The document discusses diagnostic error in healthcare. It begins by noting that inaccurate diagnoses, incorrect treatments, and lack of diagnoses contribute to unnecessary costs, inefficiency, and patient dissatisfaction. Improving diagnostic accuracy can help achieve quality, control costs, and increase patient satisfaction. The document then discusses: - The high incidence of diagnostic errors, which result in tens of thousands of deaths per year and enormous financial tolls. - Evidence that diagnostic errors commonly cause patient harm and occur across primary care, inpatient, and outpatient settings. - An innovative solution of independent virtual second opinions to address diagnostic errors by improving accuracy and ensuring appropriate treatment.

1. CONFRONTING
DIAGNOSTIC
ERROR
How the Right Diagnosis Is Key
to Quality Improvement and
Lower Costs
Mark L. Graber, MD, FACP / Lew Levy, MD, FACP
EMPLOYER INSIGHTS SERIES

2. Every day, in spite of clinicians’ best
intentions, patients receive inaccurate
diagnoses, are prescribed incorrect
treatments or are simply not diagnosed
at all. These common errors contribute to unnecessary health
care costs, system inefficiency and employee dissatisfaction. To
help combat this, employers are seeking innovative approaches
to improving clinical quality and financial performance. Evidence
confirms that improved diagnostic accuracy contributes to achiev-
ing quality, controlling costs and increasing patient satisfaction.
CONFRONTING DIAGNOSTIC ERROR 1

3. CONFRONTING DIAGNOSTIC ERROR 2
IMPROVING DIAGNOSTIC ACCURACY AND ENSURING APPROPRIATE TREATMENT SUPPORTS
THE GOALS OF THE TRIPLE AIM: improving quality, containing costs and delivering a better
member experience.
E
mployers are always on the
lookout for new and innovative
approaches for employee
benefits that improve
outcomes. Now, in combination with
established approaches, such as
evaluating hospital readmissions,
medication errors, post-surgical
complications and wrong-site
surgeries, researchers are re-focusing
on diagnostic accuracy to further
support these efforts. And employers
are beginning to take notice. “The
combination of forces driving health
care right now is energizing the
discussion of diagnostic accuracy,”
said Dr. Mark Graber, founder and
president of The Society to Improve
Diagnosis in Medicine (SIDM).
On a national scale, health care
experts are increasingly addressing
the substantial impact of diagnostic
error. SIDM is conducting research,
promoting education and raising
awareness to better understand the
causes and remedies for diagnostic
error. Additionally, the Institute
of Medicine (IOM), as part of its
Crossing the Quality Chasm series,
will release a report in later 2015
on diagnostic error, placing it as a
prominent part of the nation’s health
care policy agenda.
BETTER
MEMBER EXPERIENCE
Provide virtual access to
world-renowned medical
experts to confirm optimal
clinical pathway
QUALITY
IMPROVEMENT
Improve diagnostic and
treatment accuracy through
expert reviews of complex
and critical care cases
COST
CONTAINMENT
Minimize the costs of
unnecessary hospitalizations,
medications, treatments and
surgeries

4. THE HIGH INCIDENCE
AND HIGH COST
OF DIAGNOSTIC
ERRORS
CONFRONTING DIAGNOSTIC ERROR 3

5. CONFRONTING DIAGNOSTIC ERROR 4
The High Incidence—and High
Cost—of Diagnostic Errors.
Diagnostic error is blamed for an estimated
40,000 to 80,000 deaths in the United States
each year.1
Diagnostic errors exact an enormous toll—both
human and financial. Not only are these errors devastating to patients
and their families, but too often they lead to patient harm, wasted
resources and malpractice litigation. IOM estimates that one out of
every three health care dollars spent is wasted, resulting in nearly
$1 trillion of wasted expenditures each year in the United States.2
Misdiagnosis is an important contributor to health care waste.

