At least one in every 20 adults who seeks medical care in a U.S. emergency room or community health clinic may walk away with the wrong diagnosis, according to a new analysis that estimates that 12 million Americans a year could be affected by such errors. Experts have often downplayed the scope of diagnostic errors not because they were unaware of the problem, but “because they were afraid to open up a can of worms they couldn't close.

1. 5/17/2014 www.knowurture.com 1
HEALTHCARE INDUSTRY LANDSCAPE
Presented by:
Madhukar Kalsapura
Founder & Chief
Ramnath Sundaram
Co-Founder & Chief – Finance & Operations
Shankar Bijapur
Co-Founder & Director – Medical Services
Shally Arora
Co-Founder & Chief - Communications
ERRORS OF DIAGNOSIS – ENORMITY OF THE PROBLEM

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WHAT IS DIAGNOSTIC ERROR?
 Diagnostic error can be defined as a diagnosis that is missed, wronged or delayed, that may be detected by
a subsequent definitive test or finding.
 The ensuing harm results from the delay or failure to treat a condition present when the working diagnosis
was wrong or unknown, or from treatment provided for a condition not actually present.

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DIAGNOSTIC ERRORS MORE COMMON, COSTLY & HARMFUL THAN TREATMENT MISTAKES
“Overall, diagnostic errors
have been under
appreciated & under
recognized because they’re
difficult to measure & keep
track of owing to the frequent
gap between the time the
error occurs & when it’s
detected,” Newman-Toker
says. “These are frequent
problems that have played
second fiddle to medical &
surgical errors, which are
evident more immediately.”
 Experts have often downplayed the scope of diagnostic errors not because they
were unaware of the problem, but “because they were afraid to open up a can of
worms they couldn’t close.” He adds: “Progress has been made confronting other
types of patient harm, but there’s probably not going to be a magic-bullet solution
for diagnostic errors because they are more complex and diverse than on this
issue if we’re going to successfully tackle it.” other patient safety issues. We’re
going to need a lot more people focusing their efforts
 They found that of the 350,706 paid claims, diagnostic errors were the leading
type (28.6%) and accounted for the highest proportion of total payments (35.2 %).
Diagnostic errors resulted in death or disability almost twice as often as other
error categories.
 The human toll of mistaken diagnoses is likely much greater than his team’s
review showed, Newman-Toker says, because the data they used covers only
cases with the most severe consequences of diagnostic error. There are many
others that occur daily that result in costly patient inconvenience and suffering, he
says. One estimate suggests that when patients see a doctor for a new problem,
the average diagnostic error rate may be as high as 15 %.
 They also found that more diagnostic error claims were rooted in outpatient care
than inpatient care, (68.8 % vs. 31.2 %) but inpatient diagnostic errors were more
likely to be lethal (48.4 percent vs. 36.9 percent). The majority of diagnostic errors
were missed diagnoses rather than delayed or wrong ones.

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DIAGNOSTIC ERRORS & MEDICAL ERRORS AMONG TOP 10 KILLERS
http://www.technologyreview.com/news/518871/we-need-a-moores-law-for-medicine/
http://www.technologyreview.com/news/518876/the-costly-paradox-of-health-care-technology/
 Diagnostic errors are fundamentally obscure, health care organizations have
not viewed them as a system problem, and physicians responsible for
making medical decisions seldom perceive their own error rates as
problematic. The safety of modem health care can be improved if these
three issues are understood and addressed.
timesofindia.indiatimes.com/india/Medical-errors-in-top-10-killers-WHO/articleshow/8032059.cms
http://www.ncbi.nlm.nih.gov/pubmed/15791770
 Although there is no Indian data available on this topic, WHO lists it among the
top 10 killers in the world. While a British National Health System survey in
2009 reported that 15% of its patients were misdiagnosed.
 The Indian government has woken up to the concept. It set up the National
Initiative on Patient Safety in the All-India Institute of Medical Sciences a
couple of years back.
Medical errors in top 10 killers: WHO
Diagnostic errors in medicine: a case of neglect.

