Isabel Healthcare Blog

Travel History & Diagnostic Decision Support Tools in the Ebola Fight

Posted by Mandy Tomlinson on Wed, Nov 26, 2014 @ 05:35 AM

I wrote about Ebola and the importance of mobile diagnosis decision support in 2012 when the last outbreak occurred. Now in 2014, West Africa is experiencing the worst outbreak of Ebola in history with as many as 7000 people diagnosed and 3,338 people who have died from the disease. However, these figures may be underestimated due to under reporting and the fact that many cases are not counted as people aren’t attending health care facilities due to lack of transport or as they are full and closed to new admissions.

In the USA, media articles are reporting the Dallas Ebola case of Eric Duncan who had helped carry a pregnant woman in Liberia who was desperately ill with Ebola. Mr Duncan then returned to the USA and presented twice at a hospital with Ebola symptoms, unfortunately he was not diagnosed until his second visit when he presented with severe symptoms. During his first visit to the ED, his travel history of having recently visited West Africa was recorded by a Nurse in the Electronic Health Record (EHR) but due to a system / process / workflow breakdown key members of the care team did not see this vital information.  We could go round in circles allaying blame on the EHR, the Nurse or the Physician but this is pointless. Overall it's a system failure and the lesson to learn is how could this have been prevented from the onset and rectified so it doesn't occur again.

I trained in Infectious diseases and saw many different conditions which were rare infectious diseases by all accounts but what was fundamentally at the core in ensuring an accurate differential diagnosis for the symptoms the patients presented with was their travel history. I worked in a tertiary referral hospital for Infectious Diseases where the scenario we were repeatedly faced with was the following:   patients came to us having been unwell with their symptoms for several weeks or months and the common diseases had been worked up and ruled out. Yet because no causative agent had been found and the patient was normally worsening they were then referred to our hospital as a last resort as all other options had been exhausted.

What was interesting to see was the way the patients were worked up and examined from the admitting nurse who took a Nursing history (which always included asking about recent travel history) to the Junior Doctors (F1/F2) who took their own history, to the Specialist Registrar and Consultant who would then review the history and often take their own history or ask further questions to the patient and their family in order to gain more information which from their own experience would help assist in making a final diagnosis. Always the recent travel history was investigated and even travel history going back a number of years as well as exposure to other diseases including Infectious diseases and contact with animals or vegetation. You may think all this history taking is overkill but what was interesting on examining the notes of these Physicians and Nurses at different levels of experience was how they differed with essentially the same story being relayed by the patient. A good history and physical examination is fundamental aspect of medicine - unless you ask the correct questions you will not get the answer from the patient. What you are doing is building a puzzle out of clues which will help you find the final piece which you need to complete the puzzle.   These difficult or interesting Infectious cases where then taken to a weekly grand round where all the departmental medical and nursing staff would meet to dissect these cases, seek out more information and discuss what the next steps would be for the patient. With so many members of the wider team present for these Grand Rounds from Professors to medical/nursing students with a combination of many hundred years of experience within Infectious Diseases it was fascinating to watch and explore all forms of diseases from around the world and ultimately work out a differential diagnosis and work up for the patient to rule out diseases until the causative disease was identified and the patient successfully treated and discharged

Isabel the diagnosis decision support tool was constructed based on these templates from the Grand Round of working through cases and constructing an accurate clinical picture, creating a differential diagnosis list. Indeed the first data source and detailed part of the database was Infectious Diseases. It was realised in order to make Isabel as powerful as possible that for every disease in the database we needed to attach codes to ensure it was searched accurately by age, gender and region where the Infectious Disease occurred. This also ensured that diseases such as Malaria would only show in regions where malaria is endemic and the same for Ebola. As outbreaks occur and a disease moves to other regions as is endemic in Infectious Diseases the same process can occur with the Isabel database as it is served over the internet we can update the data to ensure its showing real time disease data for symptoms entered and the differential diagnoses list it produces. The Isabel user will initially see we give a search for symptoms based on the region where the Isabel user has set up an account but on the page where the results are generated a new field is made available stating travel history. From the clinical exam and medical history taken the Physician can then alter the region depending on the patients recent travel history and obtain a list of diagnoses from the symptoms entered which are specific to the region the patient has travelled to or from.   With Isabel integrated into Electronic Health Records this process can be automatically generated by pulling this information from age, gender, travel history and physical exam fields.

The health care professional is the key in this whole process.   From their enquiring minds, asking the appropriate questions, listening to the answers given by the patient, examining the patient and writing detailed documentation of their findings with a good differential list, they ultimately find the best and successful treatment for the patient. Every health professional who then subsequently comes into contact with the patient should be reassessing the history given and the patient’s current symptoms and always have an open mind so as not to prematurely close of all options available to them.

Diagnosis reminder tools such as Isabel are there to assist Physicians in generating a differential diagnosis but what's important and fundamental in preventing diagnosis error is a good physical exam, accurate history taking including recent travel history, tools are only as good as the information which is fed into them and these will help prevent system wide failures.

West Africa travel history for Ebola Dallas Case

ebola

 

 

 

5 Year Forward Report - NHS England Key points on Diagnosis

Posted by Mandy Tomlinson on Thu, Oct 23, 2014 @ 08:36 AM

 NHS England today 23rd October 2014 has published its 5 Year Forward Report which shows the NHS is at a cross road and needs to change and improve as it moves forward. The report is a collaboration between the six leading NHS groups including:

Monitor

Health Education England

The NHS Trust Development Authority

Public Health England

The Care Quality Commission

NHS England

As well as these leadership groups the report has been developed in partnership with patient groups, Clinicians, the voluntary sector and think tanks.

With regards to diagnosis and the NHS the report covers the following areas:

  • “Technology is transforming the ability to predict, diagnoses and treat disease.” 

