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A PHYSICIANS INSURANCE PUBLICATION
THE
SPRING 2021 PHYINS.COM
Closing the Loop on
DIAGNOSIS
ERRORS
4 Closing the Loop: 8 Overcoming Systemic 24 Leader Insights:
Safe Practices for Challenges to Reduce Navigating to
Diagnostic Results Diagnostic Errors Avoid Care Gaps
Closing the Loop: An Opportunity EDITORIAL STAFF
PUBLISHER
to Reduce Diagnostic Error
William Cotter
SENIOR EDITOR
David Kinard
MANAGING EDITORS
Diagnostic errors are the most common, possible, but it also represents a Catherine Kunkel
Kirstin Williams
most catastrophic, and most costly of all moral, professional, and public-
CONTRIBUTING WRITERS
medical errors. Every year in the United health imperative.” And despite the Paul Epner, MBA, M.Ed
Anne Bryant
States, 12 million adults are impacted complexities, there are immediate Patricia Giuffrida, MSN, RN
in outpatient settings alone by delayed opportunities for improvement. For Robert Giannini
Malia Jacobson
or inaccurate diagnoses. Approximately example, many diagnostic errors are Jennifer Tomshack
CONTRIBUTING EDITOR
250,000 harmful diagnostic errors are caused by failure or delays in closing the James Carpenter
associated with hospitalized patients loop (CTL) on specific processes, such CONTRIBUTING EDITORS—LEGAL
Melissa Cunningham, JD
annually, and estimates of premature as test ordering and result interpretation Nancy Pugh
deaths in all settings are in excess followed by patient communication. ART DIRECTOR
Jerry Kopec, Mortise+Tenon
of 300,000. Diagnostic error is the Similar issues exist with initiating,
number-one cause of malpractice claims completing, and communicating the EXECUTIVE MANAGEMENT
and is estimated to add $100 billion results of specialty referrals.
PRESIDENT AND CHIEF EXECUTIVE OFFICER
in unnecessary costs to the healthcare William Cotter
system each year. And if these statistics CTL has been studied and well- VICE PRESIDENT, CLAIMS
Kari Adams
aren’t enough to motivate addressing the described in the literature. There are
ASSOCIATE VICE PRESIDENT, DEPUTY GENERAL COUNSEL
problem, consider this: an inaccurate a variety of reasons that test results Melissa Cunningham, JD
or delayed diagnosis is likely to lead to do not receive timely and effective SENIOR VICE PRESIDENT, STRATEGY
Christina Galicia
treatments or additional procedures that follow-up, including transitions from
SENIOR VICE PRESIDENT,
will be wasteful or harmful, while the real inpatient to outpatient status, secondary CHIEF FINANCIAL OFFICER AND TREASURER
Kristin Kenny
underlying disease progresses unchecked. or incidental findings that are not
SENIOR VICE PRESIDENT, BUSINESS DEVELOPMENT
sufficiently prominent in reports or David Kinard
Improving diagnostic quality is not appreciated by the ordering clinician, SENIOR VICE PRESIDENT, GENERAL COUNSEL
Mark Lewington, JD
simple. Diagnosis, by its very nature, limitations on the designation of critical
SENIOR VICE PRESIDENT AND
involves uncertainty. And there can be value and its reporting imperatives, CHIEF INFORMATION OFFICER
Leslie Mallonee
great heterogeneity in how different split order result availability (especially
SENIOR VICE PRESIDENT, UNDERWRITING
patients with the same problems associated with “send-outs”), and failure Stella Moeller
present. Even pertaining to a single to incorporate findings of specialty SENIOR VICE PRESIDENT,
HUMAN RESOURCES AND ADMINISTRATION
patient, presentation can vary over physicians into primary-care records. Alison Talbot
the course of the problem and lead
to diagnostic pitfalls. In this issue of The Physicians Report, BOARD OF DIRECTORS
we’ll take a closer look at this important David Carlson, DO, Chairman
Research into malpractices cases opportunity to make a difference. In William Cotter
Lloyd David
involving serious harm find that on the area of diagnostic quality, there’s Joseph Deng, MD
average, there are more than three not much low-hanging fruit, but closing Jordana Gaumond, MD
Jennifer Hanscom
contributing factors to each case. the loop is as close to that as possible. Chi-Dooh "Skip" Li, JD
With no consensus standards on Readers are encouraged to seize that Shane Macaulay, MD
John Pasqualetto
measuring diagnostic error—or even on opportunity—their patients will be Ralph Rossi, MD
documenting diagnostic-safety events— thankful for it. Walter Skowronski
prioritizing and addressing sources of READ PHYSICIANS REPORT ONLINE
phyins.com/magazine
error locally can be challenging.
CONTACT PHYSICIANS REPORT
editor@phyins.com
However, as the National Academy HOME OFFICE:
Seattle, WA
of Medicine asserts, “Improving
Copyright 2021
the diagnostic process is not only Physicians Insurance A Mutual Company
Paul L. Epner, MBA, M.Ed., CEO
Society to Improve Diagnosis in Medicine
A PHYSICIANS INSURANCE PUBLICATION
FEATURES
8 Overcoming Systemic
Challenges to Reduce
Diagnostic Errors
12 Case Study
When Everything Is
Done Right, Yet Stroke
Diagnosis Is Missed
24 Leader Insights
Navigating to
Avoid Care Gaps
4 Closing the Loop
Safe Practices for Diagnostic Results
MORE NEWS EDUCATION
20 Closing the Loop: 19 Courses
Considerations for How EHR
Systems Can Help 19 Resources
34 In the Chain of Communication:
Reporting Results of Critical GOVT. AFFAIRS
Test Is Key
36 The Data Story: Diagnostic 30 Government Relations:
Errors Account for Top Liability 2021 Legislative
Claims and Lawsuits Session Update
MEMBER SPOTLIGHT MEMBER NEWS
16 Advancing Communication 40 2021 Physicians
in a Growing Market: Idaho Insurance Annual
Urologic Institute Meeting and Proxy Vote
SEND FEEDBACK
40 Welcome to Our
New Members! Tell us more about
what you would like
to see in upcoming
issues. E-mail us at
editor@phyins.com.