6. CONFRONTING DIAGNOSTIC ERROR 5
1 IN 20
primary care visits involve a preventable diagnostic
error; half of these errors are potentially harmful
PRIMARY CARE HEALTH CARE ORGANIZATIONS
10 PATIENTS
are harmed every day in
clinics or ERs
1 DEATH
occurs every month
in a typical health care
organization
A
research study led by Dr. Hardeep Singh at Baylor College of Medicine
found that 1 in 20 patients experience a diagnostic error each year. Half
of these cases cause patient harm. An analysis of diagnostic errors by
location shows that only 16 percent are made in the chaotic, pressure-
filled environment of the emergency room. Over half occur in ambulatory care
settings, and 28 percent happen in inpatient hospital settings.3
ERRORS OCCUR IN PRIMARY, INPATIENT AND OUTPATIENT CARE
Using several methods to study diagnostic errors reveals preventable harm occurs frequently
in all health care delivery systems.
HARM

7. CONFRONTING DIAGNOSTIC ERROR 6
Claims data compiled by CRICO/
RMF, the risk management and
medical malpractice company for
Harvard-affiliated hospitals and
health care organizations, show
that of the diagnostic errors which
occurred in the inpatient setting,
the level of harm was considered
“high” in 73 percent of the cases,
with 46 percent of cases resulting in
death. Similarly, in the ambulatory
care setting, the severity of harm in
60 percent of cases was classified
as “high,” and 28 percent of cases
resulted in death.4
Multiple studies support these findings.
Cognitive scientist Dr. Arthur Elstein,
an expert in physician decision-making
and behavior, calculates that 10 to 15
percent of all diagnoses are missed,
wrong or delayed.5
Moreover, research
shows that abnormalities in X-rays or
pathology findings that were missed
by a first review were detected by a
second professional’s review 2 to 5
percent of the time.6,7
Standardized
patient studies reveal that primary
care physicians or internists
misdiagnose 13 percent of cases
where a chronic condition exists.8
SEVERITY OF ERROR DIAGNOSTIC ERROR
OCCURRED
SEVERITY OF ERROR
INPATIENT (1,253 Cases) AMBULATORY (2,531 cases)
LEVELS OF HARM
OF CASES RESULTED
IN DEATHS
OF CASES RESULTED
IN DEATHS
LEVELS OF HARM
 High
 Medium
 Low
 High
 Medium
 Low
46%
73%
60%
25%
2% 5%
35%
28%
AMBULATORY
56%
INPATIENT
28%
ER
16%
DIAGNOSTIC ERROR LOCATIONS AND SEVERITIES
Diagnostic error occurs throughout the health care delivery system. When the errors occur,
the level of harm is often high and too frequently results in death.

8. CONFRONTING DIAGNOSTIC ERROR 7
Retrospective case reviews are
crucial in determining the incidence
of diagnostic error in medicine.
In a study of women with and
without breast cancer, radiologists
disagreed 11 percent of the time
on interpreting the mammogram,
and half of the radiologists had less
than an 80 percent sensitivity in
detecting the abnormal studies.9
Autopsies, considered the gold
standard in clinical diagnostics,
provide another excellent opportunity
to detect medical error. Although
declining in use, historically they have
revealed that 10 to 20 percent of the
time there is a major discrepancy
that, if addressed, would have
changed the course of the patient’s
treatment plan.10,11
Increasingly, individuals are aware
of the problem of diagnostic error.
A study from the Kaiser Family
Foundation found that nearly one
in three people indicated that they or
somebody in their family had been
affected by a preventable medical
error, with 21 percent suffering a
serious health consequence.12
Against the background of market
transformation, experts are seeking
new ways to advance the Triple
Aim framework, which involves
improving quality, containing costs,
and delivering a better patient
experience. The confluence of
several market trends—the wider
implementation of electronic health
records (EHRs), the increasing
importance of data-driven analytics,
and the focus on actively involving
patients in their health care—support
clinical efforts to improve diagnostic
accuracy.
NEARLY
ONE IN THREE
MEMBERS INDICATED THAT THEY
OR SOMEBODY IN THEIR FAMILY
HAD BEEN AFFECTED BY A
PREVENTABLE MEDICAL ERROR
Retrospective case
reviews are crucial
in determining the
incidence of diagnostic
error in medicine.

9. AN
INNOVATIVE
SOLUTION
TO ADDRESS
DIAGNOSTIC
ERROR
CONFRONTING DIAGNOSTIC ERROR 8

10. An Innovative Solution to Address
Diagnostic Error.
Independent second-opinion services, such as
the Best Doctors virtual solution, offer physicians
and employers an effective way to contain costs
and improve outcomes for complex and critical care medical
situations. Applicable across businesses of any size, the benefits of
a second-opinion consultation service include the following:
REDUCED
AVERAGE SPEND,
including reduced
hospital stays and
readmissions,
through avoidance
of unnecessary
utilization
IMPROVED
QUALITY
of care outcomes
through changes
in diagnosis and
management
BROADER
ACCESS
to medical
expertise -
available to
all employees,
regardless of
geographic
location
POSITIVE
INFLUENCE on
quality ratings,
and member
satisfaction
DIFFERENTIATED
OFFERING
in today’s
competitive
employer
environment
CONFRONTING DIAGNOSTIC ERROR 9