  • “70,000 people in England are estimated to have dementia and many are undiagnosed.  The NHS is making a national effort to increase the proportion of people with dementia who are able to get a formal diagnosis from under half, to two thirds of the people who are affected.  Early diagnosis can prevent crises and treatments available may slow down the progression of the disease.

  • “Five year ambitions for Cancer.  One in three of us will be diagnoses with cancer in our lifetime.  Fortunately half of those with cancer will now live for at least ten years, whereas forty years ago the average survival was only one year.  But cancer survival is below the European average, especially for people over 75, and especially when measured at one year after diagnosis compared with five years.  This suggests that late diagnosis and variation in subsequent access to some treatments are key reasons for the gap.  So improvements in outcomes will require action on three fronts: better prevention, swifter access to diagnosis, and better treatment and care for all those diagnoses with cancer.  Faster diagnoses.  We need to take early action to reduce patients currently diagnoses through   A&E   – currently about 25% of all diagnoses.  These patients are less likely to survive a year than those who present at their GP practice.  Currently, the average GP will see fewer than eight new patients with cancer each year, and may see a rare cancer once in their career. They will need support to spot suspicious combinations of symptoms. If we are able to deliver the vision set out in this.  Forward view at sufficient pace and scale, we believe that over the next five years, the NHS can deliver a 10% increase in those patients diagnoses early, equivalent to about 8,000 more patients living longer than five years after a diagnosis.”

  • “Medicine is becoming more tailored to the individual; we are moving from one-size-fits-all to personalised care offering higher cure rates and fewer side effects…..developing a ground-breaking new intiative….to decode 100,000 whole genomes within the NHS.  Clinical teams will support this applied research to help improve diagnosis and treatment of rare diseases and cancers” 

  • Health services redesign research to understand how patients access services and how to improve them.  “An example of the sort of question that might be tested: how best to evolve GP out of hours and NHS 111 services so as to improve patient understanding of where and when to seek care, while improving clinical outcomes and ensuring the most appropriate use of ambulance and A&E services”.

 How can Clinical Decision Support Tools help the NHS meet these 5 year targets?

  • The NHS has recognised technology is enhancing and transforming healthcare in the UK.  With an aging healthcare population in the UK due to people living longer they acknowledge they need to tackle early diagnosis of dementia, cancers and other rare genetic and metabolic diseases.  As with many medical conditions (but especially dementia and cancer) by detecting them early and treating them the outcomes are much more favourable especially as there are many good treatments available if diagnosis is made in a timely fashion.  The NHS has investigated and found that 25% of cancers are diagnosed in Accident and Emergency rather than being detected by GPs earlier in previous consultations.  By this time the cancers may be more difficult to treat as they are further advanced.  The key to offering support to GP’s and other primary health care workers is to implement clinical decision support tools.  Isabel PRO  covers over 6,000 diagnoses and when you consider out of this figure 4,000 are classified as rare diseases then the importance of having a tool where a medical practitioner can enter patient’s clinical symptoms and findings from their physical examination to search through a potential list of causative diseases cannot be underestimated.  As the report highlights a GP in their whole career may only see one case of a very rare cancer and how can they be expected to remember the key differentiating symptoms of that cancer when it could be numerous other more benign clinical conditions.  By not expanding their differential and considering the rare diseases they could be at risk of premature diagnosis closure and miss the diagnosis.  Isabel PRO offers a reminder of the rare and also the more common clinical conditions that should be considered and worked up to arrive at a final diagnosis. By detecting dementia, cancer and rare diseases early and therefore offering treatment early this will enable the NHS to meet their five year aims to improve on early diagnosis rates and hopefully exceed the European average for early detection.

  • Engaging patients and involving them in Health service access is key to enabling patients to work as a partnership with their health care providers.  A patient is often unsure in the ever changing NHS how to access the correct health care services available to them and work out where they should go based on the symptoms they are experiencing.  Many patients research their symptoms online or look up health information trying to find out where they should go to access healthcare.  This allows the patient to think through their symptoms and formulate the story of how their symptoms have presented.  This ensures the patient has done their research and can then make best use of the appointment time they have been given with their GP or health care provider.  This will allow the health care provider to expand on more directed questions with the patient on their symptoms and more time to perform a physical examination in the limited time they are given for their appointment.  This will allow a more informative discussion between the health care provider and patient and they will work as a team to work through the next steps to be taken and arrive at a final diagnosis quicker. 

The Isabel Symptom Checker enables patients to research their symptoms by entering what they are experiencing in non-medical terminology and then take a copy of the symptoms they have entered to their health care provider and facilitate an active discussion with their provider. A new feature of the Isabel Symptom Checker currently being beta-tested it to provide some information via a Where to now? application. Based on the symptoms entered and questions answered a suggestion is offered for the patient to examine and decide where they may want to go for further help which includes:

Pharmacy / Walk In Centre

GP/Primary Care Physician

Accident & Emergency

This feature could help the NHS assist patients in accessing their healthcare services.

Technology and support tools for Physicians/Patients are readily available and could help the NHS reach their five year targets on early diagnosis and patient engagement mentioned in this report if they are adopted more widely.

 

 

Topics: clinical decision support, early diagnosis, NHS, cancer, dementia

You should know about a symptom checker

Posted by JASON MAUDE on Mon, Feb 24, 2014 @ 07:18 AM

There is increasing coverage and discussion in the press about the empowered consumer and all the tools that are now available for people to use to help be empowered. The symptom checker is one of the key tools that consumers should use as it helps make sense of all the data such as symptoms, abnormal test results or abnormal readings from the various monitors that are now available.