4
CLOSING THE LOOP
Safe
Practices
for
Diagnostic
Results
By Patricia Giuffrida, MSN, RN, CPHIMS,
and Robert C. Giannini, BS, NHA, CHTS—IM/CP
In 2015, Improving
Diagnosis in Health
noted that 5% of U.S.
adults seeking outpatient
care experienced
a diagnostic error.1
A review of inpatient event reports indicates that diagnostic errors Consider the following examples.
account for 6–17% of reported adverse events,1 and failure to
respond to new, actionable information is a frequent cause of DELAYED DIAGNOSIS
diagnostic error in both the outpatient and inpatient settings. A patient was seen for evaluation of testicular pain from possible
testicular torsion. An ultrasound was performed. The initial verbal
Closing the loop means that all mechanisms are in place to report stated that no torsion was seen. One week later, the final
ensure that any patient data and information that may require report noted a “suspicious mass,” with recommendations for the
action are delivered and communicated to the right individuals, patient to follow up with a urologist. The report was signed by
at the right time, through the right mode, in order to allow for both the nurse practitioner and the physician.
interpretation, critical review, reconciliation, initiation of action,
acknowledgement, and appropriate documentation.2 Failure Unfortunately, the patient was never informed, and returned
to close the loop on diagnostic test results is one example seven months later complaining again of pain. A large
of a failure to respond to actionable information. testicular mass was discovered on physical examination.
5
THE PHYSICIANS REPORT | SPRING 2021
“Any failure to close these
loops holds the potential
for patient harm through
delayed, missed, or
incorrect diagnoses.”
IT to close these loops? (See “Closing In 2017, the Emergency Care Research
the Loop: Considerations for How EHRs Institute (ECRI) Partnership for
Can Help” on page 20.) Health IT Patient Safety convened the
Closing the Loop Workgroup, chaired
Failures to close the loop are by Dr. Christoph U. Lehman. The
multifactorial and range from a test not workgroup was comprised of health
being performed at all, to a test not IT vendors, clinicians, healthcare
performed as ordered, to the results not organizations, malpractices insurers,
being returned to the clinician, to the patient advocates, and representatives
clinician failing to acknowledge those from professional organizations and
results. Each of these chains of events societies, and held a goal to develop
creates a loop with the potential for a health IT safe practices for closing the
break, with the patient being central to loop to mitigate delayed, missed, and
all the loops involving diagnostic testing incorrect diagnoses.
(e.g., provider to provider, provider to
patient or caregiver, facility to provider). ECRI and the Institute for Safe
Any failure to close these loops holds Medication Practices’ PSO analyst
the potential for patient harm through reviewed more than 800 relevant events
delayed, missed, or incorrect diagnoses. from the PSO database and performed
This example shows multiple points of an additional review of more than 80
failure. First, the verbal report had not MISSED DIAGNOSIS medical malpractice closed-claims
provided all the information. Second, A routine mammography was ordered. reports. The analysis revealed that
despite the fact that the written report The patient failed to have the test failure to close the loop on diagnostic
was signed, its recommendations were performed, but continued with her testing is primarily seen with six types
not acknowledged. Finally, no actions routine visits. of information (Table 1). The most
were taken—and as a result, the patient common failures for safety events
was not made aware of the “suspicious Five years later, another routine occurred in laboratory testing (61%),
mass” for seven months. mammogram was ordered for the followed by events related to imaging
patient. The results indicated a breast (12%). Data from closed medical
Failing to close the loop on diagnostic lump with infiltrating ductal carcinoma. malpractice claims suggest that
testing is not a new problem. While Unfortunately, a chart review uncovered imaging was the information most likely
the introduction of health information a note from five years earlier, stating, to not be communicated (at 36%),
technology (IT) was thought to be a "Mammo pending; no result." This followed by laboratory testing (23%)
ready remedy, the issue persists. The indicates the patient was never followed and pathology (18%).
question facing healthcare providers up with, and thus the breast lump went
today is, how can they leverage health undetected for five years. (Continued on page 6)
6
(Safe Practices, continued from page 5)
Table 1. Prevalence of Reported Safety Events and Closed DIAGNOSIS NOT COMMUNICATED
Malpractice Claims A patient admitted with shortness of
breath was diagnosed with pneumonia.
AREA FOR FAILURE MALPRACTICE CLOSED CLAIMS The radiology study identified a lung
EVENTS (%) (N = 848)
TO CLOSE THE LOOP (%) (N = 82)
lesion; however, these findings were not
Laboratory testing 61 23 communicated to the patient. There
was no documentation of a follow-up or
Imaging 12 36 workup related to the lung lesion. The
patient was admitted to the hospital six
Other diagnostics 5 8
months later, and was diagnosed with
Pathology 2 18 an adenocarcinoma.
Treatment 2 5 Eliminating diagnostic error requires
closing the loop on diagnostic results—
Other 18 11 adding a plethora of technology
alerts and reminders to an already
Sources: Data were presented at the Closing the Loop Workgroup, July 11, 2017.
Note: Event reports in the ECRI and Institute for Safe Medication Practices PSO database disproportionately
dysfunctional process for result
represent the acute-care setting, as opposed to the ambulatory-care setting. Malpractice closed claims were management will only obfuscate matters.
primarily from the ambulatory setting.
The Closing the Loop Workgroup offers
A critical result is defined as a result from a test that must be reported immediately the following three recommendations
to a care provider, because it may require urgent therapeutic action. (See “Critical for communicating, tracking, and
Results Testing” on page 34.) Using this definition, we also grouped information linking, along with references and tools
that was not communicated by criticality. Both for events and malpractice claims, to facilitate their implementation:
significantly abnormal noncritical results were more likely to not be communicated
(see Table 2). SAFE-PRACTICE RECOMMENDATIONS
• Develop and apply information
Table 2. Events and Claims by Criticality technology (IT) solutions to
communicate the right information
EVENTS (%) CLAIMS (%) (including data needed for
RESULTS
(N = 848) (N = 82) interpretation) to the right people,
Critical value 28 0 at the right time, in the right format
• Implement IT solutions to track
Noncritical value but significantly abnormal result 55 84 key areas
• Use health IT to link and
Critical value with test not specified 5 0
acknowledge the review of
information and documentation of
Other 12 16
the action taken
Most failures to close the loop had multiple targets for notification. In reported Communicate
safety events, staff were the most common target of communication (at 65%), The recommendation to communicate
followed by physicians (62%). However, for claims, the most common target encourages stakeholders to design,
was the physician (89%), followed by the patient (71%) and staff (46%). test, deploy, and implement health IT
solutions that improve communication
Not surprisingly, only 19% of reported events resulted in a delay in treatment or pathways and make closing the loop a
diagnosis, while 96% of malpractice claims included a claim of delay in diagnosis seamless and elegant process, with all
or treatment. In the case of events, this delay was triggered mostly by failure to diagnostic tests communicated to the
report or communicate (80%) and lag in reporting or awareness (19%). For claims, provider, the pharmacy, and the patient
the most common reason was that a provider acknowledged information and failed in a timely manner.
to follow up (39%), followed by failure to report or communicate (30%), delay
in reporting (21%), and unclear/ambiguous communication (16%).
