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:

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 show yourself to be a concerned and caring clinician rather than one that couldn’t be bothered.

“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.

The Isabel project was inspired after my own daughter’s near fatal misdiagnosis in 1999. Last week I experienced my own misdiagnosis. Although far less serious, the episode is probably as instructive for the lessons it teaches. It showed me how easy it is to happen, how it’s often nothing to do with lack of time but just down to sloppy thinking. The discipline of doing a differential diagnosis (even for what seems a blindingly obvious, straightforward diagnosis) is crucial to avoid the sloppy thinking traps.

A landmark article published yesterday in “JAMA Internal Medicine” entitled “Types and Origins of Diagnostic Errors in Primary Care Settings” once again highlights the importance and value of traditional clinical skills and the differential diagnosis.

The study looked at 190 cases of diagnostic error highlighted by triggers within the medical record such as unexpected return visits etc. rather than malpractice suits. The settings were two large sites each with a list size of around 50,000 patients-one was public health (Veterans Administration) and the other an integrated private healthcare system. The key points from the paper for us were:

As Isabel is sometimes regarded as ‘disruptive’, we thought that an overview of “who” uses Isabel and “when” would be helpful to both current  and future Isabel users to understand how it can often make a major significant impact in patient outcomes with no negative impact on workflows.  This is the first in a series of three blog posts.  Below is a synopsis of “who” uses Isabel followed by instances of “when” they use it. We thought the best way to illustrate this would be to provide some actual cases.  The series will look at the ambulatory, emergency and inpatient settings.  Today’s blog post will cover some cases that came from the ambulatory setting and how diagnostic decision support (DDS) helped them.

Isabel is currently mainly used by:

• Physicians and PA’s in ED’s, hospitals, urgent care clinics and Physician practices
• Nurse Practitioners
• Medical Schools
• Residency Programs
• Nursing Schools
• Legal and risk management teams

On Dec 3^rd 2012 the New York Times published a fabulous article entitled “For Second Opinion, Consult a Computer?”. Science writer, Katie Hafner, also followed it up with a podcast.