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DIAGNOSTIC ERRORS ARE THE MOST COMMON MEDICAL MISTAKE
http://healthland.time.com/2013/04/24/diagnostic-errors-are-more-common-and-harmful-for-patients/
 The reason that medication mistakes and surgical errors have been confronted first is related to the fact that
diagnoses are less objective, and more subjective. Determining whether a doctor’s assessment of what is
making a patient sick is a combination of art and science, which makes diagnoses more uncertain than
treatment.
 Another force may be driving the escalating number of tests, and their costs — doctors may rely on them to
safeguard against malpractice suits and litigation. But Newman-Toker says this justification falls flat. “Of course
there is to some extent a trade-off between ordering more diagnostic tests and accepting more diagnostic errors.
In theory, if you ordered every possible test for every possible patient in every possible occasion, you would
probably break the health care piggy bank, but you would get the so-called right diagnosis in every case at the
limits of our current scientific knowledge,” he explains. “But no one believes it is good practice to obtain every
test on every patient in every situation. The best diagnosis is efficient and parsimonious as well as accurate.”
The threshold between such parsimonious testing to rule out certain conditions and hone in on a diagnosis and
excessive analysis, however, is a fuzzy one.
 “The current fragmentation of our health care system makes these errors more likely,” says Dr. Richard
Anderson,
 “Treatment starts with diagnosis. If you don’t get the diagnosis right, you can’t get the treatment right. And yet no
one is working on it,” says Newman-Toker.

6. http://www.ncbi.nlm.nih.gov/pubmed/12377672
 This considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in
medicine:
 "No-fault errors" occur when the disease is silent, presents atypically, or mimics something more
common. These errors will inevitably decline as medical science advances, new syndromes are
identified, and diseases can be detected more accurately or at earlier stages. These errors can never be
eradicated, unfortunately, because new diseases emerge, tests are never perfect, patients are
sometimes noncompliant, and physicians will inevitably, at times, choose the most likely diagnosis over
the correct one, illustrating the concept of necessary fallibility and the probabilistic nature of choosing a
diagnosis.
 "System errors" play a role when diagnosis is delayed or missed because of latent imperfections in the
health care system. These errors can be reduced by system improvements, but can never be eliminated
because these improvements lag behind and degrade over time, and each new fix creates the
opportunity for novel errors. Tradeoffs also guarantee system errors will persist, when resources are just
shifted.
 "Cognitive errors" reflect misdiagnosis from faulty data collection or interpretation, flawed reasoning, or
incomplete knowledge. The limitations of human processing and the inherent biases in using heuristics
guarantee that these errors will persist. Opportunities exist, however, for improving the cognitive aspect
of diagnosis by adopting system-level changes (e.g., second opinions, decision-support systems,
enhanced access to specialists) and by training designed to improve cognition or cognitive awareness.
 Diagnostic error can be substantially reduced, but never eradicated.
REDUCING DIAGNOSTIC ERRORS IN MEDICINE: WHAT IS THE GOAL?
5/17/2014 www.knowurture.com 6

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DIAGNOSTIC ERRORS – CENTRAL TO PATIENTS SAFETY STILL IN THE PERIPHERY OF
SAFETY RADAR
“At the 6th International
Conference on
Diagnostic Error in
Medicine Dr. Robert
Wachter gave a quick
history of patient safety
and quality
improvement but noted
that activity to reduce
diagnostic errors was
noticeably absent from
the movements'
timeline.
http://Diagnostic-errors-central-to-patient-safety-yet-still-in-the-periphery
http://www.modernhealthcare.com
 Low-tech interventions may hold the answer, he said. These include instilling a
patient safety/quality improvement culture and promoting medical
professionalism. “That has turned out to have a lot of oomph to it—more than I
expected,” Wachter said. “Professionalism is a surprisingly powerful lever.”
 “What should we do? I really don't know,” Wachter said. But before going to the
CMS for an answer, he suggested advocates should engage specialty boards,
the Joint Commission, the National Quality Forum, the Institute of Medicine, the
National Patient Safety Foundation, the Institute for Healthcare Improvement and
malpractice insurance carriers.
 “CMS should be last, not first,” he said.
 As one vivid example of how far we need to go, a hospital today could meet the
standards of a high-quality organization and be rewarded through public reporting
and pay-for-performance initiatives for giving all of its patients diagnosed with
heart failure, pneumonia, and heart attack the correct, evidence-based, and
prompt care – even if every one of the diagnoses was wrong.”
 There may well come a day when a tool such as Isabel has been proven
sufficiently beneficial that having it as a structural proxy for diagnostic accuracy
(or at least for the commitment to improve diagnosis) would be a good idea. But
until that day arrives, I would be looking to other organizations to promote the
diagnosis agenda.

