Part 3: Blind Spots Can Kill Patients—Learning How to Avoid Errors

April 10, 2013
In part one of this series, I introduced the widely accepted premise that delivering complete, accurate, up-to-date, and relevant information to care providers, surpassing today’s norms by using information technology, would lead to better care. In part two, I revealed that dozens of types of cognitive errors, when carefully studied, represented a much larger barrier to care improvement than deficiencies in HIT. I also suggested that simply mandating CPOE, drug checks, ePrescribing, problem/medication/allergy lists, calculated and transmitted quality measures, patient engagement enhancers, care coordination improvements (clinical information exchange), and privacy and security protections (collectively Meaningful Use Objectives and Measures of Stage 1) would be unlikely impact these known cognitive errors. In some cases, such as the commission bias, streamlining information delivery, documentation and taking actions (CPOE and ePrescribing) could conceivably increase the error rate.

In part one of this series (link: http://bit.ly/hCb0MP ), I introduced the widely accepted premise that delivering complete, accurate, up-to-date, and relevant information to care providers, surpassing today’s norms by using information technology, would lead to better care. In part two (link: http://bit.ly/hgjELo ), I revealed that dozens of types of cognitive errors, when carefully studied, represented a much larger barrier to care improvement than deficiencies in HIT. I also suggested that simply mandating CPOE, drug checks, ePrescribing, problem/medication/allergy lists, calculated and transmitted quality measures, patient engagement enhancers, care coordination improvements (clinical information exchange), and privacy and security protections (collectively Meaningful Use Objectives and Measures of Stage 1) would be unlikely impact these known cognitive errors. In some cases, such as the commission bias, streamlining information delivery, documentation and taking actions (CPOE and ePrescribing) could conceivably increase the error rate.

How can we reduce or avoid diagnostic errors?
In their 2008, 22-page article “Overconfidence as a Cause of Diagnostic Error in Medicine,” Eta S. Berner, EdD and Mark L. Graber, MD provided a tour de force job of addressing this in detail. I’ve reproduced their Table 2 below, which provides a summary of their findings. The article did a splendid job of highlighting the scope of the problem as being well beyond internal medicine, as might have been suggested by my last post. It provided hundreds of references, highlighting the problem and range of historically attempted approaches, like computer-based diagnostic decision support tools (a form of CDS or clinical decision support), that have had limited impact. According to the authors, “For many clinicians, these factors (elaborated in the article) may make the perceived utility of these systems not worth the cost and effort to use them.” I am grateful to both Drs. Berner and Graber for their fabulous review, their editorial work on an entire supplemental issue of The American Journal of Medicine on this topic, and their personal support through email and other personal communications.
In one of those adjoining articles, “Minimizing Diagnostic Error: The Importance of Follow-up and Feedback,” Gordon D. Schiff, MD makes several points about the management side of this, as well as the practice environment. For example, he says, “I suspect many physicians feel more beleaguered and distracted than overconfident and complacent. There simply is not enough time in their rushed outpatient encounters, and too much ‘noise.’”
The management trinity in any industry (link: manager-tools) is coaching, one-on-ones and feedback. There are at least two reasons why this kind of management has been absent for physicians:
a) physicians have been selected and trained to be highly autonomous with little real attention to building trust and team behavior and structures. More on this in Elliott Jaque’sAssociations and Bureaucracies,” and b) the commitment to professional management practices in general is often not the norm in most organizations (link: Passive Aggressive Organization).
Dr. Schiff is very clear on where that can break down for physicians in the table below. Note that each of the barriers has the potential both to improve dramatically with HCIT, as well as to degrade dramatically.

This calls for even more attention to implementation and post-implementation monitoring, a capability that has been under-developed at least in the financial planning of HCIT roll-outs. The tell-tales are the length and staffing of the dedicated, post-go live functionality roll-out completion, clean-up, evolution, stabilization, and implementation usability “real world” optimization.
Changes in the practice environment are obviously necessary as well.Perhaps, if we are wise, the “Era of Meaningful Use” combined with delivery practices like “Patient-Centered Medical Home” will produce a net decrease in these distracting and chaotic factors that contribute to avoidable cognitive errors, as well as more disciplined, thoughtful human management as outlined above.

Joe Bormel, M.D., MPH

CMO & VP, QuadraMed

Ignorance more frequently begets confidence than does knowledge.”

—Charles Darwin, 1871

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