There is a great regular Podcast series called “Stuff you should know” http://www.stuffyoushouldknow.com/ hosted by Chuck Bryant and Josh Clark and, earlier this month, they released a Podcast called “Will computers replace doctors?”  The full podcast is 36 minutes long and can be accessed from this link http://www.stuffyoushouldknow.com/podcasts/computers-replace-doctors/

We have edited this to produce an abridged version if you want to listen to just the segments related to diagnosis and using diagnosis decision support tools or symptom checkers.  Click here to listen to the edited podcast. A full transcript of the edited version is also provided in italics below.

As Chuck and Josh observe, there is an increasing desire by people to monitor their health and take more control in how they interact with their doctor. Most consumers have done some research, internet searches, etc prior to their visit to the doctor.  This engagement by the healthcare consumer can lead to a more productive visit and assist with the outcome of the visit.  No longer are they going just to be told what’s wrong with them but want to have a meaningful exchange with their physician based on what they have learned; asking questions like “what else could this be or what are the treatment options" etc.

A proven symptom checker, like diagnosis decision support mentioned in the blog, enables healthcare consumers to enter their symptoms and receive back a list of diagnosis possibilities, including both common and rare conditions.  Having a list of likely diagnoses to discuss with the doctor rather than just sitting passively waiting to be told what the doctor thinks engages the healthcare consumer to care about their care and, in turn, are more likely to engage in their treatment as well.

Diagnosis decision support for physicians and symptom checkers for consumers are formidable tools for both in helping to get to the right diagnosis and treatment as soon as possible but also in facilitating an informed conversation between the patient and physician.

symptom checker discussion

Narrator: Welcome to Stuff You Should Know from howstuffworks.com.

Josh:    Hey, and welcome to the podcast. I'm Josh Clark. There's Charles W. 'Chuck' Bryant. Our guest producer Noel is here. To me, and I don't think it's over confirmation bias, it seems like there really is a growing desire among just average ordinary people to be able to track their health...

Chuck:             Yeah.

Josh:    ...their well being, their activity...

Chuck:             Yeah.

Josh:    ...and to do it easily.

Chuck:             Yeah...

Josh:    Yeah. It seems to me this desire to kind of say hey, this is my health. This is my body.

Chuck:             Yeah.

Josh:    I want to know more about it.

Chuck:             Totally.

Josh:    Like, I don't want to necessarily cut out doctors, but I want to decide if I should go to the doctor if it's time or not.

Chuck:             Yeah.

Josh:    And, I want to use data to do that.

Chuck:             Yeah. I imagine I frustrate a lot of doctors, because I'm one of those obnoxious people that goes in and is like well, here's what I think I have based on my research.

Josh:    There's nothing wrong with that.

Chuck:             Yeah...

Josh:    That is what... You're an informed patient.

Chuck:             True.

Josh:    That's exactly what you're supposed to do, and if you're getting on your doctor's nerves then go see another doctor.

Chuck:             Yeah. I mean there's two sides to this. There's diagnoses and treatment. Some programs... A little bit of the history. This goes back to the 1970's at the University of Pittsburgh. They developed software to diagnose problems. Mass General since the 1980's has been working on their DX plan which provides ranked lists of diagnoses. Whereas the... What's the computer, the Watson?

Josh:    Watson, who won at 'Jeopardy.'

Chuck:             Yeah. That's more based, it looks like, on treatment options than diagnosis at this point.

Josh:    It's both.

Chuck:             They're using these... Well, yeah, but they said it's not... They haven't... I don't think they want to leave it alone with diagnosis yet...

Josh:    No.

Chuck:             ...and to do its thing.

Josh:    There's already something out there for diagnosis that's meant to support physicians.

Chuck:             I know we looked into this one, sort of a savant diagnoser. Is that a word?

Josh:    I don't know.

Chuck:             Diagnostician?

Josh:    Diagnostician, yeah.

Chuck: Dr. Dhaliwal in San Francisco is sort of legendary for diagnosing things to the point where he does it on stage as almost like a parlor trick.

Josh:    I would love to see it.

Chuck: I would, too. They give him 45 minutes and a bunch of symptoms basically, like really confusing, because they're trying to stump him.

Josh:    Right.

Chuck:             Generally, he comes out on top. But, he even uses a diagnostic program called Isabel.

Josh: Right.      That's the one I said earlier that's already here.

Chuck:             Yeah. Doctors are using these to help themselves out. But, he says that he's never had Isabel offer a diagnosis that he has missed.

Josh:    Right.

Chuck:             He's like the dude, though.

Josh:    Yeah, and he also admits that he's like a freak of nature.

Chuck:             Right - go ahead, quiz me.

Josh:    Exactly.

Chuck:             Yeah.

Josh:    He also reads case histories for fun, that kind of stuff. He's not...

Chuck: He really puts the time into it.

Josh:    ...a normal physician. He's a complete and total outlier.

Chuck:             Yeah.

Josh:    If every physician were like this guy then there probably wouldn't be this conversation going on right now.

Chuck:             Yeah, you're right.

Josh:    But, most physicians aren't, and it's not just with current medical research that they're just not aware of because they haven't had time to pick up 'The Lancet' the last few months.

Chuck:             Yeah.

Josh:    It's also their training, too. Like, if a doctor's in practice for 20 years... The human brain tends to create habits, because it likes to expend as little energy as possible. It's trying to be as efficient as possible. I think the same thing happens with medical practice. You're trained. You understand. You come out of medical school with a lot of book learning. Then, you put it to practice and you kind of find your niche. Along the way you forget a lot of the stuff...

Chuck:             Oh yeah.

Josh:    ...that you haven't done in 20 years or haven't learned about in 20 years. It's not just current stuff. It's old stuff, too.