11. 10
T
he Best Doctors virtual
solution addresses two
important drivers of
diagnostic errors. First,
the fragmented nature of medical
information often means that a
member’s full medical history is not
available to the treating physician.
If a member has multiple physicians
who are using different EHRs or
still relying on paper records, the
treating physician will mostly likely
not have access to a complete
medical history. For each member,
Best Doctors gathers all medical
records and retests pathology slides
at designated centers of excellence.
Best Doctors then develops a
comprehensive clinical summary
of the member and sends it to an
expert for review.
THE TOP EXPERTS FOR
A PARTICULAR MEDICAL
SCENARIO MAY NOT BE
AVAILABLE AT A LOCATION
REASONABLY CLOSE
TO THE MEMBER.
The best experts for a particular
medical scenario may not be available
at a location reasonably close to
the member. This can be particularly
devastating for members with acute
or catastrophic care needs. Because
Best Doctors engages top physicians
and specialists worldwide, the member
and treating physician benefit from the
knowledge of medical professionals
who have the specific expertise and
experience to evaluate the case
and make actionable treatment
recommendations. “We provide
state-of-the-art recommendations
to the member and the treating team
based on the best medical science
available today,” said Dr. Levy.
“Treating physicians appreciate the
thoroughness and attention to detail
we provide in the evaluation of their
patient’s case.”
“Treating physicians
appreciate the
thoroughness and
attention to detail we
provide in the evaluation
of their patient’s case.”
Dr. Lewis Levy,
Senior Vice President of
Medical Affairs and Chief
Quality Officer,
Best Doctors

12. CONFRONTING DIAGNOSTIC ERROR 11
Best Doctors’ Independent,
Virtual Second-Opinion
Service – How It Works
Typically, members initiate a case
with a simple phone call or website
visit, or they may be referred by other
vendors, with whom Best Doctors
integrates. As a first step, a
Best Doctors clinician engages the
member to obtain a thorough clinical
history. Next, Best Doctors gathers
all relevant medical documentation—
including hospital charts, medical
records and notes from physician
office visits, as well as imaging, lab
and pathology results. Pathology is
retested to confirm results.
This information is compiled into an
all-inclusive, academically rigorous
clinical summary. The physician who
develops this clinical summary also
assesses the case and develops 15 to
20 specific questions for the expert
who will ultimately conduct the
second-opinion review. The clinical
summary gives the independent expert
all of the relevant cinical information
for the comprehensive review.
The Best Doctors process is modified
for urgent, acute and catastrophic
cases. When these cases are referred
to Best Doctors, a clinician is
immediately sent to the hospital to
START
Access world-
class medical
experts
Conduct expert review
and develop report
For Critical Care, delivered
within 72 hoursReview and QA
expert response
Deliver results and
recommendations to
member, family, and local
treating team
Member initiates
contact with
Best Doctors,
or is referred by
employer
Collect all medical records
For Critical Care,
collected within 24-48
hours of initial contact
Analyze clinical
information
Create
comprehensive
clinical summary
BEST DOCTORS PROCESS
The virtual second-opinion service is a proven approach with actionable treatment
recommendations.

13. CONFRONTING DIAGNOSTIC ERROR 12
facilitate complete understanding
of the urgent case. The appropriate
critical care experts are quickly
activated to provide ongoing real-
time clinical guidance in partnership
with the local treating team. Often,
these experts are providing valuable
insights within 24 to 48 hours of
hospitalization.
BEST DOCTORS MAINTAINS
A DATABASE OF 53,000 EXPERTS,
SELECTED THROUGH A
PEER-NOMINATION PROCESS.
Best Doctors maintains a database
of 53,000 experts, selected through
a peer-nomination process utilizing a
Gallup-endorsed methodology. These
experts represent roughly the top five
percent of the medical profession.
Best Doctors selects the most
appropriate specialist to review each
case based on the area(s) of expertise
required. Once the specialist has
completed their review, the report is
sent back to Best Doctors for internal
review and quality control. In the last
step of the process, Best Doctors
communicates the independent
second opinion results to the member
and all treating physicians involved
with the member’s care.
Summary
Once considered a topic too unwieldy
to define and study, diagnostic error
is now taking center stage in discus-
sions of member safety. Employers
now have an opportunity to help end
medical uncertainty and give their
employee populations the peace of
mind that comes with obtaining the
right diagnosis and treatment.
Best Doctors offers a best-in-class
solution for providing an independent,
virtual second-opinion service. Their
ability to solve for the fragmentation
in health care by providing the treat-
ing physician with a comprehensive
and holistic review of the member’s
case history can completely alter the
course of treatment. The true value of
Best Doctors, however, comes from
their understanding of the top expert
community; these specialists provide
cutting-edge knowledge in support
of and in collaboration with the local
treating team.
It is a win for members who now know
that their diagnosis and treatment plan
is the right one. It is a win for treating
physicians who appreciate having
access to the expertise of the leaders
in specific disciplines. And it is a win
for employers who are addressing
the multiple objectives of improved
quality of care and enhanced
employee satisfaction.

