Diagnostic Allegations Focus on Office-Based Claims Experience

Transcription

1 Focus on Office-Based Diagnostic Claims Experience Increased Attention to Diagnostic Errors Awareness O/P Dx errors of 5.08% (12M patients, 1 in 20 adults)* 5 could be potentially harmful* Greater focus Though studies lag other areas, the Society to Improve Diagnosis in Medicine (SIDM) have made it a priority Incentives - ACOs Advocacy AMA s Center for Patient Safety has made diagnostic errors a key part of its agenda Apps/EHR features (gap alerts) created to help Medical Malpractice Cases *Singh H, et al. BMJ Qual Saf 2104;0:1-5 2 Increased Attention to Diagnostic Errors Awareness Difficult O/P Dx to errors Assess of 5.08% (12M patients, 1 in 20 adults)* 5 Dispersed could be nature potentially of care harmful* in amb. settings; time and place Greater focus Though studies lag other areas, the Society Frequent to Improve disagreement Diagnosis on in whether Medicine an (SIDM) error or have delay made occurred it a priority Incentives Retrospective - ACOs studies requires time-consuming and costly manual chart reviews Advocacy AMA s Center for Patient Safety has made diagnostic Easier errors to measure a key MRSA, part of treatment its agenda failures and procedures Apps/EHR features (gap alerts) created to help Medical Malpractice Cases *Singh H, et al. BMJ Qual Saf 2104;0:

2 Increased Attention to Diagnostic Errors Awareness O/P Dx errors of 5.08% (12M patients, 1 in 20 adults)* 5 could be potentially harmful* Greater focus Though studies lag other areas, the Society to Improve Diagnosis in Medicine (SIDM) have made it a priority Incentives - ACOs Advocacy AMA s Center for Patient Safety has made diagnostic errors a key part of its agenda Apps/EHR features (gap alerts) created to help Medical Malpractice Cases *Singh H, et al. BMJ Qual Saf 2104;0:1-5 4 What Clinicians (Physicians, NPs, PAs) Have to Say 3% 2% Never How often do you encounter diagnostic errors in your practice? 51% 4 Sometimes (weekly or monthly) Rarely (a few times each year) Frequently (most days) 6 of those surveyed said that up to 1 of misdiagnoses they have experienced have directly resulted in patient harm 9 of clinicians say that they believe diagnostic errors are preventable at least some of the time N=6393 Source: QuantiaResearch 5 Experience Good judgment comes from experience, and a lot of that comes from bad judgment. Will Rogers 6 2

3 Learning Objectives Discuss claims data and trends related to diagnostic errors. Identify and analyze contributing factors/root causes of diagnostic errors. Discuss opportunities to minimize frequency of diagnostic errors. 7 Claims Coding Taxonomy RMFS/Harvard Coding the important details What Allegation Where Location When Loss and Report Date Who Specialty Service (Primary, Med., Surg.) Why Contributing Factors or Risk Issues Capturing the claim specifics Procedures Diagnoses Medications Injuries 8 What? - Allegations 9 3

4 Inpatient Phys Office All except Office Inpatient Percent of Respective Allegation Claims Overall by Location and Allegation Incurred Claims Incurred Claims Incurred Claims Incurred Claims SURGICAL TREATMENT SAFETY & SECURITY DIAGNOSIS-RELATED MEDICAL TREATMENT OBSTETRICS-RELATED TREATMENT MEDICATION-RELATED 10 Physicians Only All Locations All Allegations - Frequency 7% 31% 7% 1 27% All Allegations - Severity 2% 8% 1 39% 7% 1 19% DIAGNOSIS-RELATED SURGICAL TREATMENT MEDICAL TREATMENT MEDICATION-RELATED OBSTETRICS-RELATED ANESTHESIA-RELATED OTHER 11 Clinical Severity Physician Only, All locations Order of Freq. of Allegation Low Medium High

5 Percent of Respective Allegation Physician Only Office Only Office Practice Allegations - Frequency Office Practice Allegations - Severity 1 17% 49% 1 9% 13% 6 19% DIAGNOSIS-RELATED MEDICAL TREATMENT MEDICATION-RELATED OTHER 13 Clinical Severity Physician and Office Only Order of Freq. of Allegation Low Medium High 8 of incurred dollars attributed to high severity 14 Incurred Costs per Claim Physician and Office 1.2 Per Claim Relative Incurred DIAGNOSIS-RELATED MEDICAL TREATMENT MEDICATION-RELATED OTHER All Yrs

6 Percent of All Allegations Diagnostic Allegations 16 Who Accounts for Diagnostic Allegations 2% 2% 1 12% 17% 28% 22% Primary Care Emergency Radiology Medicine Surgery Ob/Gyn Pathology Other 17 Frequency Trend 6 Diagnostic Allegation Trend as % of total allegations ALL LOCATIONS PHYSICIAN OFFICE Three Year Periods 18 6