Chuck:             Well, here's a scary stat. One in five diagnoses in the United States are incorrect or incomplete. One in five. A lot of times it's not that the doctor's a jerk or not any good. But, like you said, they just maybe haven't seen these cases that were written about in some obscure medical journal that the computer has scanned and indexed.

Josh:    Dr. Dhaliwal himself says even with me a lot of it is intuition...

Chuck:             Yeah.

Josh:    ...and intuition can be wrong.

Chuck:             Yeah. I have this one stat, too. It says according to an expert - I'm not sure what that means, it sounds hinky - only 20 percent of the knowledge of physicians used to diagnose is evidence based. So, that means 80 percent is intuition?

Josh:    Yeah.

Chuck:             I like the idea of intuition to a certain degree, for sure.

Josh:    Yeah.

Chuck:             But, there's also got to be, like, data backing it up.

Josh:    Sure, right.

Chuck:             You know.

Josh:    So, in your perfect world then it sounds like we still have physicians, but they go back and double check themselves using a program. Okay. Tell me your alarming stat.

Chuck:             All right. Johns Hopkins did a study that found as many as 40,000 patients die in intensive care each year in the US due to missed diagnosis. 40,000.

Josh:    Man.

Chuck:             And, another study found that system related factors like lack of teamwork and communication or just poor processes...

Josh:    Yeah.

Chuck:             ...were involved in 65 percent of diagnostic error, and cognitive factors in 75 percent with premature closure as the most common - which is basically just sticking to that initial diagnosis and not being open minded to other second opinions.

Josh:    Yeah. There's this thing called 'anchoring bias' that was in that 'New York Times' article...

Chuck:             Yeah, yeah.

Josh:    ...with Dr. Dhaliwal. The guy who created this program that's now around to support diagnostics where a physician will say I think it's this, but let me put in the symptoms and ask Isabel...

Chuck:             Yeah.

Josh:    ...which is the name of the program. It's named after the guy who created the program's daughter.

Chuck:             Oh, man, that story's rough.

Josh:    Yeah. When she was three, he took her to the hospital and the doctors said well she has chicken pox. She did indeed have chicken pox, but that's all they looked at.

Chuck:             Yeah.

Josh:    They completely missed a pretty nasty case of necrotizing fasciitis...

Chuck:             Yeah.

Josh:    ...which we've talked about before.

Chuck:             Oh yeah.

Josh:    Flesh eating bacteria. She almost died from it and was disfigured from it as a result.

Chuck:             Yeah.

Josh:    Her father who was a money manager said I'm going to take whatever computer programming skills I have and put it toward this program Isabel which is meant to say yes you're right with this diagnosis I agree with you, or have you considered these other diagnoses.

Chuck:             Yeah.

Josh:    He said had Isabel been around and his daughters' doctors consulted it they would not have missed the necrotizing fasciitis.

Chuck:             Well, it makes sense - as an assist, you know. There's this company called Lifecom that said in clinical trials if you use a medical diagnostic program as an assist those engines were 91 percent accurate without using exams or imaging or labs even.

Josh:    Really just symptoms.

Chuck:             Yeah.

Josh:    That's crazy. That's really, really, really good.

Chuck:             But, as an assist then I think it's kind of a no brainer...

Topics: symptom checker, symptoms, symptom checkers

“The Biggest Mistake Doctors Make” is diagnostic

Posted by JASON MAUDE on Tue, Nov 19, 2013 @ 12:53 PM

The Wall Street Journal ran a special report on healthcare this week and included two great articles that both referred to the Isabel diagnosis decision support tool:

Diagnostic error received scant attention only 2-3 years ago but now consumer press articles in highly respected papers such as the Wall Street Journal and peer reviewed studies in high impact journals are appearing frequently.

This lack of attention has always seemed odd when internal analysis of serious incidents invariably finds missed or late diagnosis to be the cause wherever it happens.

A recent study looking at appropriate prescribing of antibiotics using decision support even found the real problem was that the initial diagnosis made was incorrect over 30% of the time. This demonstrated the complete futility of trying to improve healthcare without improving diagnosis, the first and most important decision made about the patient

Bob Wachter is one of the leading patient safety figures in the USA and writes a very popular blog. He recently wrote one called “Diagnostic Errors: Central to Patient Safety, Yet Still In the Periphery of Safety’s Radar Screen”. The first comment made to the article was profound and is included in full below:

You can either have excuses or get results–but you can’t have both.

Several years ago, our integrated system recognized the limitations of the National Quality Forum’s Serious Reportable Events and The Joint Commission’s Sentinel Events. Some of our leaders added a few additional events, one of which is: “Death or Serious Disability After a Missed Diagnosis”. This is a Board level report that triggers a full event response–immediate actions including a full Root Cause Analysis, identification of causative factors, action plans, and sharing across the system.

Next week, I will be presenting our monthly events to the Board. It’s a solemn and sombre experience. This month, half of our new events are diagnostic errors.

We certainly don’t have all the answers when it comes to diagnostic error, nor do we have all of the solutions.

We have changed the culture by identifying Diagnostic Error as a system failure until proven otherwise. In doing so, we’ve provided visibility to a closeted issue, begun the long journey of learning, and most important, started to heal our patients and staff for many events that seem frankly incomprehensible.

You can wait around for Superman or Godot or you can control your own destiny. I strongly advocate the creation of a structure within your own healthcare systems to learn, share, prevent harm, and heal.”

I firmly believe that the great tool to help improve diagnosis is the differential diagnosis. It's been taught for over 100 years yet is not carried out in routine practice in spite of research showing a differential diagnosis that includes the correct diagnosis is the most accurate predictor of diagnostic accuracy. Lack of time is often the reason given for not doing this but with modern diagnosis decision support tools available for clinicians and symptom checkers available for patients there should be a renewed focus on carrying out the valuable discipline of working up a comprehensive differential diagnosis. 

