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Breaking Down the IOM Committee Report On Diagnostic Error—Part Two

David Meyers, MD, FACEP

On September 22, 2015, the Institute of Medicine (IOM) issued the report of its Committee on Diagnostic Error. In the first part of this article, published in the December 2015 QIPS newsletter, I summarized the report’s three key themes and the conceptual model used by the Committee. I will now discuss the eight goals identified by the Committee in their report to improve diagnosis and reduce diagnostic error.

Goal 1: More effective teamwork in the diagnostic process

1A: Health care organizations should ensure that health care professionals have the appropriate knowledge, skills, resources and support to engage in teamwork in the diagnostic process.
This includes:

  • Interprofessional and intraprofessional teamwork.
  • Collaboration among pathologists, radiologists, and treating health care professionals to improve diagnostic testing.

1B: Health care professionals & organizations should partner with patients and their families as diagnostic team members.
They should:

  • Create environments where patients and their families can learn and engage in the diagnostic process and share feedback and concerns.
  • Ensure patient access to EHRs, including clinical notes and diagnostic testing results.
  • Include patients and their families in efforts to improve the diagnostic process.


Goal 2: Enhance health care professional education and training in the diagnostic process
2A: Educators should ensure that curricula and training programs across the career trajectory address performance in the diagnostic process and include evidence from the learning sciences:

  • Clinical reasoning
  • Teamwork
  • Communication
  • Diagnostic testing
  • Health IT

2B: Certification and accreditation organizations should ensure that health care professionals have and maintain these competencies.

Goal 3: Ensure that health information technologies support patients and health care professionals in the diagnostic process
3A: Health IT vendors and ONC should work together with users to ensure that health IT used in the diagnostic process:

  • Demonstrates usability
  • Incorporates human factors knowledge
  • Integrates measurement capability
  • Fits well within clinical workflow
  • Provides clinical decision support
  • Facilitates the timely flow of information among patients and clinicians

3B: ONC should require health IT vendors meet standards for interoperability by 2018.
 
3C: The Secretary of HHS should require health IT vendors to:

  • Submit products for independent evaluation
  • Notify users about adverse effects on the diagnostic process related to product use.
  • Support the free exchange of information about user experiences with health IT used in the diagnostic process.


Goal 4: Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
4A & 4B: Accreditation organizations and the Medicare Conditions of Participation should require that health care organizations:

  • Monitor the diagnostic process
  • Identify, learn from, and reduce diagnostic errors and near misses
  • Provide systematic feedback on diagnostic performance to health care professionals, care teams, and clinical and organizational leaders

4C: HHS should provide funding for a designated subset of health care systems to conduct routine postmortem examinations on a representative sample of patient deaths.
4D: Health care professional societies should identify opportunities to improve accurate and timely diagnoses and reduce diagnostic errors in their specialties.

Goal 5: Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
5: Health care organizations should:

  • Promote a non-punitive culture that values open discussion and feedback on diagnostic performance.
  • Design the work system to support patients, their families, and health care professionals in the diagnostic process.
  • Ensure effective and timely communication between diagnostic testing health care professionals and treating health care professionals across all health care settings.

Goal 6: Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses.
Reporting:
6A: AHRQ or others should encourage and facilitate the voluntary reporting of diagnostic errors and near misses.
6B: AHRQ should:

  • Evaluate the effectiveness of PSOs as a major mechanism for voluntary reporting and learning from diagnostic errors and near misses
  • Modify the PSO common formats to include diagnostic errors and near misses.

Medical Liability and Risk Management:
6C: States and others should promote a legal environment that facilitates timely identification, disclosure, and learning from diagnostic errors.

  • Adoption of Communication and Resolution Programs
  • Demonstration projects of alternative approaches to the resolution of medical injuries
  • Administrative health courts
  • Safe harbors

6D: Professional liability insurers should collaborate with health care professionals to improve diagnosis through education, training, and practice improvement.

Goal 7: Design a payment and care delivery environment that supports the diagnostic process.
7A & 7B: CMS and other payers should:

  • Provide coverage for evaluation and management (E&M) activities, including time spent by pathologists, radiologists, and others in advising clinicians on diagnostic testing.
  • Reorient relative value fees to more appropriately value the time spent with patients in E&M activities.
  • Modify documentation guidelines to improve the accuracy of information in the EHR and to support decision making in diagnosis.
  • Assess the impact of payment and care delivery models on the diagnostic process & diagnostic error.

Goal 8: Provide dedicated funding for research on the diagnostic process and diagnostic errors.
8A: Federal agencies (HHS, VA, and DOD) should:

  • Develop a coordinated research agenda on the diagnostic process and diagnostic errors by the end of 2016.
  • Commit dedicated funding for implementation.

8B: The federal government should pursue and encourage opportunities for public–private partnerships among a broad range of stakeholders to support research on the diagnostic process and diagnostic errors, such as:

  • PCORI
  • Foundations
  • Diagnostic testing and health IT industries
  • Health care organizations
  • Professional liability insurers


Clearly, the recommendations cover a broad range and many will require new thinking about the provision of clinical care generally, about diagnosis, about education and about many more elements of health care and related fields. While there is a lot of attention to diagnostic error in the several months since the Report, the risk is that, like the Titanic, momentum of the status quo is very powerful, and overcoming it will be challenging. That is perhaps best illustrated by the very recent IOM conference (Dec 10, 2015) marking the 15th anniversaries of publication of the landmark IOM reports, “To Err Is Human” and Crossing the Quality Chasm. The day-long session illustrated what progress has been made but also what a long way we have to go to fulfill the goals of those reports. Meanwhile, we can all get started on improving diagnosis by downloading and reading the Report of the Committee on Diagnostic Error. For comments and questions please contact me via email

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