Diagnostic Malpractice Risk

1. Diagnostic Malpractice Risk Learning from the worst-of-the-worst… Robert Hanscom JD CRICO Strategies / CRICO-Risk Management Foundation

2. Signals from the Tip of the Iceberg: The “skeptics” on coding medical malpractice claims Unique Events Small “n”— • Emphasis on most severe injuries • Relatively large number of rare events • CBS multiplies the value A look to the past— • Richer details available for analysis and learning • Trends related to significant events often lost in “fix-and-move-on” process Unique Convergence— • Codes beyond the “headline” • Provides common causation factors • Breaks down “silos” of individual analysis Not-so-unique underlying issues Failure to monitor physiological status Failure to follow protocol Inadequate communication Narrow diagnostic focus Lack of adequate assessment Failure to ensure patient safety Resident supervision Failure/delay ordering diagnostic test

3. Diagnosis

4. 15,873 cases | $3B total incurred National Malpractice Landscape: Top Major Allegations Diagnosis-related claims round out the top three most prevalent case types N=15,873 coded PL cases asserted 1/1/07–12/31/11. 20% 15% 30% 17% % = Total incurred dollars

5. Comparative Perspective: Diagnosis-related allegations are more prevalent in the Community Hospital setting… CBS AMC N=2,716 coded CBS PL cases asserted 1/1/07–12/31/11. CBS Community N=2,462 coded CRICO PL cases asserted 1/1/07–12/31/11. All Cases: Top Major Allegations

6. 3,316 cases | $941M total incurred No Surprise: General Medicine is the most frequently named “responsible service” N=3,316 coded PL cases asserted 1/1/07–12/31/11 with a diagnosis-related major allegation. Total incurred includes reserves on open and payments on closed cases. Diagnosis-related Cases: Top Responsible Services

7. 3,606 cases | $1.1B total incurred The majority of diagnosis-related cases originate in the outpatient setting… Diagnosis-related Cases: Claimant Type N=3,606 coded PL cases asserted 1/1/06–12/31/10 with a diagnosis-related major allegation. ED Inpatient Outpatient (excl. ED)

8. 1,851 cases | $523M total incurred Distribution of Diagnoses – and Cancer Types – in Ambulatory Cases Ambulatory Diagnosis-related Cases: Final Diagnosis N=1,851 coded PL cases asserted 1/1/07–12/31/11 involving outpatients (excluding ED location) and with a diagnosis-related major allegation. Breast Other Diagnoses Cancer Diagnoses Other Cancers Colorectal Lung Prostate

9. 1,851 cases | $523M total incurred Where in the course of care are errors most prevalent in outpatient diagnosis-related cases? Ambulatory Diagnosis-related Cases: Diagnostic Process of Care *A case will often have multiple factors identified. N=1,851 coded PL cases asserted 1/1/07–12/31/11 involving outpatients (excluding ED location) and with a diagnosis-related major allegation. Total Incurred=reserves on open and payments on closed cases. Process of Care Clusters causative factors into steps of care from access issues in seeking care, to reporting test results and appropriate follow up including referrals.

10. Hypotheses of Risk General Medicine and Emergency Medicine

11. Hypotheses of Risk Diagnostic Error • Cognitive variability plays a significant role • It is confounded – even magnified – by imperfect processes • It is made even more challenging by the lack of feedback • -- and missed cancer cases miss our reporting systems... • It is not productive to divide diagnostic failure into camps, e.g. “cognitive” vs. “systems” – look instead at entire set of diagnostic steps • Relying on human memory is not a viable strategy for making correct diagnoses • ….Too many parts, too many data points, too many perspectives

12. The Tension • The Third-Party Payers: “Less Tests”! • Lower cost care, more efficiently delivered, but raise the “quality” • Avoid defensive medicine… • The Malpractice Defense Insurers: “More Tests”! • Lower cost care, more efficiently delivered, but raise the “quality” • When in doubt, order more diagnostic tests… What’s the answer? Will this tension ever be resolved?

13. Strategies and Models

14. The Model Methodology: Data into Action Capture vulnerabilities as they occur • Contemporaneous analysis of asserted malpractice cases Put them into context • Integration of relevant denominator data and peer comparative data Are you still vulnerable? • Assessment of present-tense risk through risk assessments, focus groups, and through validation by other data sets Determine potential solutions • Continuous identification of relevant models, processes, education, and training programs that address key risk areas Implement, educate, train: the “reinvestment” • Championship by high-level leadership to effect real change and to sustain it; leverage by insurer to accelerate movement Measure/Metrics • Measure the impact in the near term (with a predictive eye for the long term)

15. Prevention of Diagnostic Errors Prevention of Missed/Delayed Diagnoses • Reliable office-based systems or processes that support— • Routine updating of family history • Receipt of test results by ordering providers (including critical test results) • Tracking/managing follow-up steps related to pt.’s subsequent care • “Close-the-loop” management/accountability of specialty referrals • Communication of all test results to patients, including routine chest x-rays (“incidental findings”) • Ongoing, interval-based education of clinicians to avoid fixation, narrow diagnostic focus • Decision-support guidelines/algorithms embedded into I.T. system so providers can access them in the flow of patient care • Presence of health I.T. system with all features • All features are turned on • Providers trained • Record audits – are features being used? • Record audits: differentials documented? • Adherence w/ decision support guidelines

16. CRICO’s Reinvestment in Patient Safety • Algorithms and Guidelines • Symposia dedicated to Diagnostic Risk • Improving reliability in systems: emphasis on test results • ANCR: Radiologists can find accountable provider (vs. the “ordering provider”) • Processes to ensure closing the loop on referrals • Exploration of cognition simulation • Office Practice Evaluation (OPE)

17. Need More Reliable Test Follow-up, Referral Management, Pt. Follow-up General Medicine • There is a business case for I.T. systems that can cleanly do these things • Accountability for follow-up should be identified and plainly visible • Gaps should be flagged Emergency • Reliable follow-up mechanisms for patients following ED care • Close communication with PCP, reliability in specialist referrals • Mechanism for test results that return after pt. has left ED • Standardized, clear discharge instructions

18. Better Ways to Calibrate Accuracy and Competence; Need Pt. Feedback General Medicine • Asking “how confident are you in your answer?” • Need culture where one can (a) feel free to admit uncertainty, (b) not get blamed because of the uncertainty, and (c) get support in a practical, logistical way • Feedback from pts. is often lacking, leading to “overconfidence” that right diagnosis was reached • Automate patient feedback – make it simple Emergency • Standard follow-up / QA nurse call; if findings in hospital or at follow-up visit differ from initial ED diagnosis, develop an I.T.-based way to consistently provide that feedback • Build into the sign-out across shifts an uncertainty factor

19. Role of Patients (and Pt’s Family) in Helping to Make the Diagnosis General Medicine and Emergency • Patient portals: teach them what to look for • Allow them to be proactive in looking for their test results • Teach pts. to be “keen observers” (e.g., reporters) of their symptoms • Give them assigned reading, open the door for them to be better informed • Recruit the family for support • Emphasize the need for compliance, both in showing up for appts and in doing what they need to do (e.g., taking their meds) • Develop relevant, easy-to-absorb patient/family education materials