Topics: diagnostic error, Differential diagnosis, symptom checker, patient safety

Guiding patients early crucial to flow through to primary care

Posted by JASON MAUDE on Fri, Nov 08, 2013 @ 11:52 AM

A study entitled ‘The Ecology of Medical Care Revisited’ from the NEJM of June 2001 graphically shows how important it is to try and guide and influence the patient from a very early stage in order to ensure appropriate flows into primary and secondary care. Encouraging patients to use a symptom checker could be one way to help them at that crucial stage when they are considering seeking care.

The study looks at a population of 1,000 men, women and children and shows how many of those 1,000 in an average month report symptoms, consider seeking medical care, visit their doctor and finally end up in hospital.

The results showed that, on average, for 1,000 people each month:

800 report symptoms

327 consider seeking medical care

217 visit a doctor, of which 113 go to primary care

65 visit a complementary or alternative provider

21 visit a hospital outpatient clinic

14 receive home health care

13 visit an emergency department

8 are hospitalised

1 or less end up in an academic medical centre

Clearly the behaviour of the 80% that report symptoms and 33% that consider seeking medical care has an enormous bearing on subsequent flows to primary and emergency care.

You can start guiding your patients by providing them with the right tools.  The Isabel Symptom Checker enables patients to enter multiple symptoms in everyday language and read up on possible diagnoses. Each diagnosis is linked to knowledge from various commonly used resources such as Medline Plus, Wikipedia, NHS Choices, patient.co.uk etc. 

symptom checker helps when patients seek care

Topics: symptom checker, primary care

Patients’ diagnostic accuracy better than physicians!

Posted by JASON MAUDE on Mon, Oct 07, 2013 @ 11:52 AM

Perhaps a controversial headline but a study recently appeared in JAMA (Journal of the American Medical Association) ‘Physicians' diagnostic accuracy, confidence and resource requests which revealed some rather shocking figures about the levels of physicians’ diagnostic accuracy, confidence and the contribution to diagnostic accuracy made by lab tests and imaging.

  • The study is brilliant and the authors are to be congratulated. However, the results, which show a diagnostic accuracy rate of 55% for the easy cases and just 6% for the hard cases, are truly shocking and the authors’ statement that  "overall diagnostic accuracy was rather low- 31% across the 4 cases” must be the understatement of the year!
  • The cases used for this study are known to be quite difficult so one could excuse a low level of accuracy if the physicians weren’t so confident that they were right. The study looked at how confident the physicians were in their diagnoses and what was also shocking was how little their level of confidence changed from the easy to hard ones. For the easy cases it was 7.2 out of 10 and for the hard cases it was 6.4 out of 10. So, even with an accuracy rate of only 6% for the hard cases, the physicians were still 64% confident that they were right! The issue here from the patient’s perspective is they can put up with 6% accuracy if they know that the person is only say 10% confident of being right as they know where they stand but if it’s a respected professional who appears confident this can be very dangerous. With the high confidence and low accuracy the patient has the illusion that he’s being reasonably well looked after.
  •  The study also looked at the accuracy at 4 different chronological stages in the diagnostic process:
  1. Chief complaint and medical history
  2. Physical examination
  3. General laboratory and imaging
  4. Definitive or specialized laboratory and imaging.
What is alarming is that the accuracy of diagnosis appears to have been barely improved after the history and physical stages with the labs and imaging, begging the question what is the point of all that expensive testing? Perhaps this shouldn’t be a surprise when one of the old adages in medicine is that 75-80% of the diagnosis is revealed by the patient’s story. The lab tests should just be used to confirm a suspected diagnosis but not as a scattergun approach that hopefully reveals the answer.
  • Lack of time did NOT seem to be an issue in the low levels of accuracy, although physicians often cite this as a problem. It seems that the high levels of confidence meant that the physicians did not request additional resources. Rather than the term 'over confidence' a more apt explanation may be the 'illusion of knowledge'; the over confidence resulting from the illusion of knowledge. My personal view is that often a lack of time is simply an excuse not to do something which is either not perceived as sufficiently important or where the person believes they know what they need to already. 
  • The 31% overall rate of physician accuracy could be compared to results from a Pew Survey written up in a previous blog which showed that 41% of patients ‘own diagnoses were confirmed by their physicians! This is clearly taking both studies out of context but the point to emphasise is that physicians' diagnostic accuracy is far less than they would like to believe and that patients’ diagnostic accuracy is far better than physicians tend to assume. This is a perfect argument for the two groups to work together as a team towards a jointly created differential diagnosis.
  • One of the solutions suggested in the study is  "engaging patients in creative ways". One could be actively encouraging patients to use a sophisticated symptom checker, like Isabel, before the consultation so that they could contribute more productively. With the Isabel symptom checker integrated into a patient portal, the patient could enter their details before the consultation which could then be available through the institution’s EMR system so that when the patient presented the physician could bring it up on his computer and discuss it with the patient.Technology is the driving force behind patient engagement which allows patients to become more involved and more proactive in managing their healthcare outcomes.  Patient engagement tools like symptom checkers, drug databases and medical calculators provide instant access to health information and ensure patients become active participants in their healthcare.        

Topics: symptom checker, symptom checkers, patient engagement, diagnostic decision support

How to avoid Diagnostic Errors in the ED - Robert Hitchcock, M.D.