14. Clinical History
52-year-old female was
diagnosed with metastatic
cervical cancer
Biopsy of the mass
demonstrated cancer, and
imaging showed multiple
masses in the pelvis and
abdomen, including in the
colon and liver
Member was treated with
radiation to her pelvis and
chemotherapy for cervical
cancer
Follow-up imaging did
not demonstrate a good
response to chemotherapy,
and the member
engaged Best Doctors for
recommendations about
her diagnosis and optimal
treatment regimen
Clinical Impact
• Expert performed specialized testing (immunohistochemistry)
on the biopsy specimen that had not been done at the treating
institution; this testing definitively diagnosed colon cancer, not
cervical cancer
• Second expert confirmed the diagnosis of colon cancer
that had spread to the cervix and changed the treatment
to optimally treat the member’s colon cancer
Outcome
• Member quickly sought care with a colon cancer specialist
and started treatment with the expert-recommended
chemotherapy regimen
• Treatment is going well and has been effective
Financial Impact
• $42,000 cost savings
• Cost avoidance by averting cancer progression and
complications by providing the appropriate cancer therapy
BEST DOCTORS MEMBER STORY:
Correct Cancer Diagnosis
Leads to Optimal Treatment
MEMBER TESTIMONIAL
“I am tremendously appreciative that Best Doctors
spent so much time on my case.”
Best Doctors Experts
Marisa Nucci, MD - Associate Professor of Pathology, Harvard Medical
School
Dennis Ahnen, MD - Medical Oncologist and Professor of Medicine,
University of Colorado Denver School of Medicine

15. Clinical History
Previously healthy 50-year
old male was found to have
worsening kidney function
Kidney biopsy led
to a diagnosis of AL
amyloidosis, a rare disease
that occurs when a
substance called amyloid
builds up in the organs
Initial pathology review
suggested that the source
of amyloid was buildup
of antibodies (called AL
amyloidosis) produced by
abnormal white blood cells
Bone marrow transplant
was recommended by the
treating team to eradicate
the abnormal white blood
cells and halt production of
AL amyloid
MEMBER TESTIMONIAL
“I’m so thankful for Best Doctors, and the service
made a difference in my life.”
Clinical Impact
• Biopsy specimen was sent and expert noted a very unusual
distribution of amyloid in the kidney and challenged the diagnosis
of AL amyloidosis; he recommended mass spectrometry to
uncover the true identity of the abnormal protein
• Mass spectrometry was used to precisely identify the culprit
protein as apolipoprotein A-IV, which has never before been
described as causing amyloidosis in the kidney
• Best Doctors expert pathologists changed the diagnosis to a
different type of amyloidosis, one that is caused by a genetic
defect and not by abnormal white blood cells
• The expert changed treatment, advising against a bone
marrow transplant, since it would not have any effect on the
member’s amyloidosis
• Since the slow buildup of amyloid from the apolipoprotein
A-IV defect had likely been going on for many years and was
progressing only very slowly, the member could be observed
safely without any risky or costly interventions
Outcome
• Plans for stem cell (bone marrow) transplant were cancelled
• The member and treating physicians are extremely grateful
that this high-risk and ineffective treatment was avoided
Financial Impact
• $250,000 cost savings
• Cost avoidance by preventing bone marrow transplant and
follow-up treatments
BEST DOCTORS MEMBER STORY:
Expert Pathology Review
Results in Correct Diagnosis
and Treatment
Best Doctors Experts
Helmut G. Rennke, MD - Director, Renal Pathology, Brigham and Women’s
Hospital; Professor, Harvard Medical School
Sanjeev Sethi, MD, PhD - Anatomic Pathology, Mayo Clinic College of Medicine
Bijay P. Nair, MD, MPH - Assistant Professor of Medicine, Myeloma Institute
for Research and Therapy, University of Arkansas for Medical Sciences;
Central Arkansas Radiation Therapy Institute (CARTI), Internal Medicine,
Hematology, and Medical Oncology