7 Percent of All Allegations Percent of Diagnostic Claims Severity Trend 8 Diagnostic Allegation Trend as % of Total Incurred $ Closed Claims OFFICE ONLY ALL LOCATIONS 2 Three Year Periods 19 Inpatient/Outpatient 19% 81% OUTPATIENT INPATIENT 20 Claimant Status by Specialty OUTPATIENT INPATIENT 21 7

8 Frequency Percent of All Diagnostic Claims $$ Severity Focus on Outpatient Physician Office Outpatient Physician Office 22 Allegation by Specialty -Office $ 62% PRIM SURG MED SPEC DIAGNOSIS MEDICATION MEDICAL SURGICAL DIAGNOSIS MEDICATION MEDICAL SURGICAL 23 Age Distribution 3 Age Distribution - Diagnostic Allegations Office Cases % 1 1 Age <1 Age 1-10 Age Age Age Age % Age Age Age 71- Age >

9 Percent of Age Bracket Percent of Age Bracket Gender by Age Bracket Male Female All Age Age Gender by Age Bracket % 53% 58% % 18% 17% Compliance with Tx/Appt Failure to Obtain Consult Failure to Order Dx Test Male Female 4 Male Female 3 3 All Age Age Diagnoses - Office Diagnoses All Specialties Severity 1% 2% 2% 2% 3% Frequency 22% 9% 4 1% 1% 8% 7% 19% 9% 1 38% Cancer Heart Related Infection Vascular Congenital Anomalies CVA Fractures Appendicitis Renal Related Eye Related Other 27 9

10 Percent of Diagnoses Cases by Respective Specialty Diagnoses - Cancer 2 Frequency 7% 21% 13% Cancers All Specialties 1 1% 11% 19% Lung GI Breast Prostate OroPharynx Bone/Connective Skin Lymphoma Other Severity 11% 2 19% 28 Diagnosis Heart Related Severity Frequency 1 9% 4 12% 13% 32% 18% 57% MI PE Endo/Myocarditis Other 29 Top Diagnoses by Specialty Type Cancer Cardiac Infection Cerebrovasc Appendix 1 PRIM SURG MED SPEC 30 10

11 Percent of Diagnoses Cases by Respective Specialty Percent of Total Diagnoses Percent of All Cancer Diagnoses Cancer Type GI GU Lung Breast Oral Pharynx Bone PRIM SURG MED SPEC 31 Diagnosis Trend Last 5 years All 10 years 32 Top Cancer Diagnoses Trend Last 5 Years All 10 Years 33 11

12 Percent of All Diagnoses Myocardial Infarction Trend Last 5 years All 10 Years Female Male 34 What went wrong 35 Clinical Judgment The most prevalent risk issue in all allegations A broad based category Patient assessment Selection and management of therapy Failure or delays in obtaining consults/referrals Other factors Therefore, tends to present the most difficulty in terms of finding simple fixes 36 12

13 Communications Between providers Consultation reports (consult vs referral) Coordination of care Speaking the same language Between physician and patient Phone calls Informed consent Education Follow up instructions 37 Documentation Content Complete, timely, factual, consistent Consistency No conflicting notes among providers Appropriateness Nothing other than what s pertinent to the care of the patient Mechanics Legibility, correct method for making addendums or corrections, alterations 38 Clinical Office Systems Office processes that involve the coordination of patient care activities along a continuum of care: Closing the loop on Systems for tracking tests, Consults / missed appointments Scheduling or performing tests Coordinating care Patient follow up systems 39 13

14 Administrative The operationalization of office systems, including: Existence of/adherence to policies and procedures Physician coverage/staffing issues (e.g. ensuring pertinent information is communicated to covering physician) Staff training and education 40 Perfect Storm 41 System of Care Testing Suspect Order Physician Patient Educate Action Identification Critical Value Facility Office Receipt File F/U Receipt Action Patient Consult/Referral Scheduled Appointments Suspect Order Physician Patient Educate Action Ownership Critical Value Consultant Office Receipt File F/U Receipt Action Patient 42 14

15 Percent of All Claims Percent of All Claims Percent of All Claims Contributing Factors All Diagnoses CA Cardiac 43 Clinical Judgment Factors All Diagnoses CA Cardiac 44 Clinical Judgment - Patient Assessment All Diagnoses CA Cardiac 45 15