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DIAGNOSTIC ERRORS & THEIR ROLE IN PATIENT SAFETY
“health IT has it’s own biases. Remember GIGO – garbage in, garbage out. A simple example is an over-reliance on
“template charting,” whether electronic or in paper form. Let’s say the patient tells the triage nurse “I’ve been vomiting
and my chest hurts.” If one chooses too early the template for “Vomiting,” “Gastroenteritis,” or “Abdominal Pain,” one
could easily lead oneself and others astray, causing them to overlook the fact that what the patient really meant to say at
triage was “I started having this heavy chest pain and have been vomiting ever since.” If the template is too focused, the
patient may well be discharged with an undiagnosed MI – or worse. http://www.kevinmd.com
Charles A. Pilcher
 “Thinking errors” include:
 Anchoring bias – locking on to a diagnosis too early and failing to adjust to
new information.
 Availability bias – thinking that a similar recent presentation is happening
in the present situation.
 Confirmation bias – looking for evidence to support a pre-conceived
opinion, rather than looking for information to prove oneself wrong.
 Diagnosis momentum – accepting a previous diagnosis without sufficient
scepticism.
 Overconfidence bias – Over-reliance on one’s own ability, intuition, and
judgment.
 Premature closure – similar to “confirmation bias” but more “jumping to a
conclusion”
 Search-satisfying bias – The “eureka” moment that stops all further thought.”

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The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the
moment of truth arrived, and the room was silent with anticipation. At last he spoke. “Lymphoma with secondary
hemophagocytic syndrome,” he said. The crowd erupted in applause.
http://www.nytimes.com/2012/12/04
Dr. Gurpreet Dhaliwal
FOR SECOND OPINION, CONSULT A COMPUTER?
 Isabel, the diagnostic program that Dr. Dhaliwal sometimes uses, was created
by Jason Maude, a former money manager in London, who named it for his
daughter. At age 3, Isabel came down with chickenpox and doctors failed to
spot a far more dangerous complication — necrotizing fasciitis, a flesh-eating
infection. By the time the disease was identified, Isabel had lost so much flesh
that at age 17 she is still having plastic surgery.
 Mr. Maude said that while someone like Dr. Dhaliwal would probably have
thought of necrotizing fasciitis, his daughter’s doctors were so stuck in what is
called anchoring bias — in this case, Isabel’s simple chickenpox — they
couldn’t see beyond it. Had they entered her symptoms — high fever, vomiting,
skin rash — into a diagnostic program, Mr. Maude said, the problem would
probably have been identified.

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FACTS
What is the cause of diagnostic error?
 It’s multi-factorial and can present as a perfect storm of multiple factors lining up: 6 factors on average
were found per case of diagnostic error in an internal medicine study (Graber 2005).
 Lack of physician knowledge is least often the problem. It is more often due to cognitive error, systems
errors including communication errors, and most common of all, the combination of cognitive and systems
errors (Graber 2005).
 Is it the rare diagnosis that is the subject of diagnostic error?
 No, it is the common diagnosis and the common killers: heart attack, cancer and stroke.
 Overall, the top diagnosis in claims related to diagnostic error is breast cancer (PIAA Data Sharing Report
1985-2009).
 Acute myocardial infarction is the top subject of diagnostic error in claims for the specialties of adult
primary care, emergency medicine and cardiology (PIAA Data Sharing Report 1985-2009).
 Stroke is associated with diagnostic error 9% of the time (Newman-Toker et al 2008).
 For family and general practice, the top diagnoses involved in diagnostic error in descending order were
myocardial infarction, breast cancer, appendicitis, colorectal cancer and lung cancer.
 In a study of physician self-reported diagnostic errors, the diagnoses most often involved were pulmonary
embolism, drug reaction or overdose, lung cancer, colorectal cancer, acute coronary syndrome, breast
cancer and stroke (Schiff et al 2009).
 Certain diagnoses like pulmonary embolism and aortic dissection may not be found until autopsy, but the
rate of autopsies performed in the US has declined steeply, so these and others are under-detected at an
unknown rate.
http://www.improvediagnosis.org

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MYTHS ABOUT DIAGNOSTIC ERRORS
From a Patient’s Perspective
 No news is good news.
 My doctors are talking to one another.
 My doctor is different.
 Somebody is in charge of my diagnosis.
 There is always an answer.
 My hunches don't count as much as my
physician's.
 I would be disloyal if I ask for a second opinion.
 My insurance won't pay for a second opinion.
 The more tests I have, the better.
 Diagnosis errors won't happen to me.
•
From a Physician’s Perspective
 It won't happen to me.
 I can trust my intuition.
 We know what they know & know what they don't
know.
 I communicate effectively with my patients.
 I'm a good listener.
 Most diagnostic errors involve rare or uncommon
diseases.
 I always make a complete differential diagnosis.
 If I made a diagnostic error, I'd find out about it.
 I speak with the Radiologist about important tests.
 I have a reliable system to track requested tests.
http://www.improvediagnosis.org/?page=Myths

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HEALTHCARE INDUSTRY LANDSCAPE
CONTACT
Madhukar Kalsapura
Founder & Chief
Madhukar@knowurture.com
+91 9845035436
Ramnath Sundaram
Co-Founder & Chief – Finance & Operations
Ramnath@knowurture.com
+91 9845147779
THANK YOU