7
THE PHYSICIANS REPORT | SPRING 2021
To guarantee closed-loop communication,
it is essential to notify the patient of test results,
including the follow-up plan, treatment, or therapy.
The loop begins and ends with the patient.
The lack of standardization in To ensure successful communication, Track
healthcare creates a dangerous functionality must be available to It is essential to implement health
inconsistency across systems. One generate reminders and disperse IT solutions to track key areas in
basic requirement for effective information as needed. This the results-management process.
communication is the use of standard functionality may require providers and Providers, healthcare organizations,
nomenclature and structured data provider organizations to reevaluate and leadership all need to know when
(e.g., SNOMED CT, LOINC) to improve their systems to ensure that all systems a loop remains open. Accurate tracking
the overall efficiency and usability of are working as intended. EHRs and and monitoring of diagnostic results—
transmitted test results for reporting clinical workflows must align to ensure including occurrence, transmission
diagnoses. Today, providers work in that work is being performed as of information, acknowledgment,
multiple electronic health records intended. Adopting and implementing documentation, and responses—are
(EHRs) as they move from the inpatient, standard nomenclature and terminology, essential to identify closed loops.
ambulatory-care, and surgical centers. display icons, and reporting criteria—
Information contained in records in including the timing and results The safe-practice recommendation
these various settings is not often priority for reporting findings—will suggests that tracking and monitoring
kept in the same location, formatted make the process of closing the loop of test results is critical to identify
the same, or readily retrievable; this more efficient and effective. Finally, to interruptions and potential failure
compromises safety, timely information guarantee closed-loop communication, points in the process, including the
gathering, and readiness to action. Well it is essential to notify the patient of ability to react to and remedy failures
thought-out and agreed-upon standards test results, including the follow-up to close the loop. Results that do
can help reduce the cognitive workload plan, treatment, or therapy. The loop not reach the intended recipient, or
of physicians. begins and ends with the patient. that are not reviewed or acted upon,
(Continued on page 28)
8
Overcoming
Systemic
Challenges
to Reduce
Diagnostic
Errors
As part of its efforts to support higher quality and safety
Medical errors are a leading standards in healthcare, the Washington State Hospital
cause of death in the United Association (WSHA) performs ongoing work to discover the
root causes of diagnostic errors, which may occur in up to
States, causing preventable 15% of medical diagnoses, according to Johns Hopkins
harm to around 400,000 Medicine. When the causes of diagnostic error are examined,
some clear patterns emerge, says Trish Anderson, WSHA’s
Americans annually, at a cost of senior director of safety and quality.
approximately $20 billion per year.
“Some of the many causes of diagnostic error that we’ve been
In "Preventing Medical Injury," published in the Quality able to identify throughout healthcare settings are episodic
Review Bulletin, researchers define four types of medical care and limitations to clinical assessment, which affect
errors: diagnostic errors, including missed or delayed subsequent decision-making,” says Anderson. “Additionally,
diagnosis; treatment errors, which include medication there can be a lack of time for sufficient communication
mistakes; preventative errors, or the failure to provide between patients and providers and between clinicians.”
protective monitoring or care; and other errors, which include By addressing these core contributors to diagnostic error,
communication failures. organizations can make progress toward closing the loop.
9
THE PHYSICIANS REPORT | SPRING 2021
“You can have a spotless process
with a beautiful checklist, but are you
communicating well with the nurse
or with the patient in terms of what
needs to be done next?”
“Communication is
Replacing face-to-face communication
between providers and staff with where it really falls
digital data stored in electronic health
apart. You can have
records (EHRs) won’t solve systemic
communication problems, notes Doten, a spotless process
who previously served as Chief of
Emergency Medicine at Swedish with a beautiful
Medical Center in Seattle. “I think checklist, but are you
electronic health records make some
communication easier, but sometimes communicating well
it’s not effective because the signal-
to-noise ratio is off; the piece of
with the nurse or with
information that I need from the the patient in terms
patient’s medical history is in the
EHR, but so is all of this additional of what needs to be
information. If I’m in the emergency
done next?”
department with a patient and there are
two pieces of medical information I need
to make a decision, that information can IAN DOTEN, MD, PHYSICIAN
easily get buried in the data.” AND MEDICAL DIRECTOR,
INSYTU ADVANCED
HEALTHCARE
Reducing communication lapses SIMULATION, SEATTLE
in medical settings remains a
persistent challenge, in part because
communication styles and preferences
vary from person to person, says
Ben Wandtke, MD, BMS, Vice Chair, single communication touchpoint—
Quality and Safety, and Chief of for example, communicating with
CHALLENGE: COMMUNICATION Diagnostic Imaging at FF Thompson patients about follow-up care via an
Miscommunication between providers Health in Canandaigua, New York. electronic patient portal—Wandtke
is a leading cause of diagnostic errors, In his study “Reducing Delay in found that establishing a series of
particularly during shift changes when Diagnosis: Multistage Recommendation different types of communication
caregivers hand off medical information Tracking,” published in the American interventions—including letters, phone
about patients to other providers. Journal of Roentgenology, multiple calls, and reminders from primary-
According to Stanford Medicine communication interventions were care providers—was most effective for
research, shorter shifts for medical assessed to determine the most closing the loop.