16 Bias Anchoring - locking onto initial presentation Availability recent experience Confirmation Bias Looking for confirming evidence Diagnosis Momentum dx labels stick over time Gender Bias determining factor when no basis exists Need for Closure time pressure or feelings of doubt Outcome Bias opt for dx decisions with better outcomes Sunk Costs more time invested in a dx, less alternatives Zebra Retreat under confidence in remote or unusual dx Too many patients, too little time 46 Case 60 y/o male with 40 pk. yr. smoking hx treated by Pulmonary as IP for respiratory difficulty attributed to COPD. Subsequent routine OP visits over next year noted slight weight loss at each but respiratory function good. Next visit for kidney stone, CT of pelvis/abd. revealed small nodule of unknown type and re-ct recommended. No f/u testing ordered until later and patient never had it done. CXR subsequently done that did not show the nodule. Patient continued to be seen by Pulm. for COPD. Exacerbation of COPD put patient in hospital where a CT revealed stage 4 CA. Chronic dx assumed, resulting in low index of suspicion. Failure to follow-up on test. Behavior of patient. 47 Case 40 y/o female with allergic rhinitis saw new Allergist after prior Allergist moved OOA. Patient was seen at regular intervals and since start of relationship had indicated at each visit that she had a cough. It was noted that prior Allergist was aware of cough. Asthma treatments were later prescribed as cough worsened over several years. CXR ultimately revealed mass base of lung, too advanced for aggressive treatment. Physician assumed that cough was taken care of originally, and later allergic in nature because the other physician had known about it. Reliance on prior/other physician impression. Assuming that worsening of symptom was related to prior diagnosis

17 Percent of All Claims Percent of All Claims Communication Factors All Diagnoses CA Cardiac Among providers With patient/family 49 Case 60 y/o male for inguinal surgery. Surgeon rx d preop. labs/cxr & referred pat. back to IM for medical clearance. Surg. and IM received results of test which included a 2.4cm node rt lung and recommendation for CT. Surg. spoke with IM office staff and learned that Pat. had appt. in a few days for clearance f/u. CXR report never made it into chart and IM never discussed with pat. Surg. did not f/u. IM stated later that they had new EHR that separated CXR from labs and EKG. 18 months later for hip pain metastases from lung tumor Coordination of care, incidental finding, IM in office w/new EHR did not see the results, Surg. assumed IM following. 50 Communications with Patient/Family 1 9% 8% 7% 3% 2% 1% Follow-up Instructions Poor rapport All Diagnoses CA Cardiac 51 17

18 Percent of All Claims Percent of All Claims Percent of All Claims Behavior Related - Patient Non-Compliance 1 12% 1 8% All Diagnoses CA Cardiac 2% Noncompliance w/ treatment Noncompliance w/ f/u 52 Documentation Factors All Diagnoses CA Cardiac Lack of documentation Content Mechanics 53 Documentation Content 8% 7% 3% 2% 1% All Diagnoses CA Cardiac Inconsistent Altered 54 18

19 Percent of All Claims Percent of All Claims Case 60 y/o male w/ CP 3 mos. Triglyc. High, EKG & other cardiac studies note LBBB, PVCs & low EF. Impr: anxiety related CP. FP notes on stress test report that he informed pat. of results & advises stop smoking & cardiology f/u. NO notes in med. rec. Patient seen in office over several months w/ unrelated issues until seen for heart skips. Impression: anxiety & tobacco abuse. Documents that previous stress test indicates no PVCs (not true). No EKG done this visit no discussion of cardiology consult. Further visits over next year, unrelated complaints. No docum. of further assessment of CP or consult. Pat. suffered MI later. Argued that stents earlier could have prevented the MI. Inconsistent documentation, lack of documentation 55 Clinical Systems Factors % 1 8% All Diagnoses CA Cardiac 2% Reporting findings delay Delay in sched test Coord. Care 56 Clinical Systems Test Results 12% 1 8% All Diagnoses CA Cardiac 2% Patient - results Clinician - results 57 19

20 Percent of all Claims Cases Lung CA CXR reveals possible tumor, CT recommended. Result to office, filed without FP aware would call with abnormal results. Prostate CA PSA high but located on 2 nd page of lab report not viewed by Card(IM). Gallbladder CA Porcelain GB noted on study, Rad did not indicate signif. in report, GYN did not inform pat. of high CA risk with that finding. Breast CA Mammo reveals micro-calcifications, rec. f/u 3-6 months, PA nor FP call patient. Seen several times for other issues over 1.5 years. Chart not flagged. Having patient call for results if not already called could potentially have prevented these cases. 58 Administrative Factors 8% 7% 3% All Diagnoses CA Cardiac 2% 1% Policy/protocol Medical record-related 59 Case 50 y/o female to urgi-center FP for chest pain. Sx of heart racing, numbness R arm, sl. SOB coming and going since yesterday. EKG done nl. (cardio over read later and concurred). Pat. was noted to be asymptomatic at present and in no distress and was discharged with recommendation to go to ED or at least f/u with PCP. Pat. refused ED (not documented). Urgi-center has policy that states that all CP must go to ED. Informed refusal if refused. Patient expired later that night, CAD/MI. Policy not followed 60 20

