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VA Research Currents archive
July 18, 2014
Dr. Hardeep Singh of VA's Houston-based Center for Innovations in Quality, Effectiveness and Safety studies issues relating to patient safety and the electronic medical record. (Photo by Deborah Williams)
In business or the military, leaders improve by studying the results of their efforts for lessons learned. In medicine though, the same feedback loops don't always exist. "Right now providers often diagnose and treat patients in an open loop fashion," says Dr. Hardeep Singh, chief of health policy, quality, and informatics at the VA Center for Innovations in Quality, Effectiveness and Safety, at the Houston VA Medical Center. "They think their patients are getting better but there is no tracking system...no feedback loop to find out what's happening. In many of these cases, no news isn't necessarily good news."
Singh recently authored a study, published online May 5 in the journal BMJ Quality & Safety, which estimated about five percent of outpatient diagnoses are erroneous. "In layman's terms, it's a misdiagnosis," says Singh, also an associate professor at Baylor College of Medicine. "Say you come in complaining of left leg pain and swelling and I think you have arthritis, and then three days later it turns out you had a blood clot. If you went to see another doctor or went to an emergency room, I might never know that I made an error."
For the study, Singh analyzed the results of three previous studies, based in VA and in private systems with electronic medical records. Two of the studies used algorithms to detect certain high-risk situations suggestive of error and the third examined patients with lung cancer. Singh's team then compared those results to the U.S. adult population. Based on the results, Singh estimates the nationwide misdiagnosis rate at 5.08 percent, or around 12 million U.S. patients per year.
Those errors can not only affect a patient's health, but also have a financial impact.
"Take for example the patient with the clot in his leg," says Singh. "If that clot later travels to his lung and he has to be hospitalized for 10 days, we are adding financial cost to the psychological and health-related impact of that error."
VA, for its part, has more knowledge of what happens to its patients because it's a closed system. "We've got more measurable data in VA," says Singh. "If a VA provider sends the patient to a specialist, the provider will know the result of that specialist visit soon after it's completed. VA maintains comprehensive electronic records of outpatient and inpatient events and provides a far better look on patient care events. That's not always the case outside of VA, where providers might not receive updates from other providers."
Nevertheless, even with VA's electronic medical record, errors do occur, says Singh, whose March 2010 study in The American Journal of Medicine found errors in follow-up of abnormal lab results despite VA's EMR. "It [EMR] is a very good system, but there is a lot of information there and providers are very busy and sometimes miss things," says Singh. "Lots of data and not enough time can mean information chaos."
In an editorial in the Journal of General Internal Medicine in May 2014, Singh commented that just because most patients don't contact their clinicians to let them know they are not better, doctors should not assume that no news from the patient is good news. "Receiving routine feedback on patient outcomes could help physicians recalibrate their confidence in diagnostic and treatment decisions," he wrote.
"Processes to provide clinicians with constructive feedback need to be developed. Further research is also needed to study how clinicians deal with diagnostic uncertainty and how that uncertainty is best communicated to patients," says Singh.
Meanwhile, Singh says patients should ensure they're sharing information with their providers and should feel empowered to contact them. "If you get a test, you must follow up. Reach back to the doctor and don't assume things are normal," he says. Doctors too, need to find time in their schedules to seek feedback. "It's a cultural shift. Right now we don't get any feedback, so we assume everything we do is correct and that patients are getting better. We need better follow-up systems and need to track patients better so we can prevent them from 'falling through the cracks' of the health system."
