Defining a Conceptual Model for a Future Health Policy and Quality Program

INTERVENTIONS TO REDUCE DIAGNOSTIC ERRORS IN AMBULATORY CAREMark Graber, MD, Stephanie Kissam, MPH, Hardeep Singh, MD, MPH, Asta Sorensen, MA, Nancy Lenfestey, MHA, Elizabeth Tant, BA, Ken LaBresh, MD, and Kerm Henriksen, PhD

Collaborators: RTI International, Northport Veterans Affairs Medical Center, Michael E. DeBakey Veterans Affairs Medical Center and the Houston VA HSR&D Center of Excellence AHRQ Action I Master Task Order Mechanism, Contract Number HHSA290200600001 Task 8

Sponsored by AHRQ

PROJECT GOALSPerform a comprehensive literature review of interventions that could reduce diagnostic errors

Identify and pilot test an intervention targeting diagnostic errors in an ambulatory care settingBLUNT end

SHARP endPatients Clinical Course

SYSTEMMDCommunication, coordination, training, policies, procedures

CognitiveFRAMEWORK FOR ADVERSE EVENTSThis is the basic framework we use to understand adverse events in medicine. If a patient is injured, one can think of the root causes as reflecting one of two possible problems (or both): the provider erred, usually a cognitive mistake or slip, or there were inherent flaws in the healthcare system that contributed to the error. System-related problems include communications breakdowns, problems coordinating care, insufficient training, weak policies, problems in the work environment, and many other factors. So the solutions to diagnostic errors could focus on the cognitive skills of the provider, on the characteristics of the healthcare system, or conceivable on the patient as a possible collaborator in reducing error.

4ETIOLOGY OF DIAGNOSTIC ERRORS

METHODSHandpicked articles: Non-medical databases (business, psychology, military, engineering)Recommendations from expertsAnalysis:All articles reviewed by one of three health service researchersAny questionable inclusions reviewed by collaborating physicians

PubMed database search: 2000 2010 INCLUSION CRITERIAArticles describing tested interventions to reduce error in medical diagnostic settings Studies demonstrating outcome measures in the field of diagnostic errorsArticles providing a theoretical basis on how to reduce diagnostic errors (from any field)

EXCLUSION CRITERIAStudies describing inter-rater or observer variation Articles describing validations of screening instruments, tests, case reports, or techniques to enhance diagnosis Articles describing screening instruments, tests, or technology aides Studies reporting diagnostic error frequency; etiology; or assessments of provider satisfaction, preference, or acceptance of interventions

RESULTSTotal number of articles: 949Articles meeting inclusion criteria:157Tested interventions:37Cognitive: 32System-related: 5Engaging patients:0Suggested interventions:120Hardeep Singh, MD MPH Houston HSR&D Center of Excellence, Michael E. DeBakey VA Medical CenterINTERVENTIONS TO REDUCE DIAGNOSTIC ERRORS IN AMBULATORY CARESYSTEMS INTERVENTIONS

Result of collaboration between RTI International, Northport Veterans Affairs Medical Center, Michael E. DeBakey Veterans Affairs Medical Center and the Houston VA HSR&D Center of Excellence AHRQ Action I Master Task Order Mechanism, Contract Number HHSA290200600001 Task 8.RTI International is a trade name of Research Triangle Institute10SYSTEMS FACTORS Communication and coordination of care issues (transitions)Teamwork/SupervisionTechnology/equipment related issuesOrganizational featuresSafety culturePolicy, processes and procedure related issuesLeadership, management, or personnel problemsInadequate resources or available expertiseTraining issues

11History, exam or ordering diagnostic tests for further work-upPatient-Provider EncounterOrdered tests either not performed or performed/interpreted incorrectly Diagnostic TestsProblems with follow-up of abnormal test results or scheduling of follow-up visitsFollow-up and TrackingLack of appropriate actions on requested consultation or communication breakdown from consultant to referring providerReferralsDelay in seeking care or adherence to appointmentsPatient RelatedLOOKING FOR INTERVENTIONS IN THESE PROCESS DIMENSIONSGENERAL RESULTSOnly 1 of 5 controlled study; 2 were only post-test evaluationsAll effectiveMost interventions in the literature were conceptualLack of standardization in process or outcome measures PATIENTPROVIDER ENCOUNTERChange the process of care deliveryForm designated trauma response team in ERConduct comprehensive reexamination in EREstablish educational programs (suggested only)Reinforce history-taking skillsProvide teamwork training in medical setting

Perno JF, et al. (2005)Howard J, et al. (2006)2 tested interventionsDIAGNOSTIC TESTSImplementation of Picture Archiving and Communication System (PACS) for radiology imagesWeatherburn, G et al. (2000)One tested intervention FOLLOW-UP AND TRACKINGImproving delivery of test results through electronic means

Other suggested interventions: Establish criteria for communication of abnormal test resultsStandardize steps involved in the flow of test result informationImprove management and presentation of test result dataUse an ER manager to monitor radiology test results reportingCreate processes to ensure easy retrieval of test result information Develop highly structured hand-off processes that are performed systematically

2 tested interventionsSingh, H,et al. (2009)Poon, EG, et al. (2002)suggested onlyPATIENTSNotify patients of test results Address patient preferences for receiving test resultsCommunicate normal test resultsUse computerized test results management toolDesignate patient navigator