Posted by Mandy Tomlinson on Wed, Aug 28, 2013 @ 07:53 AM

It is with great pleasure that we introduce our guest post from Robert Hitchcock, M.D., FACEP, Chief Medical Informatics Officer, Vice President, T-System, Inc. describing 'How to avoid Diagnostic Errors in the Emergency Department'.

diagnostic errors in the EDDr. Robert Hitchcock is a frequent contributor to highly regarded  industry  print and online publications, and was the reader's choice No. 3 pick for ONC National Coordinator in a poll conducted by Modern Healthcare magazine. He has more than 20 years of experience in healthcare with more than 10 years as a practicing emergency physician. Along with his role as T-System’s CMIO, Hitchcock is a practicing ED physician. He currently serves on the Emergency Department Practice Management Association (EDPMA) board of directors and the ACEP EM Informatics section. He received his medical degree from SUNY  Stony Brook and his Bachelor of Arts in Computer Sciences from SUNY Oswego.

The unique environment of the emergency department (ED) makes it more prone to diagnostic errors than other settings of care. It’s imperative for EDs to optimize the diagnostic process in order to avoid serious errors in patient care.

 What makes the ED unique?

  • ED physicians only have one shot at getting it right. They’re likely not seeing a particular patient again – and, even if the patient comes back, he or she will likely see another physician.
  • The time frame to reach the correct diagnosis is measured in minutes to hours and follow-ups the next day are rarely an option. This creates an imperative to get the diagnosis right the first time.
  • Without a previous relationship with the patient and often limited access to previous records, ED physicians lack much of the information necessary to help inform their decisions. Even with the data, the physicians and staff generally don’t have the time to parse through it.
  • The ED is a chaotic environment with numerous opportunities for interruptions. Physicians and nurses can easily get distracted and, without the right tools, distractions can lead to errors.
  • ED physicians are accustomed to treating common chief complaints with common diagnoses. Diagnostic decision support tools can help avoid cognitive errors and provide assistance with atypical presentations of diseases. 

 Top criteria to look for when selecting an ED diagnosis tool:

  • Limits data entry burden
  • Requires only data expected to be available to the practitioner at any time
  • Presents support based on the most current medical literature
  • Includes “artificial intelligence” learning – the output is based on a system’s ongoing fluid and dynamic learning as opposed to human programmed rules
  • Produces plausible diagnoses and next steps
  • Provides available references as to why the system concluded with a decision
  • Output can be filtered and ranked based on need (high-risk diagnoses, likely medication side effects, etc.)

Diagnosing and treating most patients is straight forward.  In atypical cases, physicians need the right tool to help them quickly and easily reevaluate the diagnostic process. The decisions the ED physician makes drives the next stages of patients’ care, and diagnosis errors can have a broad negative impact on more than just the patients’ ED visit. For example, if a patient is diagnosed with pneumonia in the ED and admitted, the admitting physician will likely treat them for the next day or more for pneumonia. Before you know it, you’re two or more days into admission before it becomes evident something else is going on.

Increasingly, technology provides opportunities to improve patient care, but also has the
potential to complicate a physician’s work flow. The right technology solutions with the right attributes can naturally fit in and help ensure patient safety while protecting efficiency.

                                           

 

Topics: clinical decision support, diagnosis decision support, T-systems, Robert Hitchcock, www.isabelhealthcare.com

1 Minute Read: Normal Labor and Delivery

Posted by Mandy Tomlinson on Mon, Jul 22, 2013 @ 11:14 AM

With the Duchess of Cambridge being admitted to the Lindo Wing at St Mary’s Hospital, Paddington, London there is worldwide interest as to when the royal baby will arrive, especially as her husband the Duke of Cambridge was also born there.  Isabel Healthcare which produced the Isabel clinical decision support system for Health Professionals and the Isabel Symptom Checker has strong links with St Mary’s Hospital in Paddington as it is where Isabel Maude was treated, at age 3, with Necrotizing Fasciitis on the Pediatric Intensive Care Unit (PICU) after being misdiagnosed at her local hospital. It is where Jason Maude and Clinicians from St Mary’s conceived the structure of what became the Isabel clinical decision support system.  Further reading on how Isabel was developed can be found here.

Background and Overview:

Labor is the sequence of physiological events that results in a fetus being transported from the uterus through the birth canal to delivery as an Infant.  Labor is a clinical diagnosis where many things happen including:

  • Changes in cervix ( lower part of uterus which connects with vagina) to allow passage of the fetus through the birth canal
  • Synchronous, coordinated contractions of the cervix to produce the hormone Oxytocin which facilitates the  thinning of the cervix membranes and movement of the fetus into the vagina for delivery.  The Contractions progress in magnitude, duration and frequency as the labor progresses.

Labor is divided into three stages:

Stage 1 (Cervical stage): This occurs from onset of uterine contractions until full dilation of the cervix at 10 cms.  Stage 1 contains the latent phase where contractions are mild, short and irregular (less than 45 seconds).  The uterus contracts but there is little change in cervical dilation or effacement (thinning of the cervix).  The next phase of stage 1 labor is called the active phase which begins around the time of cervical dilation of 3-4 cm and contractions are strong, regular (every 2-3 minutes) and last longer than 45 seconds.

Stage 2:  This is from onset of complete cervical dilation (at 10 cms) to the time the Infant is delivered.  This stage is influenced by the 3 P’s: Passenger (Infant size and presentation), Passageway (size of pelvis and soft tissues), Power (uterine contraction strength).

Stage 3:  This stage occurs from when the Infant is delivered until delivery of the placenta.  This stage can be as quick as 10 minutes but can sometimes take up to 30 minutes.

The length of time it takes for these three stages to be completed varies for each woman.  Typically the lengths of the first 2 stages for women who have never given birth to a live infant before are significantly longer.

Symptoms of Labor:

  • Intermittent low abdominal pain with or without low back pain, occurring regularly at least every 5 minutes.
  • Each episode lasts 30-60 seconds.
  • Sudden release of clear fluid from vagina or constant perineal wetness can represent rupture of membranes (rupture of amniotic sac the baby is in inside the body).  This can also be called “breaking of waters”. This may not happen until the fetus is in the second stage of labor.   Sometimes the waters can rupture prematurely before labor contractions start.  If you experience this release of clear fluid then you should contact your Obstetrician or Midwife.

