of system standardization and interoperability can limit data sharing No central repository to collect/analyze IT-related safety glitches Most systems are vendor inspired; user needs, workflow, and usability issues have been neglected Data entry/retrieval and awkward interfaces are issues • Information is the lifeblood of health care • With IT, providers can make better decisions, avoid duplication of tests and procedures, and prevent unwanted medication interactions • PCMHs and patient engagement more easily realized • In-home monitoring allows tracking of patient vitals and activity

7. How do EMRs and Health IT fit into your vision? • As currently designed, EMRs and Health IT often add another layer of complexity • The shortcomings need continued attention; vendors and HCOs need to work together on design, implementation and use issues • Users should be involved at the earliest stages of design • It’s not just the technology. IT needs to be aligned with the needs of the greater socio-technical system – the organizations, people, and clinical processes that interact and depend on it. • Improvement is a steady, incremental process.

8. Recent Literature Reviews Find Few Outcome Studies System-related interventions (Singh et al., 2012) Our literature review of system-related interventions to reduce diagnostic error . . . yielded very few empirical outcome studies. . . Our findings highlight a large gap between suggested interventions and those that have been operationalised and evaluated empirically. Cognitive interventions(Graber et al., 2012) We found that most interventions . . . were simply ideas or suggestions. Many of these are well conceptualised and widely endorsed, and seem ripe to be tested in experimental and real-world clinical settings . . . Our findings also affirm that the science of outcome measurement in this area is underdeveloped.

9. Progression of Patient Safety Initiatives • Stage 1: identify problem areas, raise awareness, build capacity and culture • Stage 2: develop innovative measures and approaches, demonstrate viable practices, implement • Stage 3: disseminate, create spread • Stage 4: sustain by integrating into the fabric and infrastructure of work

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

11. 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) Proposed Checklists to Reduce Diagnostic Error

12. Checklists Come with Challenges • It’s not all about the checklist. Evidence-based practices, patient safety culture, teamwork, leadership commitment, measurement , implementation issues all need alignment. • Checklists do not guarantee safety (subject to cognitive drift; performed in perfunctory manner; minimal compliance) • Most successful so far with discrete, observable tasks; diagnostic perceiving, thinking, interpreting are less observable; do these mental activities have a discernable start- and end-point for which a checklist could be used? • Some diagnostic pursuits can be characterized as “wicked problems” – no true or false end-result; actions taken lead to new problems; uncertainty not reduced, but magnified. Are checklists appropriate here?

13. What works; what doesn’t What doesn’t • Expecting quick improvements, simple fixes • Ignoring contextual, organizational and cultural factors • Relying on knowledge in the head • Rushing into control group comparisons before intervention is fully developed • Treating cognitive-based and system-related errors as separate research camps • Raising awareness only What does • Balanced and flexible approach for the long term • Viewing tools and technology as part of larger socio-technical system • Put knowledge in the world • Spend more effort on development and efficacy • Recognize that humans with their biases and flawed systems are not going to disappear; both will continue to impact the diagnostic process • Growing the evidence-base and implementation strategies

14. 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

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

16. 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.

17. Some 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!