No tested interventionsPATIENTSProvide patient access to test resultsUse online portal Provide access to entire medical record

Improve patient-clinician communicationConsider cognitive limitations when taking patient historyConsider communication strategies to optimize patient understanding of medical information

Increase patient engagement in health careInvolve patients to ensure the follow-up of test results

GENERAL INTERVENTIONS (NO SPECIFIC DIMENSION)Manage error-producing conditions (suggested only)Provide education on error-producing conditions like fatigueAddress workrelated conditions that could produce boredom, time pressure, etc.Establish systematic tracking of diagnostic error in organization (suggested only)Downstream feedback

CONCLUSIONS SYSTEM ISSUESLimited literature on systems interventions that reduced diagnostic error in ambulatory care Empiric data only for 3/5 dimensions of diagnostic process Many interventions well conceptualized but poorly operationalized as testable interventions Much discussion of methods to notify patients of test results, but little focused on abnormal resultsHealth IT potential and workflow related issues

CONCLUSIONS SYSTEM ISSUESGaps in tested interventions aimed at patientsEfficacy of patient and family engagement in preventing or reducing diagnostic error?Multiple organizations and experts advocate for patient engagement in patient safety, yet limited studies successfully do so No studies report actual interventions engaging patients and families in the process of making medical diagnoses. OPEN DISCUSSION SYSTEM ISSUESQuestion How and when can we effectively engage patients and families in diagnostic error reduction? Mark L Graber MD FACP VA Medical Center, Northport NY & SUNY Stony BrookINTERVENTIONS TO REDUCE DIAGNOSTIC ERRORS IN AMBULATORY CARECOGNITIVE INTERVENTIONS

Collaborators: RTI International, Northport Veterans Affairs Medical Center, Michael E. DeBakey Veterans Affairs Medical Center and the Houston VA HSR&D Center of Excellence AHRQ Action I Master Task Order Mechanism, Contract Number HHSA290200600001 Task 8.23COGNITIVE ERRORS

COGNITIVE ERRORS Most cognitive errorsinvolve breakdowns in synthesizing the available data, due to ..

faulty context assumptionspremature closurethe inherent shortcomings of heuristic (intuitive) thinkingaffective biases and environmental factors that detract from optimal conditions: distractions, fatigue, stress, workload

INTERVENTIONS TO REDUCE COGNITIVE ERRORImprove clinical reasoningGet helpIncrease medical knowledge and expertiseINCREASE KNOWLEDGE & EXPERTISEIncrease training time & events to increase experience (3 tested interventions)

Use simulation to provide compacted experience (1 tested intervention)

Increase feedback to improve calibration and reduce overconfidence (3 tested interventions)

IMPROVE CLINICAL REASONINGImprove evidence-based medicine skills, normative decision-making skillsImprove intuitive decision-makingTeach heuristics & biasesUse de-biasing techniques; improve metacognitionReflective practice; checklists; be comprehensive, consider the opposite

suggested onlyNo tested interventionsGET HELPIncrease consultation, second opinions, fresh eyes

Use decision support tools; increase access to medical knowledge (web access, texts, info buttons)

10 tested interventions12 tested interventionsCONCLUSIONS - COGNITIVE FACTORSA broad array of ideas for interventions (N=157), but few tested (N=37)

Gaps: Most interventions apply to diagnostic specialties (radiology, pathology, laboratory), not the ED or PCTests have been done under artificial conditionsLearning assessed only in the short termTools developed arent used

SUGGESTED PROJECT: CHECKLIST(S)Checklists are ideal in dealing with COMPLEXITY

Checklists can combine system-based, patient-based, and cognitive interventions

Checklists are HOT

A GENERAL CHECKLISTObtain YOUR OWN, COMPLETE medical historyPerform a FOCUSED and PURPOSEFUL physical examinationGenerate some initial hypotheses and differentiate these with appropriate questions, examination, or diagnostic testsPause to reflect Take a diagnostic time out:Was I comprehensive ?Did I consider the inherent flaws of heuristic thinking ?Was my judgment affected by any other bias ?Do I need to make the diagnosis NOW, or can I wait ?Whats the worst case scenario ? What are the dont miss entities ?Embark on a plan, but acknowledge uncertainty and ENSURE A PATHWAY FOR FOLLOW-UP

A SYNDROME-SPECIFIC CHECKLISTCHEST PAIN MI PE Pneumonia Pericarditis Musculoskeletal Gerd Herpes ZosterPleurisy Aortic stenosisTumors lung, lymphoma, mediastinum Spinal cord compression Esophageal spasmPsychiatric

OPEN DISCUSSION COGNITIVE ISSUESQuestion Question 2 What would it take to convince frontline providers to use a checklist ?Question Question Question 3 - Will they help reduce diagnostic errors, or are we better off just trusting our initial (intuitive) diagnoses ?

Question 1 Which would be more effective a GENERAL checklist, or SYNDROME SPECIFIC checklists ?other questions?Measurement of diagnostic errors?How to evaluate quality of clinical reasoning?How do you teach this stuff?

ACKNOWLEDGMENTS:AHRQ, RTI, VA