16. REFERENCES
1. Leape LL. Counting deaths due to medical errors. JAMA. 2002;288:2404–05.
2. Institute of Medicine of the National Academies. Best Care at Lower Cost: The Path
to Continuously Learning Health Care in America. Washington, DC: The National
Academies Press; September 6, 2012.
3. Singh H, Meyer AND, Thomas, EJ. The frequency of diagnostic errors in outpatient
care: estimations from three large observational studies involving US adult
populations. BMJ Qual Saf. 2014; 0:1-5.
4. Siegal D. Analysis of Diagnosis-Related Medical Malpractice Claims. CRICO. CBS
Learning Collaborative presentation. 2014.
5. Elstein A. Clinical reasoning in medicine. In: Higgs J, ed. Clinical reasoning in the
health professions. Oxford, England: Butterworth-Heinemann Ltd. 1995;49–59.
6. Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine—analysis of 583
physician-reported errors. Arch Int Med. 2009;169:1881–87.
7. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in
the ambulatory setting: a study of closed malpractice claims. Ann Intern Med.
2006;145:488–96.
8. Peabody JW, Luck J, Jain S, et al. Assessing the accuracy of administrative data in
health information systems. MedCare. 2004;42:1066–72.
9. Beam CA, Layde PM, Sullivan DC. Variability in the interpretation of screening
mammograms by US radiologists. Findings from a national sample. Arch Intern Med.
1996;156:209–13.
10. Shojania K, Burton E, McDonald K, et al. The autopsy as an outcome and
performance measure; Evidence report/Technology assessment #58 (Prepared
by the University of California at San Francisco-Stanford Evidence-based Practice
Center under Contract No. 290–97–0013). AHRQ Publication No03-E002. Rockville,
MD: Agency for Healthcare Research and Quality, 2002.
11. Sonderegger-Iseli K, Burger S, Muntwyler J, et al. Diagnostic errors in three medical
eras: a necropsy study. Lancet. 2000;355:2027–31.
12. The Kaiser Family Foundation, Agency for Healthcare Research and Quality,
Harvard School of Public Health. National Survey on Consumers’ Experiences With
Patient Safety and Quality Information. October 2004. http://kff.org/health-costs/
poll-finding/national-survey-on-consumers-experiences-with-patient/. Accessed
August 1, 2014.
R

17. Mark L. Graber, MD, FACP
Senior Fellow, RTI International
Professor Emeritus, SUNY Stony Brook School of Medicine
Founder and President, Society to Improve Diagnosis in Medicine
Dr. Mark Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at the State
University of New York at Stony Brook. Dr. Graber is a national leader in the field of patient safety and
in 2002 originated Patient Safety Awareness Week, an event now recognized internationally. He is also
a pioneer in efforts to address diagnostic errors in medicine. In 2011 he founded the Society to Improve
Diagnosis in Medicine), and this year Dr. Graber launched a new journal, Diagnosis, devoted to improving
the quality and safety of diagnosis and reducing diagnostic error.
Dr. Graber graduated from Stanford University School of Medicine and completed residency training at
Mount Zion Hospital in San Francisco as well as a fellowship in nephrology at Boston University School
of Medicine.
Lew Levy, MD, FACP
Senior Vice President of Medical Affairs and Chief Quality Officer, Best Doctors
Internist, Harvard Vanguard Medical Associates
Instructor, Harvard Medical School
Dr. Lew Levy is the Senior Vice President of Medical Affairs and Chief Quality Officer at Best Doctors.
He provides medical leadership to the clinical operations team to deliver the highest quality clinical
information on diagnosis and treatment to members and their treating physicians. He has over 25 years
of clinical experience as an internist at Harvard Vanguard Medical Associates in Boston. Dr. Levy also has
an extensive teaching career as a preceptor in the Internal Medicine Residency Program at Brigham and
Women’s Hospital and is an instructor at Harvard Medical School. He continues to practice primary care
internal medicine and has participated in pioneer ACO, HMO and FFS arrangements.
Dr. Levy earned his medical degree from the University of Rochester School of Medicine and Dentistry and
completed his residency in internal medicine at the Graduate Hospital of the University of Pennsylvania.