Posts Tagged ‘information technology design’

How do we address medical diagnostic errors?

Larry H. Bernstein, MD, FCAP, Curator



It is my observation over the course of 50 years in medicine that there is no simple resolution to a frequently identified problem, which has grown more serious with the implementation of hospital-wide and system-wide health information technology.  There has been reduction of hospital staff, nurses and physicians, with an increased patient load even while the technology has advanced significantly.  Over this investment in technology and manpower the hospital staff time has become dependent on the medical record and a large portion of their time is drawn away from patient care.  This is not a substantial improvement in the last decade.  The problem has been a lack of focus on the correct design of these systems.  They should be interactive and they should have incorporated anticipatory logic.  Instead, they are not that much more than large electronic filing cabinets. There are large sources of information in laboratory, radiology and pharmacy and are siloed.  When one drives a car, one does not need to look under the hood, a sentiment that has been expressed by a real expert.


Diagnostic Errors Get the Attention of the Institute of Medicine, Reinforcing Efforts by Nation’s Clinical Pathology Laboratory Scientists to Improve Patient Safety

March 25, 2016         DARK DAILY via


Along with its assessment of the rate of errors in diagnosis, the IOM has a plan to improve, but will doctors accept the IOM’s advice, or continue business as usual?

Diagnostic errors in the American healthcare system is a problem that is now on the radar screen of policymakers at the Institute of Medicine (IOM). Pathologists andclinical laboratory professionals will welcome this development, because recommendations from the IOM carry weight with Congress.

Thus, should the IOM develop specific actions items intended to reduce medical errors, not only are these suggestions likely to involve more effective use of medical laboratory tests by physicians, but there is a strong probability that Congress might eventually write these recommendations into future healthcare legislation.

The Institute of Medicine is a division of the National Academies of Sciences, Engineering, and Medicine. The IOM recently convened a committee that released a list of recommendations to address the problem of diagnostic errors in medicine. Those recommendations, however, are running up against ingrained mindsets and overconfidence on the part of physicians who are reluctant to include decision-support technology in the diagnostic process.

Misdiagnoses in healthcare has led to tragic consequences. Over the years, the IOM has worked to increase the public’s awareness of the problem of misdiagnosis. It has also encouraged health information technology (HIT) developers to provide clinicians with the decision-support systems they need to prevent misdiagnosis from happening in the first place. But getting physicians to use the new tools has become a challenge.

IOM Dedicated to Improving Diagnostic Accuracy 

Preventing diagnostic errors has been a primary target in medical reform for many years. A 1999 report by the U.S Institute of Medicine (IOM) titled: “To Err Is Human: Building a Safer Health System” first drew attention to the rate of preventable medical errors in the U.S.

Since then, much has been written about the problem of diagnostic inaccuracy. Although many provider organizations are working to improve it, progress has been slow.

Click here to see image

Edward Hoffer, MD (above), FACP, FACC, FACMI, is a faculty member at the Massachusetts General Hospital Laboratory of Computer Science. He told Modern Healthcare that getting doctors to use diagnostic software is a hard sell. “The main problem we face is trying to convince physicians that they actually need to use it,” he concluded. (Image copyright: Massachusetts General Hospital, Laboratory of Computer Science.)

Solutions for Preventing Errors Face Many Challenges

From the first evaluation of the patient, to the clinical laboratory, to physician follow-up; errors can occur throughout the chain of care. And a culture that discourages reporting of medical errors can make it very difficult for healthcare organizations to resolve these issues.

For example, an investigation by the Milwaukee Journal Sentinel uncovered what they say is a “secretive system [that] hides [medical] lab errors from the public and puts patients at risk.”

To make matters worse, according to the Journal Sentinel article, federal agencies that are tasked with oversight of the more than 35,000 clinical laboratories in the U.S. (such as the Joint Commission) are overloaded and thus may be missing many violations that would lead to sanctions or outright loss of accreditation.

The Milwaukee Journal Sentinel stated that, “even when serious violations are identified, offending labs are rarely sanctioned except in the most extreme cases.” And that “in 2013, just 90 sanctions were issued—accounting for not even 1% of the 35,000 labs that do high-level lab testing in the United States.”

Additionally, there are different types of misdiagnoses, which also complicates matters. A study by three professors at the Dartmouth Center for Healthcare Deliver Science investigated the cost of what they termed “silent misdiagnoses.”