It should be noted that patients in the third trimester (final three months of pregnancy) who have abdominal pain or vaginal bleeding should contact their Obstetrician or Midwife as vaginal bleeding is not associated with labor and could be an indication of abnormal labor complications such as placental abruption or placenta previa.

Physical Examination and Workup:

Once you have been seen by a Midwife or Obstetrician they will perform some examinations and tests to confirm you are in labor and what stage you are at:

  • Assess fundal height – height of top of uterus to the top of the pelvic bone to determine fetal growth and development compared to number of weeks of pregnancy.
  • Sterile pelvic exam to assess cervical dilation (how many centimetres dilated) and effacement how thin the cervix is) unless vaginal bleeding is present then the pelvic exam shouldn’t be performed.
  • A complete blood count, type and screen should be sent.

The patient is assessed to correctly determine they are in labor and rule out other possible diagnoses which could explain their symptoms including:

  • Braxton Hicks contractions (false labor) which are irregular uterine contractions without associated cervical changes and contractions can be every 10-20 minutes
  • Muscoskeletal back pain
  • Uterine ligament pain
  • Other causes of abdominal pain including appendicitis, ovarian cyst or a urinary tract infection

Pain Control during Labor:

Various methods can be employed during labor to relieve pain and your Obstetrician or Midwife would have discussed these with you in your birth plan prior to being admitted in labor.

 Some common methods are:

  • Self-help: learn about labor, how to cope with the pain, visit the antenatal unit where you may give birth.  Learn how to relax and stay calm.  Bring a partner, relative or friend with you.
  • Gas and Air (Entonox) – This is a mixture of oxygen and nitrous oxide gas.  It won’t remove all the pain but can help to reduce it and make it more bearable.  It’s easy to use as delivered through a mouthpiece and you control how often you want to use it and when.  There are no harmful side effects to the baby but it can make you feel light-headed, sick, sleepy or unable to concentrate.
  • Pain Killing Injections – Intramuscular injection into the thigh or buttock of a drug such as Pethidine can help you relax and lessen the pain.  After the injection is administered it can take 20 minutes to work and the effects last 2-4 hours.  The side effects can make you feel sick or woozy and  if the effect hasn’t worn off by the time you have to start pushing it can make it difficult to push in the second stage of labor.
  • TENS – Transcutaneous Electrical Nerve Stimulation.  These can be hired or some hospitals have one you can borrow.  It’s most effective during the early stages of labor during the latent phase of stage 1 rather than the active phase.  Electrodes are taped onto your back and are connected to the machine or simulator.  You press a button on a handheld attachment which delivers small amounts of current through the electrodes.  It is believed to work by simulating the body to produce endorphins which are its own natural painkillers.  It also reduces the number of pain signals sent to the brain via the spinal cord.
  • Epidural anaesthesia – An anesthetist in the hospital sets up an epidural (injection into lower back containing an anesthetic) which numbs the nerves which carry the pain impulses from the birth canal to the brain.  For most women, an epidural gives complete pain relief and can be helpful for women who have a long or painful labor.  Side effects can occur including drowsiness, sickness, make your legs heavy.  It can also prolong the second stage of labor as you can’t always feel the urge to push.

Labor and delivery is an amazing and exciting process which, after nine months of nurturing and protecting your growing baby – you finally get to meet them.

 

 

    

 

 

Topics: royal baby, st mary's hospital, lindo wing, labour, labor, delivery, baby, Duchess of Cambridge

Documented differential diagnosis could save you in malpractice case

Posted by JASON MAUDE on Wed, Jun 19, 2013 @ 11:28 AM

We are often asked by clinicians whether they would be better or worse off in a malpractice case if there was a record in the medical notes of their full differential diagnosis and the diagnosis missed was in that list. Our view is that it’s always better to have documented what you have done and thought. If you were wrong and had a reasonable explanation for why you did not think the diagnosis missed and on the list was the most likely and the one that you treated for, then it is better to be able to show that you thought about other possibilities. At the very least you appear to be a concerned and caring clinician rather than one that couldn’t be bothered.

A case described in “The Clinical Advisor” this week demonstrates this very clearly.

The case concerned a urology physician assistant (Ms P) who saw a teenage boy who presented 6 weeks earlier in the ED with blood in his urine. The teenager had been seen in the ED by a urologist (Dr B) who had ordered lab results which had revealed both hematuria and proteinuria. The urologist diagnosed a urinary tract infection and prescribed antibiotics.

The teenager had returned to the ED as he had not responded to the antibiotics and was complaining of continued hematuria, sore throat, fever and right flank pain.

The urology PA called the urologist who made the original diagnosis. He maintained his view it was a UTI and said to continue the antibiotics. The PA challenged the diagnosis and questioned whether it could be something else but was overruled.

2 years later the teenager returned to the ED spitting up blood and with pain in his side below his ribs. Tests showed that his kidneys had failed and that he had immunoglobulin A nephropathy, a severe kidney disease that would require hemodialysis three times a week. A malpractice case followed.

In his certification for the lawsuit, the nephrologist alleged that Dr. B and Ms. P had departed from the standards of practice among members of the same health professions with similar training and experience by failing to include nephritis as a differential diagnosis for the patient when he presented to the ED. 


Ms. P explained to her defense attorney that she had had reservations about the diagnosis at the time, but had not noted anything on the chart and had deferred to Dr. B. The attorney explained that without notes proving that she had challenged the diagnosis, they had no choice but to proceed on the basis that the presentation appeared to be a UTI.”