residents are increasing such effective ways to communicate
handoffs, along with the risk for with patients and providers about A SYSTEMIC SOLUTION FOR
preventable errors. recommended follow-up care. “When COMMUNICATION LAPSES
we worked with patients, we found Improving team communication through
“Communication is where it really falls that they have variable preferences in the creation of small work groups,
apart,” says Ian Doten, MD, a Seattle- how they want to be communicated teaching teamwork behaviors and
based emergency-department physician with, so there’s not one communication skills, and developing communication
and Medical Director at InSytu method that works for everyone,” habits for teams can help reduce
Advanced Healthcare Simulation. he says. Rather than relying on a communication-related errors,
(Continued on page 10)
10
(Overcoming Systemic Challenges, continued from page 9)
according to research supported by the a patient’s hospital care contribute to improve communication. But while
U.S. Army. In their study of emergency- the risk for medical error, particularly information technology may support
department malpractice incidents at diagnostic errors and treatment errors, patient safety in some instances, it
eight hospitals, published in the Annals during care transitions, says Wandtke. has also been shown to contribute
of Emergency Medicine, researchers “There may be two or three hospitalists to medical errors. According to
judged more than half of the deaths or making recommendations for follow-up research published in the Journal of
permanent injuries to be preventable care, but only one puts in discharge the American Medical Informatics
through improved teamwork. The study instructions for the patient,” he says. Association (JAMIA), healthcare
found an average of 8.8 teamwork “So there are inherent risks in the information technology can have
failures per care episode. transition of care from hospital care to unintended consequences that
outpatient care, and hospital offices are contribute to diagnostic errors, from
Collaborative goal-setting is another not equipped with resources to provide disrupting existing communication
strategy that’s been shown to improve appropriate safety nets to engage a high- processes, to offering flawed decision
communication between patients and reliability approach to their healthcare.” support, to overburdening providers
providers and reduce the likelihood with tiring data-entry responsibilities.
of inaccurately reported medical A SYSTEMIC SOLUTION FOR
information. In this model, patients TRANSITIONS “Electronic health records were built
work with their providers to monitor and Patient-centered approaches to error for billing, not for patient care,” says
report their progress toward personal reduction are the key to reducing Doten. “The challenge is designing
health goals. medical errors, according to a study tools that provide meaningful, real-time
published in Australian Prescriber. information. With healthcare, especially
CHALLENGE: CARE TRANSITIONS Actively involving the patient in in the emergency room with a patient in
The risk for medical errors doesn’t end discharge planning and double- cardiac arrest, a lot of the meaningful
when patients leave the hospital or checking prescription-medication communication is in real time.”
clinic. In fact, more than half of medical instructions after each episode of care
errors take place outside of a clinical can reduce the risk of medication errors While EHRs can support early diagnosis
setting. Research shows that the risk and adverse drug events. “Our health by flagging certain patients for
for medical error increases significantly system needs to keep an eye on these recommended cancer screenings, other
after hospital discharge or episodic patients,” notes Wandtke. “It is really patients are easily missed. “EHRs have
care: a study published in the Annals of a chain of communication, and it can been successful at identifying patients
Internal Medicine found that more than break at any point in the process.” for breast-cancer screening and colon-
50% of hospital patients experienced cancer screening, because it’s very easy
a clinically significant medication error CHALLENGE: ELECTRONIC to find patients in the system who are
within 30 days of discharge. HEALTH RECORDS the right age and gender for screening,”
Electronic health records (EHRs) says Wandtke. “For lung cancer, it
Disjointed or nonexistent communication can support more accurate medical hasn’t been as easy, because it’s harder
between the many providers involved in diagnoses, create efficiencies, and to identify a patient’s smoking history11
THE PHYSICIANS REPORT | SPRING 2021
in an EHR. As a result, there has been
slow uptake and low participation
[in lung-cancer screening] without
adequate tools in the EHR. We know
Resources,
that about 5% of eligible patients
are receiving their screening for lung
education, and tools
cancer, and that is concerning.”
for closing the loop
A SYSTEMIC SOLUTION FOR EHRS
The JAMIA researchers focus NATIONAL ORGANIZATIONS Public Health Accreditation Board
their discussion on latent or silent Agency for Healthcare Research and A national non-profit accreditation
medical errors that result from a Quality (AHRQ) body dedicated to improving quality,
mismatch between the function of the The federal agency leading nationwide safety, and performance among
information-technology system and the efforts to improve diagnostic safety, tribal, state, local, and territorial
day-to-day demands of healthcare work. the AHRQ offers a Diagnostic Safety public health departments.
This mismatch contributes to two main and Quality Toolkit and measures state
categories of errors that organizations performance on quality and safety Surgical Outcomes & Quality
must address to effectively improve metrics in its State Snapshots. Improvement Center (SOQIC)
quality and safety: errors in the process Created to drive safety and quality
of entering and retrieving information, American College of Radiology research and develop improvement
and errors in the communication and Commission on Quality and Safety strategies for surgical care across the U.S.
coordination processes the system The Commission on Quality and Safety
is designed to support. Information- provides oversight and management The Joint Commission
technology systems must address for all radiology quality and safety The nation’s oldest and largest
these two main categories of errors programs and initiatives of the ACR. standards-setting and accrediting
to facilitate safer care. body in healthcare, the Joint
Child Health Patient Safety Commission offers patient-safety
Involving the EHR’s end users—doctors, Organization education and resources.
nurses, and other key personnel—in the The only patient-safety organization
system’s design and implementation dedicated to children’s hospitals that is ARTICLES AND TOOLS
can facilitate a better match between recognized by the AHRQ. Denver Health Medical Center.
the system and the needs of its users. Improving Patient Safety Through
“As medicine gets more complex, we Emergency Medical Error Reduction Provider Communication Strategy
need to make sure it works for the end Group (EMERG) Enhancements Toolkit.
user,” says Doten. “The people closest Part of the non-profit Center for
to the work should design the work. You Leadership Innovation and Research AAP News. “Improve Patient Handoffs
can set goals as an organization, but in EMS, EMERG promotes continuous to Prevent Medical Errors, Reduce
what’s meaningful is how you actually improvement within the field of Malpractice Risk.”
execute them when you get down to the emergency medicine.
doctors and nurses.” EHRIntelligence. “Reducing Medical
Institute for Healthcare Improvement (IHI) Errors with Improved Communication,
CHALLENGE: COVID-19 Created as part of the National EHR Use.”
