Minimizing diagnostic errors
Diagnostic error is a huge problem in the United States. According to a Johns Hopkins University study, as many as 160,000 patients incur permanent damage or die every year from diagnostic mistakes. In the Philippines, we have not had any such study.
Diagnostic error is the leading cause of malpractice claims in the United States, accounting for 35 percent of the nearly $39 billion in insurance payout from 1986 to 2010.
It is likely that all physicians have committed diagnostic errors that led to permanent injury or death, but most of them may not be aware they have made such a mistake. Why? Because here in our country, the number of autopsies is going down every year. About 30 years ago, approximately 400 autopsies would be done at the Philippine General Hospital every year; in the past several years the number has gone down to 70 a year, even less.
If the medical community, specialty organizations, the government and the patients put their hands and heads together, we can prevent most diagnostic errors. Such collaboration could translate into huge financial savings and fewer deaths.
The first step is to require all physicians and hospitals to use for a reasonable number of years (like up to 2020) the smart-relational EMR (electronic medical records) that is tablet- and smartphone-based. PhilHealth and other insurance companies can take the lead in educating their members and clients on the beneficial applications of EMR. Unless the physicians and hospitals can show that they have the EMR on a patient, PhilHealth and insurance companies should have no obligation to pay for their services.
The second step is to make mandatory the submission by all hospitals of the annual record and report of the number of deaths among their patients and the number of autopsies they performed. Hospitals that conduct no autopsies or where the number of autopsies are declining will be penalized with reduced payment. Those doing a better job will be rewarded with a bonus.
With their EMR on hand, physicians should be required to display a record of their performance and post this in their clinics’ waiting areas for patients to see. For example, they can show in a bar graph the number of diabetic patients and the percentage of those who have hemoglobin A1C and the number of asthmatics they are attending to. Other diseases may be measured depending on the physicians’ field of specialization. Penalties should also be imposed on physicians who do not have EMR and do not report their performance.
The third step is for hospitals to record and report HAI (hospital-acquired infections). After three to five years of recording, they should be able to show that their HAI is going down, otherwise they don’t get a full payment of their hospital billings. They should also report the average number of days spent by patients with common illnesses (like pneumonia, asthma, diabetes, stroke, depression, head injury) with them.
The fourth step is to launch a national campaign—using TV, newspapers, social media, churches, schools and all medical organizations—to educate the public on how patients can help reduce medical and diagnostic errors. For example, encourage patients: to call or contact their physician if their laboratory, x-ray, CT, or MRI report is not received in two to four days; to list the symptoms they notice and their concerns and make sure to discuss these with their physician; to ask for a second opinion if they are not getting better after a reasonable period of time or if their physician is not sure of the diagnosis (patients should know that the first diagnosis is not the final one and it could change); and to ask, “what else it could be.”
Fifth, create a department within the Medical Board of Examiners that will monitor hospitals if they are reporting and publishing their HAI record, the number of autopsies, success rate of coronary heart surgery, etc; and if physicians are keeping an EMR and are posting their performance as required. The department shall submit to PhilHealth and the insurance firms a report on the physicians’ and hospitals’ compliance with the requirements—for the appropriate reward or penalty.
Sixth, revise specialty programs to make attendance in CME (continuing medical education) courses optional. CME attendance does not change the behavior of most physicians. It only unnecessarily increases the physicians’ overhead expenses. Time spent in CME sessions could be better spent for patients.
Seventh, national medical societies or the Department of Health should study the diagnostic error rates of private hospitals with more than 100 beds and publish these in newspapers of national circulation.
Eighth, once a hospital has a fully functioning EMR, it should review if the results of targeted tests like PSA (for prostate cancer) were communicated to the concerned patients and their respective physicians. This method was adopted by the Kaiser group of hospitals. Its maiden review covered 8,076 patients with abnormal PSA results; more than 2,200 patients were subjected to follow-up biopsies. From 2006 to 2009, 745 patients were diagnosed with cancer. The result: the Kaiser group met no malpractice claims related to missed PSA tests.
If we can implement these eight steps, we will be the first country to nationally tackle diagnostic errors. Less costs, better healthcare, fewer deaths are welcome side effects.
Dr. Leonardo L. Leonidas (nonieleonidas68@ gmail.com) retired in 2008 as assistant clinical professor in pediatrics from Boston’s Tufts University School of Medicine, where he was recognized with a Distinguished Career in Teaching Award in 2009. He is a 1968 graduate of the University of the Philippines College of Medicine and now spends some of his time in the province of Aklan.
