Associate Director's Note: Playing a role in reducing diagnostic errors

Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.”

That’s according to the Institute of Medicine’s (IOM) September 2015 report, “Improving Diagnosis in Health Care,” the latest in its so-called Quality Chasm Series. Its earlier reports—the 2000 publication of “To Err is Human” and the 2001 publication “Crossing the Quality Chasm”—pulled back the proverbial curtain on a host of healthcare errors illuminating a frightening picture of a broken U.S. healthcare system that often causes more damage and death than the ailments which brought patients to seek care in the first place.

The latest report darkens the picture further, estimating that diagnostic errors contribute to 10% of patient deaths and 6-17% of hospital adverse events. About 5% of all adults seeking outpatient care every year will experience a diagnostic error, the report states.

Its authors rightly point out that diagnostic errors stem from a wide variety of causes including inadequate collaboration between clinicians, patients, and their families. While this type of disconnect—between the clinically minded and the patients they treat—is troubling, albeit understandable enough, the IOM asserts that such errors also stem from a “healthcare work system that is not well designed to support the diagnostic process.” It also states that our collective culture discourages transparency and disclosure of diagnostic errors which, in turn, impedes attempts to learn and improve.

“Diagnostic error may involve any of various types of overlapping missed opportunities to make a correct and timely diagnosis; a diagnosis may be missed completely, the wrong one may be provided, or diagnosis may be delayed, all of which can lead to harm from delayed or inappropriate treatments and tests,” according to an article from the New England Journal of Medicine (NEJM) regarding the new IOM report.

CDI programs need to look at NEJM’s list honestly and openly. Consider which of these elements CDI staff touch. Clarifying missed diagnoses represents one of the most basic purposes for query creation. Just look back at your collection of query practice briefs from ACDIS and AHIMA.

“No doubt CDI may contribute to misdiagnoses by leaving queries that may not be relevant and/or the physician checks off a box in responding to the query but fails to give much clinical thought to the response, thereby perpetuating misdiagnoses,” says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, director of enterprise solutions for ZirMed, in Louisville, Kentucky.

CDI programs focused singularly on financial outcomes may be at greater risk for such negative outcomes, hurriedly querying for a single CC/MCC and moving on to the next record with limited thought to the total clinical picture.

Yet, there may be an opportunity here, as well.

Like most problems, finding a resolution to missed diagnosis will require a multi-disciplinary response, IOM says. And as the role of CDI specialists shifts toward quality assurance and moves past its traditional boundaries closer to clinical validation, the profession may have an opportunity to help improve this status quo.

Certainly it won’t be easy. It’s difficult enough to push for CDI program expansion, difficult enough to push past those who ardently believe that the physician’s judgement should never be questioned.

Just the other day on our ACDIS LinkedIn page, one CDI system director lamented a physician’s callous (if not outright impudent) response to a CDI professional’s query. He rightly pointed out that while the physician ultimately bears the responsibility for the patient’s diagnosis, CDI staff members are trained to interrogate the totality of the medical record and to assist the physician with his or her documentation of their clinical decision making.

Let me recount a related anecdote. A 70-something gentlemen complained of leg pain following a knee replacement earlier in the year. The orthopedist gave him a special sock brace and sent him on his way. Two days later his leg shattered. A series of unfortunate events later, he ended up septic and, once stabilized, spent nearly a month in a rehab facility. Aside from the cost associated with the situation, comes the physical and emotional drain on this gentleman and his family.

I’ve my own repeated visits to my physician attempting to diagnosis some malady or other but thankfully nothing of the magnitude of life threatening. Nevertheless, according to the recent IOM report, my chances of having such an experience are high.

CDI professionals can do their part, simply by doing their job as meticulously and compliantly as possible.