The COVID-19 pandemic is likely to Demonstration Project on Quality
increase rates of diagnostic errors for Improvement in Health Care, the IHI Pocket Guide: TeamSTEPPS. Agency
several reasons, according to 2020 offers education and resources on for Healthcare Research and Quality.
research from the Society of Hospital reducing medical errors, including its “Team Strategies & Tools to Enhance
Medicine. Early in the pandemic, Triple Aim framework for optimizing Performance and Patient Safety.”
rapidly evolving diagnostic information health-system performance.
for COVID-19 made missed or delayed HealthIT.gov. “Improved Diagnostics and
diagnosis more likely. Situational factors Patient Outcomes.” U.S. Department of
including staffing shortages, staff Health and Human Services.
(Continued on page 38)12
You could do everything right.
You could make a judgment that isn’t questioned by your peers.
You could meet the standard of care.
But the patient could still be harmed—and then you could be sued.13
THE PHYSICIANS REPORT | SPRING 2021
Having strong backup support can make or break the outcome.
That’s what happened to Dr. Dalvi, a Seattle radiologist. her head hurt so badly. Then she couldn’t speak clearly for
And what happened to his patient, Allison Carter, baffled the two minutes. 911 was called immediately, but her speech
many medical providers she encountered in October 2014. was normal by the time the paramedics arrived. Carter, who
had a previous history of anxiety, stated that she must have
In the following case, the names of people and facilities panicked. She was transported to a local hospital.
have been modified for privacy protection. Consider how
each component affected the diagnostic process and the No Signs of Stroke
eventual outcome. The doctor who evaluated Carter at the hospital suspected
dissection and/or stroke, so he initiated an MRI stroke
Puzzling Pain protocol, which is a diagnostic imaging order set. The set
At the time, Carter was a 26-year-old assembly mechanic in was read by Dr. Dalvi. Of the 1,600 images generated, Dr.
manufacturing at Boeing. Her health odyssey began when she Dalvi found no signs of stroke and concluded there was no
Carter returned to the local hospital the
next morning, after waking up unable to speak.
experienced neck pain for several days, followed by a headache dissection present. Based on Dr. Dalvi’s findings, the doctor
for 24 hours. On October 12, she went to the urgent-care clinic prescribed a migraine cocktail, and Carter was discharged.
and was diagnosed with sinusitis and discharged.
Carter returned to the local hospital the next morning, after
But the headache continued for three more days. In fact, waking up unable to speak. The doctor who evaluated her
it was severe enough to keep her awake at night. On October discussed her condition with a hospital neurologist, who
15, she visited her primary-care physician. The doctor ordered agreed to see her for an outpatient evaluation.
a CT to rule out a hemorrhage, which was performed later that
day at a local hospital. The physician who interpreted the In the meantime, Carter’s primary-care physician consulted
CT saw no acute disease or source at the root of with the neurologist at the local hospital about Carter’s
Carter’s problems. condition. Carter met with the neurologist on October 24 for
an urgent neurological evaluation. She now also had weakness
Carter’s headache continued for six more days. On October and numbness on the left side of her face and in her left leg.
21, she saw a chiropractor near her home. She told him she He noted that “although symptoms are suggestive of a cortical
had sharp, shooting pains in her neck when she moved her process, such as a brainstem stroke, her MRI brain stroke
head, and that her primary-care physician had told her that protocol was unremarkable.”
her headache was probably coming from her neck.
Based on her symptoms, the chiropractor diagnosed her with He later testified that he’d reviewed the actual imaging read
a cervicogenic headache. by Dr. Dalvi in detail, and not just Dr. Dalvi’s report of the
same. He testified that he agreed with the report and that
He performed a diversified-technique adjustment to her he felt there was no evidence of dissection or stroke on the
cervical spine. When Carter sat up, she started crying because imaging. Based on his review of the imaging and his exam,
he ruled out dissection and stroke.
(Continued on page 14)14
“The lesson is, even
when you do everything
right, you can still get
sued—but having a
strong supportive team
makes the difference.”
LAUREN HALEY, CLAIMS MANAGER,
PHYSICIANS INSURANCE
(When Everything Is Done Right, continued from page 13)
Mental-illness Diagnosis who agreed with the night-read and also found “no acute
Later that day, Carter went to the emergency department at a intracranial process.”
Seattle tertiary-care hospital. She told medical professionals
there that she had fallen to the ground after her visit to the Carter was admitted to the Seattle hospital in the early
neurologist. A neurology consult was ordered, and neurologists morning of October 27. Later that afternoon, while still in the
there also suspected dissection, but ruled it out because hospital, Carter was suddenly unable to speak or swallow. She
it wasn’t found on the previous radiology reads. Doctors could move her left extremities but nothing on her right side.
discussed the possibility of anxiety affecting her presentation of
symptoms. She was discharged with a diagnosis of a mental- She had another CT in the middle of the night, and her
health condition. symptoms continued to wax and wane. After the CT was read in
the early morning hours, the radiologist reported to her doctor
Rapid Decline “a critical result,” namely, there were bilateral vertebral artery
In the evening of October 26, while watching TV at home, dissections/occlusions in the distal ends at the V-4 segments,
Carter started drooling, lost bladder control, and became as well as a complete occlusion of the basilar artery.
unresponsive for several minutes. Her husband took her to
the emergency department at the local hospital. There was At 6 a.m, Carter was intubated and Code Stroke was
no available on-call neurologist at that time, so she was initiated. An MRI showed an acute infarct of the pons. The
transferred via ambulance to a Seattle hospital. A repeat head on-call endovascular neurosurgeon decided to perform a
CT was ordered prior to transfer. cerebral angiogram with acute stroke intervention. Catheter
angiography revealed dissection of the bilateral vertebral
The remote night-read radiologist found “no acute or active arteries and occlusive thrombus in the basilar artery. The
intracranial process” and “no change” compared to the October surgeon removed the blood clot from the basilar artery, with
15 CT. The CT was subsequently read by Dr. Dalvi’s partner, some difficulty.15
THE PHYSICIANS REPORT | SPRING 2021
Lawsuits Filed The plaintiffs’ attorneys tried to argue,
Carter sued three hospitals and using expert testimony, that Dr. Dalvi
seven different medical providers, should have recommended additional
alleging medical negligence and loss imaging. However, defense experts did
of consortium claims against each not identify any findings of dissection
defendant, including allegations that on the stroke protocol and found that
Dr. Dalvi breached the standard of care the standard of care didn’t call for
by failing to identify dissections. additional imaging.