21 Percent of All Claims Administrative - Policy And Procedure 8% 7% 3% All Diagnoses CA Cardiac 2% 1% Need for P&P P&P not followed 61 Case 40 y/o male treated in IM office for pharyngitis, Rx d antibiotics. Several months later pat. called in early AM and got answering service. C/o malaise and cough for 3 days. Wife received call from office admin. stating that they will s/w IM and call back. Upon call back pat. instructed IM could not speak w/ pat., and office too busy for appt., but the IM could give Rx for antibiotic as it sounded similar to prior illness. Office RN called in Rx. Pat. expired within 24 hrs. from a cardiac arrythmia d/t myocarditis. Office policy was that Rxs written only after clinician speaking to patient. Policy not followed, ED not offered/suggested if appts. are not available. 62 Almost there! 63 21

22 Percent of Diagnostic Cancer Claims Percent of Diagnostic Cancer Claims Specialty Differences 64 Cancer, Contributing Factors: Specialty Differences Primary Med Specialty Surg Specialty 65 Cancer Patient Assessment Primary Med Specialty Surg Specialty 66 22

23 Percent of Diagnostic Cancer Claims Percent of Diagnostic Cancer Claims Percent of Diagnostic Cancer Claims Cancer - Documentation Lack of Content Mechanics 1 Primary Med Specialty Surg Specialty 67 Cancer - Communication Primary Med Specialty Surg Specialty Patient/family Providers 68 Cancer Patient Communication 1 9% 8% 7% 3% 2% 1% Follow up instructions Poor rapport Primary Med Specialty Surg Specialty 69 23

24 Percent of Diagnostic Cancer Claims Cancer - Testing Results % 1 8% Delay reporting findings 2% Patient - results Clinician - results Primary Med Specialty Surg Specialty 70 CRICO Strategies 2014 Benchmark Report 58% of cases had an Initial Diagnostic Assessment failures 29% of cases had Testing and Results Processing failures 4 had Follow Up and Coordination failures 71 CRICO Strategies 2014 Benchmark Report 58% of cases had an Initial Diagnostic Assessment failures 1. Problem Noted, Care Sought Access, scheduling or waiting 2. History and Physical Patient s personal and family not fully recorded or updated; the PE is inadequate or absent 3. Patient s complaints or symptoms are not thoroughly addressed 4. Narrow Diagnostic Focus No differential diagnoses, reliance on previous dx or condition 5. Diagnostic Tests not ordered due to incomplete or biased assessment 72 24

25 CRICO Strategies 2014 Benchmark Report 29% of cases had Testing and Results Processing failures 6. Test Performed Not performed, performed incorrectly, specimen mishandled 7. Test Interpreted Report is incomplete/inaccurate, abnormal findings not R/O 8. Test Results Transmitted to/received by Ordering Physician Receipt/review of result not completed/delayed 73 CRICO Strategies 2014 Benchmark Report 4 had Follow Up and Coordination failures 9. Physician Follows up with Patient Findings not communicated to patient F/U testing is not arranged F/U not documented 10. Referrals/Consults Referrals not made/managed Physician coordinating care not clear 11. Patient Information Communicated Among Care Team Failure to share a key piece of information 12. Patient and Providers Establish Follow-up Plan Patient fails to adhere to plan - treatment, appointments 74 CRICO Strategies 2014 Benchmark Report Assessment (9% assessment & follow-up) Follow-up (1 all) (29% assessment & testing) Testing ( testing & followup) 75 25

26 Risk Efforts Awareness/Suspicion Listening/History Consults/Testing Education Tracking and Follow-up Tests Consulting Appointments Reconsideration Documentation 76 Apps visualdx 77 Clinical Reasoning Toolkit 78 26

27 Patient Involvement The Patient s Toolkit for Diagnosis Developed by: Society to Improve Diagnosis in Medicine (SIDM) Patient Engagement Committee Four Part Toolkit: 1. Prepare for my medical appointment 2. My symptoms or pain 3. My medications 4. After my doctor s visit: What s next? 79 Summary Resource Allocation 80 Summary In office practice Diagnostic Allegations are the most frequent (49%) AND most costly (6) Cancer most frequent (4) and most costly (38%) Lung, Colorectal, Breast and Prostate most common (5) and costly (6) CA Risk/Patient Safety Efforts High suspicion/consider alternatives Clinical expertise: differential, consults, Communicate: coordinate, establish owner, educate, Establish safety net: track and f/u tests, visits, consults Document: all the above 81 27