According to a Dartmouth Now article outlining the study, the disparity between “the treatments patients want and what doctors think they want” accounts for a great number of misdiagnoses. The study’s authors call these misdiagnoses “silent” because they are rarely reported or recorded.

Click here to see image

Albert G. Mulley, Jr., MD, MPP (above), is Managing Director, Global Health Care Delivery Science, The Dartmouth Institute for Health Policy and Clinical Practice; Professor of Medicine, Geisel School of Medicine at Dartmouth; and the lead author of the Dartmouth study. Mulley says that listening to the patient is more important than ever. “Today, the rise in treatment options makes this even more critical, not only to reach a correct medical diagnosis but also to understand fully the patients’ preferences, and reduce the huge waste in time and money that comes from delivery of services that patients often neither want nor need.” (Photo copyright: Dartmouth Now.)

IOM Committee on Diagnostic Error in Healthcare Releases Recommendations

In September, 2015, the IOM released its latest report in the series of reports about medical errors and diagnostic problems that goes back 17 years. The series started in 1999 with “To Err is Human: Building A Safer Health System” in 1999. This was followed in 2001 by “Crossing the Quality Chasm: A New Health System for the 21st Century.”

This newest report is titled, “Improving Diagnosis in HealthCare.” It comes from the IOM’s National Academies of Medicine’s Committee on Diagnostic Error in Healthcare. The study lists recommendations that the IOM says will help improve the rate of diagnostic errors. Included are:

• Facilitate more effective teamwork in the diagnostic process;

• Enhance education in the healthcare community on the topic of improving diagnostics;

• Incorporate diagnostic support into electronic health records (EHRs), and make EHRs fully interoperable;

• Set up systems to identify, learn from, and reduce diagnostic errors;

• Establish a culture that encourages investigation of mistakes;

• Develop a collaborative reporting system that involves clinicians, government agencies, and liability insurers that allows everyone to learn from diagnostic errors and near misses;

• Design a payment system that supports correct diagnosis; and

• Provide funding for research into how to improve the diagnostic process.

Click here to see video

This video (above) is of the IOM’s public release in September, 2015, of the Committee on Diagnostic Error in Healthcare’s report, “Improving Diagnosis in Health Care.” A full text of the report can be downloaded by clicking here, or by visiting

Technology Exists to Support Accurate Diagnoses

One area of development that offers real hope for lowering the rate of misdiagnosis is medical decision-support software—specifically in clinical informatics, where the integration of health data with health information technology (HIT) supports physician decision making at the point of care.

Whether that software is part of an organization’s EHR system, or is a standalone program dedicated to reducing diagnostic errors, can make a difference. For example, a research study published in the Journal of Clinical Bioinformatics) suggests that health information technology has an important role to play in improving diagnostic accuracy.

The challenge is that, although the technology currently exists, diagnostic error rates remain high. A research study published in the Journal of the American Medical Association Internal Medicine (JAMA) in 2013 may explain why. It states that overconfidence could prevent some physicians from re-evaluating questionable diagnoses.

In a Modern Healthcare article, Edward Hoffer, MD, FACP, FACC, FACMI, a faculty member at the Massachusetts General Hospital Laboratory of Computer Science, said that getting doctors to use diagnostic software is a hard sell. “The main problem we face is trying to convince physicians that they actually need to use it,” he concluded.

All of the building blocks for improving the diagnostic process are either in place, or as in the case of EHR interoperability, in the works. Clinical laboratory personnel are uniquely positioned to assist physicians in improving through communication and the careful use of technology.

—Dava Stewart

Related Information:

To Err Is Human

Weak Oversight Allows Lab Failures to Put Patients at Risk  

Dartmouth Study: ‘Silent’ Misdiagnoses by Doctors Are Common, and Come at Great Cost 

Press Release: Doctors ‘Silent’ Misdiagnoses Cost Patients Dearly . . . And US Health Care Billions

Improving Diagnosis in Health Care

Clinical Decision Support Systems for Improving Diagnostic Accuracy and Achieving Precision Medicine 

Using Software To Avoid Misdiagnoses 

In Conversation with…Mark L. Graber, MD 


All of the building blocks for improving the diagnostic process are either in place, or as in the case of EHR interoperability, in the works.   Nothing could be further from reality than what has been stated.   There is no minimization of keystrokes.  There is no anticipatory logic.  There is no automated comparison of medication and diagnoses electronically.  There is no check to determine the consistency of the laboratory results with a probability of diagnosis, or automated identification of tests that would clarify the situation.


Read Full Post »