At the outset of the case, all of the Strong Support Is Key
defendants and their attorneys planned The jury agreed with Dr. Dalvi’s
to work as a team against the claims. defense, and he won the case.
The plaintiff voluntarily dismissed the
cases against the emergency-room “The lesson is, even when you do
doctors. The rest of the defendants everything right, you can still get sued—
settled—except Dr. Dalvi, leaving him but having a strong supportive team
as the only remaining defendant. makes the difference,” Haley says.
Lauren Haley, Claims Manager at And if you do get sued, Aye says, trust
Physicians Insurance, who worked on your defense team. “Understandably,
Dr. Dalvi’s case, had to decide whether it’s hard for a doctor to be in the role
she and Dr. Dalvi would settle as well, of ‘patient’ in the hands of other
or take their chances at trial. professionals,” she says. “They’re not
used to that. But working together as
“Of course, when all the other defendants a team is the best way to help us build
settle, you have to consider doing the the strongest defense possible.”
same,” Haley says. “Sometimes it does
Slow Recovery make sense. But we don’t take a seven- Being sued is always devastating to
Following surgery, Carter developed figure settlement lightly.” a doctor, Haley notes. “They’re being
acute respiratory failure and remained told someone suffered because of what
in a coma. On October 30, a neurologist Once Dr. Dalvi’s defense team got they did or didn’t do,” she says. “It
noted an improving exam but gave her feedback from other experts, they knew leaves a scar.” As evidenced by Dr. Dalvi
a poor prognosis. She was taken off his actions were defensible. “He did messaging both Haley and Aye on the one-
the ventilator on November 15, then everything right,” Haley says. “Three year anniversary of the verdict to thank
was discharged to a skilled-nursing different hospitals and seven different them again, it sticks with you—even when
facility on December 2 and transferred doctors didn’t catch it. The reality is, her it ends as well as it could have.
PR PR
to inpatient rehab on February 10. She presentation was atypical, and despite
remained there until March 3, when everyone’s best efforts, the medical
she was finally discharged home. She professionals were unable to identify the Miranda Aye, JD,
received rehab services at home until root of the problem. Unfortunately, this Partner, Johnson
switching to outpatient therapy in April. sometimes happens.” Graffe Keay,
Moniz & Wick
She plateaued with occupational and Still, it was a risky stance. According
physical therapy in 2016. She now to Dr. Dalvi’s defense counsel, Miranda
walks slowly with a walker or four-point Aye, the plaintiffs’ legal representation
cane, and has a speech impediment. and expert witnesses were very strong. Lauren Haley, JD,
She was unable to return to work at Additionally, “the plaintiff was very Claims Manager,
Boeing. In 2018, she gave birth to her sympathetic at trial,” Aye says. “She Physicians Insurance
first child, a healthy girl. Her mother was young, with a new baby, and she
and sister help her with housework and had worked so hard to recover.”
childcare, while her husband works.16
MEMBER SPOTLIGHT
Advancing
Communication
in a Growing
Market
Idaho Urologic Institute
With clinics in Boise, Nampa,
and Meridian, Idaho Urologic
Institute (IUI) serves one of
the country’s fastest-growing
populations.
According to the latest U.S. Census, the Boise metropolitan region men, women, and children at three clinics and collaborates with
is the eighth fastest-growing area in the country. The influx of new more than 20 surgeons of varying specialties at IUI’s ambulatory
patients makes effective communication an evolving challenge, surgical center in Meridian. Since taking the helm seven years
says Gregory Feltenberger, Ph.D, IUI’s chief executive officer. ago, Feltenberger has implemented continual communication
improvements to keep up with the region’s dynamic needs.
“Our region is experiencing rapid growth, with about 150 people “Communication is a forever project, and it is consistently the
moving here each day,” he says. “The majority of them are over biggest area of focus for improvement and change,” he says.
50, and we don’t know what kind of care they had previously—
each one is like a brand-new patient in our system.” Here, Feltenberger highlights some key communication
initiatives that have allowed IUI to provide world-class care
Communicating across disciplines and locations is critical to IUI’s for its growing community.
success, because its staff of 14 dedicated providers cares for17
THE PHYSICIANS REPORT | SPRING 2021
providers can easily communicate with
one another. Our radiologists are onsite
doing their reads and collaborating with
physicians, which is far more streamlined
than what you might find elsewhere.
We’ve got a medical director who oversees
the surgical center and the IUI ancillary
space, one of the physicians oversees “Communication
another clinical quality zone, and another
is a forever
physician is our lab director. As a result,
we’re far more agile and communication project, and it
is far more efficient—and this shows in
our statistics and outcomes. Our 2020
is consistently
infection rate was 1 percent, whereas the biggest area
typical rates in hospitals are in the
2 to 4 percent range. of focus for
improvement
HOW DO YOU ENSURE THAT
NEW HIRES THRIVE IN THIS and change."
HIGHLY COMMUNICATIVE,
EFFICIENT ENVIRONMENT? GREGORY FELTENBERGER,
With new hires, we’re looking for a great PH.D, CEO, IDAHO
fit with our professional family. So much UROLOGIC INSTITUTE
of their success is based on fit. I hold
a 30-day meet-and-greet with all new
employees where I ask them, what’s
going well? What do you need? What’s
not going well?
Because our physicians are owners,
they are truly invested in the success
of the organization, their relationship
with their patients, and their connection
to the organization.
HOW HAVE YOU WORKED TO
IMPROVE COMMUNICATION
BETWEEN PROVIDERS, STAFF,
AND IUI LEADERSHIP?
IDAHO UROLOGIC INSTITUTE We have implemented increased
PROVIDES COORDINATED UROLOGIC rounding among our staff and improved
CARE FOR MEN, WOMEN, AND communication with our leadership team,
CHILDREN, FROM DIAGNOSIS TO from a weekly meeting with physician and
TREATMENT TO RECOVERY. HOW DOES staff leaders to a monthly meeting with our
THIS MODEL CREATE EFFICIENCIES board. Additionally, over the past two years
FOR PATIENTS AND PROVIDERS? we have implemented a transition to a new
We’re a lower-cost provider of high-quality electronic health records (EHR) system
care. Our services generally cost 50 to 80 to facilitate improved communication
percent less than if the patient were to get throughout the organization.
the exact same treatment in the hospital.
We have created an environment where
(Continued on page 18)18
For patients with
advanced prostate
cancer, IUI’s linear
accelerator provides
more precise
treatment with
less damage to
surrounding tissues.
