According to a recent Institutes of Medicine report, clamor for reform of the delivery and payment of health care has all but ignored a crucial aspect of patient care: diagnosis. But after the report’s authors got top billing in the Journal of the American Medical Association’s December 15 issue, we are one step closer to giving this issue the attention it deserves.
Because diagnosis serves as the starting point for all subsequent health care decisions, arriving at an accurate diagnosis is crucial for patient safety. The IOM report—titled “Improving Diagnosis in Health Care”—estimates that diagnostic errors account for up to 17 percent of hospital adverse events and are implicated in 10 percent of patient deaths. Most Americans will be misdiagnosed at least once in their lifetime. And, as healthcare becomes more complex, IOM researchers predict that incidence of diagnostic errors will likely rise.
The IOM report urges the healthcare industry to commit to a concerted effort to address diagnostic error. And it offers a few fundamental strategies towards this aim: targeting training and education for healthcare professionals; improving teamwork among healthcare providers, patients, and families; creating a payment and care delivery environment that supports the diagnostic process; and focusing on research related to diagnosis and diagnostic accuracy.
Improving teamwork is particularly crucial for better diagnosis. Effective diagnosis depends upon effective collaboration between patients, families, and health care professionals with different educational and training backgrounds. Teamwork between clinicians may be difficult when the diagnostic process unfolds across different settings or takes place in a frenzied environment. In emergency room settings, for instance, doctors, nurses, and technicians must multi-task and work together to arrive at a diagnosis amidst a constant stream of new patients and information.
In confronting these challenges, the IOM report urges health care organizations to facilitate teamwork in the diagnostic process, ensuring that all health care professionals have the knowledge, skills, resources, and support to collaborate effectively and in a timely manner. The IOM committee also suggests educational approaches, such as adding diagnostic skills training to professional school curricula and developing certification and accreditation programs that reinforce and evaluate those skills.
Payment and care delivery models also influence the diagnostic process and the occurrence of diagnostic errors. The committee notes that current fee-for-service payment systems incentivize procedure-oriented care and divert attention from tasks in diagnosis, such as performing a thorough clinical history, interview, and physical exam. The report proposes changes to fee-for-service payment to improve collaboration and emphasize tasks in the diagnostic process. For example, the committee recommends that Medicare, Medicaid, and other payers extend coverage for evaluation activities that are not currently coded or covered, such as time spent by pathologists and radiologists in advising physicians on testing for specific patients.
The report goes on to assert that diagnostic errors have been a “blind spot” in the delivery of quality health care at least in part because of a lack of available data and research. In the IOM’s view, reducing the prevalence of misdiagnosis will require collecting information about its occurrence and learning from these errors to implement necessary changes. The report suggests that health care organizations can encourage professionals to identify and learn from errors by promoting a non-punitive work culture. Additionally, the IOM committee urges federal agencies to develop a coordinated research agenda on the diagnostic process by the end of 2016 and commit dedicated funding to it. Diagnostic errors represent a complex challenge, and specific interventions must be rigorously evaluated for efficacy and safety.
Fifteen years ago, the landmark IOM report, “To Err is Human,” began a crucial discussion about patient safety within the health care community and spurred subsequent health care quality reform efforts. Here’s hoping that this IOM report sparks a similar revolution when it comes to medical diagnosis.