It is interesting to note that Isabel’s list of possibilities for just the clinical features from the initial visit to the ED shows the actual diagnosis at the top of its list but does NOT include UTI within its top 10 suggestions. Had the PA used Isabel it may have given her much more confidence in challenging the urologist’s diagnosis and also she would have had a documented differential diagnosis proving her challenge.

 

Differential diagnosis for blood in urine,hematuria and proteinuria

Topics: Misdiagnosis, Differential diagnosis, malpractice

Isabel could have improved the differential diagnosis in these cases

Posted by JASON MAUDE on Mon, Jun 10, 2013 @ 07:08 AM

“Old GP” is an actual GP based in North America who is close to retirement. He has a keen interest in strange presentations of diagnoses and a wealth of experience. He has been using Isabel over the last few months and has gone back over some memorable old cases to see whether and how Isabel could have helped. We thought that his experiences would be of great use and interest to other clinicians, not only to hear about these cases but also how Isabel could have helped in building the differential diagnosis. “Old GP” wishes to remain anonymous out of respect for the privacy of patients and colleagues.

Down memory lane…

Some pre-Isabel diagnostic failures of the past . . .We missed them – Isabel would have got them first time. It may be tedious and unproductive to put every case through a computer program, but at the end of a busy day there are always a couple of uncertain cases worth computing.

  • There's the uncommon presentation of a common disorder . . .

A 3-year old boy, presented increasingly weak and listless over the past two days, has  rapid pulse and breathing, and warm dry skin. He had no neck stiffness,rash, his chest was clear, belly soft and a dry diaper.

Our immediate thoughts was a viral infection and obviously in need of hospital support. The Pediatrician did a spinal tap in the emergency department. The laboratory technician had the thoughtfulness to check the spinal fluid for glucose as well as everything else. Strongly positive! The child had Type 1 Diabetes Mellitus, was given Insulin and all was fine.

The parents thanked us from the bottom of their hearts for our speed of action and investigative thoroughness. We didn't feel so clever ourselves. What a complicated way to reach a simple diagnosis. Turned out the mother had put on a new diaper just before coming to our clinic – she hadn't wanted to offend us with a wet one. (Since then we've always asked parents to bring in a used diaper. Even then it's not always easy to squeeze a few drops from the new super-absorbent brands. And then we had to fire a college-trained secretary who said that dipping urine wasn't in her job description. After that we hired pizza-waitresses – they're perfect for medical clinics, good memories, don't mind dirty work, good at handling drunks and delighted to get clinic rates of pay.)

How did Isabel do in the retrospective trial?  A checklist of tachypnea, tachycardia, dry skin and lassitude put Diabetic Ketoacidosis top of the search list.

 Differential diagnosis for tachypnea,tachycardia,dry skin and lassitude 

Diabetic Ketoacidosis top of Isabel’s differential diagnosis

  • And the common presentation of an uncommon disorder . . .

An Irishwoman in her 30s staggered into an emergency department, confused, irritable and smelling strongly of beer. The Emergency Medical Officer (not me, I'm glad to say), took offence at a visit by an apparent drunk, and ordered her to leave. In the small hours of the next day she had a seizure and her friends took her to a different hospital. Again, a diagnosis by spinal tap – Meningeal Tuberculosis.

Could Isabel have expedited matters? Yes. A checklist of two features only, confusion and irritable, gave a search-list of possibilities including Meningeal Tuberculosis .

 Differential diagnosis of confusion and irritable 

Tuberculosis Meningitis presents on Isabel’s differential with 2 key symptoms

 The key word here is possibilities to help build a good differential diagnosis. Medical and Nursing training give us a good sense of the probabilities, but we humans are not so good with the possibilities, and that's where a computer search can help so well.

  • Sometimes the viewpoint of a beneficent alien like Isabel is better than human assumptions . . .

An 80-year old man, a widower, living alone, was on our regular visiting-list. (My father used to say that he'd rather see ten old people in the daytime – even if only one of them showed any hint of decompensation – than be called out at 3 a.m. to deal with a single paroxysmal nocturnal dyspnea.)

This old gentleman, though never acutely ill, did seem to be going gradually downhill. His house became messier, he complained that his dentures hurt, and we saw petechiae on his forearms.  His diet appeared good – there was always a bowl of fresh fruit on his living-room table. It took referral to an internist to reveal that he had scurvy.

How would Isabel have done, if we'd had her back then? A checklist of lassitude, gingivitis and petechiae gives Vitamin C Deficiency top of the list. But what about the fruit bowl? “Well, doctor, I never liked fruits. I just keep them as treats for my grandchildren when they visit.”

 Differential diagnosis for lassitude,gingivitis and petechiae

Vitamin C Deficiency (Scurvy) – a reminder never to assume!

  • Last of all I want to boast of a diagnostic triumph of mine, made without any computer aid.

A LOL in NAD (Little Old Lady in No Apparent Distress) came to our general practice office on a rather busy day with the complaint of frequent falls. She needed a complete examination, but I was daunted by her many layers of clothing (it was winter-time). Undressing and dressing again, even with the help of our excellent assistant, would have delayed the day's appointment sequence to a crawl.

“I notice, Ma'am, that your house is on the road between my home and our clinic. Would it be possible for me to drop by tomorrow morning, say half-past-seven? Perhaps you could stay in your nightgown, so I could check out your heart more easily?”

She agreed, said she'd leave the door unlocked. Next day I entered the house and called her name.

She called back “I'm still in my bedroom, doctor , come right on up.”

So up I went, and damn near broke my neck.

Though Isabel has a checklist for falls frequently, her list of diagnostic possibilities does not, as yet, include Loose Stair Carpet!

Well, time to sign off,

“Old GP”.

Topics: Differential diagnosis, ddx, diagnostic decision support, diagnostic skills

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