FAST FACTS
ESTABLISHED: 2005
LOCATIONS: 3
PROVIDERS: 9 physicians
and 5 PAs (across three clinic
locations)
MEMBER SINCE: 2010
(Member Spotlight, continued from page 17)
WHAT FACTORS DID YOU CONSIDER a year, but of course we did not anticipate involved our PAs and scribes in designing
BEFORE DECIDING TO TRANSITION TO the COVID-19 pandemic. Pre-pandemic, templates within the EHR to streamline
A NEW EHR SYSTEM IN 2020? we had planned to transition to the new patient visits. It is an ongoing process;
When I first arrived at IUI, they were system in April and May, and temporarily we’re still optimizing our templates based
using an EHR system that was a complete lower our patient volumes during the on our physicians’ preferences.
suite of modules for billing, practice rollout. We planned to be back at normal
management, and scheduling. Our practice volumes within a month, but then COVID HOW DID YOU KEEP CLINICAL
was one of the first to use the system, hit and naturally decreased our volumes STAFF INVOLVED AND UP-TO-DATE
so we were instrumental in helping its for a longer period. We were changing a DURING THIS TRANSITION?
developers by sharing our comments and lot of our workflows in response to COVID Going into this transition, I knew that I
feedback. But we found that that company just as everyone was learning the new EHR wanted to have clinical staff be closely
wasn’t as responsive as we’d hoped, and system, which was a challenge. Hindsight involved. When you have an IT professional
that the system was based on antiquated is 20/20, and had we known about who spends most of their time writing
programming language. We saw the need COVID’s impact, we might have delayed code and then has to come out as part
to move to a cloud-based system for a the launch. But by the time the pandemic of an EHR implementation team and
higher level of security, where we would no hit, we had been planning the transition train physicians on clinical workflows,
longer need to house our servers onsite. for 18 months, so that train had left the there’s a huge gap in communication,
We rolled out the new system in spring of station, so to speak. understanding, and frame of reference. I
2020 during COVID-19, which posed an didn’t want IT professionals determining
additional challenge. However, with lower patient volumes our clinical workflows in the EHR system
during the spring, we were able to involve without appreciating what real clinical
HOW DID IMPLEMENTING A NEW more clinical staff in the transition, which workflows should look like.
SYSTEM DURING THE PANDEMIC was important to the project’s success.
IMPACT YOUR EHR TRANSITION? We shifted the bulk of our physician- It made all the difference in the world to
The transition was planned for more than assistant visits to physicians and have clinical staff become super-users19
EDUCATION
of our new system—the individuals who
can take the lead on the implementation COURSES
from the clinical side. Our medical
director, Dr. Todd Waldmann, became We’re continually adding courses and settings. You will explore the types of
a super-user, as did one of our more other resources to our library—all free medical errors, including error-prone
experienced PAs, Missy McClenahan. I to our members. Visit phyins.com/ situations, and use of root-cause
recommend for others that someone with courses to search for a wide array of analysis to determine why and how an
a clinical background take a leadership titles, including: error has occurred. You will also explore
role in the entire process, from planning best practices that will help improve
to implementation. If I ever go through Medical Error Prevention client safety and outcomes within your
another EHR transition, that is definitely for Healthcare organization. Finally, you will learn your
something I’ll do again. Professionals (1 Credit) responsibilities regarding the reporting
Given the significant impact that of medical errors.
WHAT OUTCOMES CAN YOU SHARE? medical errors can have on health and
Our transition is ongoing, because we are safety, all licensed professionals caring phyins.com/courses
still refining our new system and running for patients must understand how these
it in parallel with our legacy system, which errors occur and how to prevent them.
was part of our plan. We are still using the This course will discuss the factors
billing module in our legacy system, and that increase risk for medical errors, RESOURCES
plan to transition completely to the new and how root-cause analysis and other
system by the end of this calendar year. evidence-based strategies can aid in • Steps-In-Dealing-With-An-
preventing them. In addition, five of the Unanticipated-Event_0.pdf
But anecdotally, physicians have shared most misdiagnosed medical conditions
that the new system, in combination with will be reviewed, along with strategies • WA-OR-ID-WY-Response-To-A-
the use of medical scribes by some of for preventing misdiagnosis. Subpoena-For-Medical-Records-Or-
our physicians, has created significant Deposition.pdf
efficiencies. Physicians were spending Reducing Medical
two to three hours at night inputting Treatment Errors • Utilizing-Curbside-Consults.pdf
patient data into our old EHR, and that in Behavioral Health
burden has been dramatically reduced. (1 Credit) • Moving to Dismissal of Care.pdf
We have created the capacity for two In this course, you will learn the
additional patient visits per provider scope of medical treatment errors • Upset Patient Letter
per day. Additionally, we have the cost within the overall healthcare system
savings of not needing to house servers and specifically in behavioral-health phyins.com
onsite. COVID-19 threw us a curveball,
but overall, this has been a positive
change, and one that has enhanced
communication among physicians and
between providers and patients.
ABOUT IUI
Idaho Urologic Institute provides advanced
urologic care for men, women, and
children, including diagnostic imaging,
minimally invasive surgery, and radiation VISIT PHYINS.COM/COURSES
oncology. Providers care for patients at
three locations in Boise, Meridian, and
Nampa, and perform surgical procedures to learn about the CME that is
at a multispecialty ambulatory surgery included with your Physicians
center on the Meridian campus.
PR PR Insurance policy at no additional cost.20
CLOSING THE LOOP
Considerations
for How
EHR Systems
Can Help
When correctly implemented,
electronic health record (EHR)
systems can help physicians deliver
safe, quality care. In a national survey
of physicians conducted by the U.S.
