IMPROVING DIAGNOSTIC SAFETY: THE NEXT GRAND CHALLENGE & OPPORTUNITY FOR INFORMATICS

HARDEEP SINGH, MD, MPHHOUSTON VA CENTER FOR INNOVATIONS IN QUALITY,

EFFECTIVENESS & SAFETY

MICHAEL E. DEBAKEY VA MEDICAL CENTER

BAYLOR COLLEGE OF MEDICINE

Twitter: @HardeepSinghMD

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Medical Informatics

Dean ShailajaTraberDaniel Ashley Roosan

Viraj JanetEliseViral Jessica DanielDonna

Physician/Health IT

Social Work/ Qualitative Research

Psychologist/Analyst

Medical Informatics

Sociologist/ Qualitative Research

Human Factors

Physician/Health IT

Physician/Health IT

Project Coordinator

ResearchCoordinator

Project Coordinator

ResearchCoordinator

Multidisciplinary Team• Reducing diagnostic errors• Improving health IT-

related patient safety

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IOM Definition of Diagnostic Error7

The failure to

a) establish an accurate and timely

explanation of the patient’s health

problem(s) or

b) communicate that explanation to the

patient

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GOAL 1 Facilitate more effective teamwork in the

diagnostic process among health care

professionals, patients, and their families

GOAL 3 Ensure that health information

technologies support patients and health

care professionals in the diagnostic process

GOAL 4 Develop and deploy approaches to

identify, learn from, and reduce diagnostic

errors and near misses in clinical practice

3 of 8 IOM Goals Relevant for Informatics

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Our Research Shows Emerging Risks

Common diseases missed despite clear

red flags (1 in 20 US adults annually)

Failure to elicit or act on key history/exam

finding

Time

Do templates constrain thinking?

Singh et al JAMA IM 2013; Singh et al JCO 2012

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The Famous Ebola Misdiagnosis

Temperature of 103℉ but “no fever”

Travel history in nurse’s EHR notes not seen by the doc

Day 1-Blame Nurse

Day 2-Blame EHR

Day 3-None of the

above

Few lessons learned

Upadhyay D, et al. Diagnosis 2014

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Emerging Risks - #2

Disappearing differential diagnosis

Docs often don’t seek help when they most need it

Implications for decision support (computer or human)

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Singh et al JAMA IM 2013; Meyer et al JAMA Intern Med 2013

Diagnostic Accuracy and Confidence

118 Physicians assessed 4 clinical

vignettes (2 easy & 2 difficult) based on

real-world cases

Goals

Assess how diagnostic accuracy is aligned

with perception of confidence in that

accuracy

Meyer et al JAMA Intern Med 2013

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Diagnostic Accuracy vs. Confidence

Emerging Risks - #315

Data display and comprehension

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Patient Perspectives-Portal Usability17

“When I log in, I can

see the new labs. But

once I’ve viewed them

already, it moves them

to somewhere else. I

couldn’t figure out

where to go to find

them. Not user

friendly.”

“The lab results are

not organized in any

logical order…like

by date. I have

trouble finding the

newest result. And

the graphs. They

are just wrong.”

Giardina et al J of Pt Exp 2015

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Emerging Risks # 4

Overlooking documented critical information in EHR

Communication breakdowns persist despite EHRs

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Communication of Test Results20

Evaluation of 1,163 outpatient abnormal lab &

1,196 abnormal imaging test result alerts

7% abnormal labs lacked timely follow-up

8% abnormal imaging lacked timely follow-up

Why abnormal test results continue to get

missed in health IT-based settings

Singh et al Am J Med 2010 & Singh et al Archives of Int Med 2009

Ambiguous Responsibility a Huge Issue

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And More Digital Data Is on the Way

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Wearables Smartphone

“Patients can now continuously monitor their

data real-time and send it to their docs”

How can Health IT Support Diagnosis?

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Health IT must be safe

Health IT must be used safely

We must use health IT to improve

diagnostic safety

Leveraging health IT to identify delayed,

wrong or incorrect diagnosis before patient

harm

Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60

Singh Sittig BMJ Qual Saf. doi:10.1136/bmjqs-2015-00448625

Big Data Safety Net

EHR-based triggers that look for follow-up actions

on clues (or red flags) to detect delays

prospectively

Basic versions:

+ hemoccult or microcytic anemia with no subsequent

colonoscopy in 60 days

suspicious chest-x ray with no follow-up CT scan in 30

days

Murphy, Singh et al BMJQS 2013; Radiology 2015; Chest 2016

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Must Evaluate How We Are Doing

ONC-sponsored “Safety Assurance Factors for EHR Resilience (SAFER)” Guides

Proactive risk assessment and guidance

“1st draft” of best practices and knowledge

Self-assessment; not meant to be regulatory

Focused on high-risk areas including Test results & Communication

Nine guides—all freely available

Singh et al BMC Med Inf 2013

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http://www.healthit.gov/safer

Opportunities for Patient Engagement 30

Need Novel Ways to Help Patients31

“The result was abnormal but I

didn’t realize it. There’s a

comment section but the doctor

never leaves a comment. My

triglycerides are high. Ok,

what does that mean? What

am I supposed to do?”

“I’m not a doctor. I hope

they’ll call if it’s problematic.”

“I had to figure out

the sodium was low.

There’s a problem

with low sodium,

what can I do?”

Giardina et al J of Pt Exp 2015

Health IT Innovations to Support Diagnosis

Dimension Examples

Software Better health IT tools/functions

Content Smarter alerts & diagnostic decision

support

Usability Better user-interfaces; ↑ signal to noise

ratio

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Need More Than Just Health IT

Dimension Examples

Workflow Time interacting with patients

People Culture change

Organization Policies for closed-loop test results

follow-up

External rules National entity for shared learning

Evaluation &

Measurement

Data to separate reality vs. hype;

Triggers & ONC SAFER Guides

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Improving Diagnosis Needs a Socio-Technical Approach

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Sittig Singh QSHC 2010

Thank you and Acknowledgements

Funding Agencies: Department of Veterans Affairs

National Institute of Health

Agency for Health Care Research & Quality

ONC for SAFER Guides

Multidisciplinary team at VA Health Services Research Center for Innovation

Email: Hardeeps@bcm.edu

Web: http://www.houston.hsrd.research.va.gov/bios/singh.asp

Twitter: @HardeepSinghMD

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