Department of Health and Human Economic Journal, EHR system adoption resulted in “a 27%
Services, 75% reported that their reduction in aggregated patient safety events, a 30% decline
in negative medication events, and a 25% decrease
EHRs improved patient care, and 88% in complications regarding tests, treatments, or procedures.”
found that their system generated But EHR systems are most effective at reducing errors
and improving safety when they fit seamlessly into an
clinical benefits for the practice. organization's goals, culture, and clinical practices. When
they don't, substantial risk-management and reimbursement
challenges can arise, according to Bret Connor, senior vice
Research that shows the right EHR system can reduce risk and president and chief customer officer with Athenahealth, a
save money for healthcare organizations. A study published in provider of cloud-based EHR technology. “The closure of key
Healthcare Financial Management reported that a community care gaps has become much more complex than in the past,
hospital saw a 60% decrease in near-miss medication events so it’s critical that the EHR tool can keep up,” he says.
after implementing an EHR system. Another study published
in the Southern Medical Journal found that using an EHR The following considerations will help organizations
facilitated improvements to documentation and coding that select, integrate, and employ an EHR system that delivers
yielded a cost savings of more than $100,000. In a seven-year multifaceted value, both as an enhancement to clinical
study of Pennsylvania hospitals published in the American practice and as a valuable error-prevention tool.21
THE PHYSICIANS REPORT | SPRING 2021
The selection of an EHR system should be a
multidisciplinary process involving clinicians
and support staff, along with administrators.
administrators. Allowing the end users group and $5–20 million for a hospital.
of an EHR system to provide input in But implementation costs are only one
the selection process helps eliminate part of the system’s long-term costs.
unwanted surprises down the road, notes To accurately compare pricing between
Tennant. He also recommends speaking prospective EHR systems, organizations
with colleagues in other organizations must consider maintenance and other
who have successfully selected and fees associated with the system’s total
implemented an EHR system, particularly cost of ownership.
those with firsthand experience related to
systems you’re considering. “Critical for the practice, as you
develop your project budget, is
“In addition to discussing the products clearly understanding your financial
with the vendors and viewing demos, commitment in terms of both the
we recommend reaching out to up-front price of the software and
colleagues in similar-sized practices the ongoing maintenance fees,” says
and in the same specialty who have Tennant. “Also, inquire about any
CONSIDERATION 1: implemented an EHR,” says Tennant. potential add-on expenses, such as the
STAKEHOLDER SUPPORT “Talking directly to end users, not just cost for additional training or fees for
The first challenge for practices is to sales representatives, will give you modifying clinical templates.”
determining which EHR system to more unbiased perspectives on the
select, says Robert Tennant, director of performance of the software in real- An EHR’s hidden costs are any
health information technology policy for world applications, and a better insight expenditures not included in its
the national Medical Group Management into the vendor-contracting process.” up-front pricing, from licensing and
Association (MGMA). “We’re talking maintenance to consulting and labor.
about an enormous change to both CONSIDERATION 2: SUSTAINABILITY Even less obvious are the costs like
the administrative and clinical sides A sustainable, safety-enhancing EHR decreased revenue or reduced patient
of the organization, and a significant system must fit comfortably within volumes during EHR implementation or
investment for the practice in terms of an organization’s budget, both now transition. “Inevitably, however much
staff time and financial resources,” he and for years to come. Costs for EHR you expected to pay, you always end up
says. “With this in mind, it is critical to implementation and maintenance vary spending more,” says Tennant.
make the right software choice.” widely, depending on the needs of each
healthcare organization. According to CONSIDERATION 3: SCALABILITY
The selection of an EHR system should research and consulting firm EHR in The ideal EHR system is both
be a multidisciplinary process involving Practice, a typical EHR implementation reliable and responsive, serving an
clinicians and support staff, along with costs $162,000 for a small physician organization’s current needs with the
(Continued on page 22)22
“For a doctor to have the ability to use an EHR to access insurance
authorizations, potential medication interactions, and other medical
information during a patient visit, in real time, means that physician can
offer better, safer guidance to the patient.”
ROBERT TENNANT, MA, DIRECTOR OF HEALTH
INFORMATION TECHNOLOGY POLICY, MGMA
(Considerations, continued from page 21)
ability to adapt rapidly to growth, these legacy models.” When evaluating “An EHR solution needs to integrate
regulatory changes, and emergency prospective EHR vendors, inquire about with an organization’s practice-
scenarios. “When a medical practice is how the system is updated, scaled, management system and its revenue-
making technology decisions, I suggest and modified. Do system updates or cycle process,” agrees Connor. “It
they choose a platform that is modern, additions take place on-site, or in the needs to be able to share clinical data
scalable, and easy to use for both cloud? Additionally, inquire about with other systems. This connectivity
providers and staff, and that will deliver how data from another practice or is critical to success, providing a
great outcomes,” says Connor. organization might be integrated into more holistic view of medical-practice
the system in the event or a merger, performance and contributing to
Modern cloud-based EHR systems offer acquisition, or consolidation. the delivery of high-quality care
maximum flexibility for growth and to patients.” Incorporating staff or
organizational change, notes Connor, CONSIDERATION 4: administrators from an organization’s
because adjustments and updates to REVENUE MANAGEMENT billing department into the selection
the organization’s system can be rolled Securing medical records for billing and and implementation process can help
out across an entire health system Medicare reimbursement are critical ensure that a new EHR system fits an
almost immediately. This allows multi- for healthcare organizations, notes organization's business practices as
hospital systems to operate seamlessly Tennant. “Patient medical and billing well as its clinical needs.
and continuously as updates take place. records are the lifeblood of the practice
But most healthcare systems still use and must be protected,” he says. “If CONSIDERATION 5:
on-site hosted EHR systems that differ you’re moving to an EHR, you need to CLINICAL INTERFACE
from clinic to clinic or hospital to work with your vendor to determine the The most technologically advanced
hospital, making them more difficult to most appropriate approach to backing EHR won’t help reduce medical errors
scale, adjust, and maintain. up these data. With the two most if it interrupts a physician’s preferred
important words in practice management workflow or contributes to fatigue.
“Healthcare lags behind other industries being ‘what if,’ the practice must By adding to a physician’s burgeoning
in the adoption of modern technology establish protection and contingency workload, EHR systems can escalate
solutions,” Connor notes. “As far protocols in the event of the data being physician burnout, according to
as EHR, practice-management, and compromised due to cyberattack, theft, research published in the Annals of
revenue-cycle solutions go, most and natural disasters such as fires or Internal Medicine. “We know that EHR
healthcare providers are still using on- floods. Preferably, your data should be fatigue is contributing to burnout,
premise technology or hosted versions of backed up in the cloud and immediately so we’re thoughtful in the way we’ve
on-premise software. I would estimate accessible, should it be needed.” designed our EHR platform,” says
that 90% of the industry is still utilizing Connor. “We want to minimize theYou can also read
