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Diagnostic Failures Prompt Referral Changes


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Diagnostic Failures Prompt Referral Changes

By Tom A. Augello, CRICO

Related to: Ambulatory, Diagnosis, Emergency Medicine, Primary Care, Other Specialties, Surgery

Armed with its own malpractice data, a large group practice uses an existing electronic record system to ensure that when its doctors order a referral, the referral actually takes place.

Guest Commentators

  • Jessica Bradley, MPH; CRICO; Cambridge, MA
  • Richard Lopez, MD; Atrius Health; Newton, MA


In a medical malpractice case from the Harvard medical system, a 62-year-old man saw his new PCP for a new complaint of rectal bleeding. He had no record of screening. The rectal exam showed blood, which the PCP diagnosed as hemorrhoids. He prescribed fiber and suppositories, instructed the patient to follow up in two weeks, and referred the patient to GI for a colonoscopy.

Unfortunately, no follow-up appointment was scheduled, and the imaging never took place. About three months later, the patient called back complaining of abdominal bloating and pain. He spoke to a nurse on the phone who recommended a change in diet, but did not schedule an appointment and did not speak with the PCP. He called back again a few months later with the same complaints but did not see the PCP. About nine months after this episode began, the patient presented to the Emergency Department twice in three days with weight loss, abdominal pain, nausea, and his stool was negative for blood. He underwent surgery for an intestinal obstruction, which revealed advanced colorectal cancer.

In the Harvard medical system, the allegations most frequently raised in malpractice claims involve a wrong diagnosis or delay in diagnosis. The setting in these cases is usually outpatient.

At the patient safety summit sponsored by Harvard's medical malpractice insurer, CRICO, in June 2009, two speakers showed how the malpractice data led a large primary care group practice to implement a change to reduce the risks. A starting point was to look at how diagnoses are missed in these cases by defining the common steps in the diagnostic process. Then the analysts determined how often each step turns up as a problem in these malpractice cases.

"One thing that we're able to do with these diagnosis-related cases is we're able to look at the process of care, and this is really the breakdown of what goes on when a patient presents to the office to seek care regarding a primary complaint."

Jessica Bradley is a program director in the loss prevention and patient safety department at CRICO.

"So the patient presents with a problem. A history and physical is performed. The order of diagnostic and lab tests is performed. They perform the tests. The tests are interpreted. The rest results are received by the patient. There is follow-up. There is referral management, and the patient is compliant with the plan."

One of the top categories in the diagnostic process in these diagnosis-related cases was referral management. Problems with referrals turn up 20 percent of the time in a data set of 260 diagnostic-related claims over a 5-year period from 2004 to 2009.

"And referral management to us means things like they didn't believe the referral was required. There is lack of knowledge regarding the clinical condition, that there were communication breakdowns between the patient and the provider around getting that referral. Who was responsible for scheduling it? How long you needed before you had to have that referral happen? After the referral was completed, did the information get transmitted back to the patient?"

Bradley said that one of the Harvard system's large group practices reviewed the analysis of its malpractice data. This began a year-and-a-half project to work on its own referral management process to reduce diagnostic problems. Atrius Health includes Harvard Vanguard Medical Associates, where Dr. Rick Lopez has been a primary care provider since 1982. Now the Chief Physician Executive for all of Atrius Health, Dr. Lopez followed Bradley's presentation at the patient safety summit.

"When we looked at that and we thought about our referrals, we have actually quite a few and that's not unusual. We have 500 physicians, 17 locations, 350,000 patients, but each one of those referrals is an opportunity for an error. As Jessica mentioned, CRICO highlighted our need to really look at closing the loop on referrals, particularly making sure that when a referral is made that there is appropriate work done to ensure that the referral actually did happen."

Dr. Lopez's team analyzed the referral process at its sites, and did not like what it saw. Even though they shared the same electronic medical record, there was a lot of variability—with significant shortcomings.

"The hand-offs were not clearly defined. There were no consistent guidelines in terms of if a referral was made, how much of a follow-up should be done. And there were no standards in terms of what the referring physician needed to include in the referral and what the specialists needed to have back."

The team turned to an obscure function within its existing electronic medical record system that was not being utilized. By activating this functionality, Atrius was able to promote a more reliable follow-up when a referral was ordered.

Of course, not all referrals are equal, so they first had to develop categories of priority that doctors chose once they ordered the referral.

"And part of the reason behind this was we felt we needed to differentiate the very routine referral from a referral that had real clinical import. You know, a referral for acne might be considered routine. If it doesn't happen, it doesn't happen. But referrals where there is a serious diagnostic question that is urgent, maybe not urgent on a time basis but maybe a priority like follow-up of an elevated PSA."

Guidelines were developed, and the staff was trained to respond if the system showed a referral wasn't scheduled or kept. Referral monitors or medical assistants see the referrals and their priority designations in a queue on a computer screen. Top priority referrals required two phone calls, a letter documented in the record, and follow-up with the PCP if the referral didn't happen. Even low priority referrals at a minimum got a phone call.

Dr. Lopez says the rate of completion of priority referrals has steadily gone up since the project was implemented, and their goal is to reach 100 percent. He shared some of the lessons they have learned along the way.

"So the lessons learned are, you know, we had to build the case and provide context. So that's not as you all know not always easy to do to get people to understand the importance of this and why it's helpful. The leadership was absolutely critical, otherwise one gets drowned in the weeds. We had to make an organizational priority, and at Harvard Vanguard as I'm sure in your organizations, there are lots of priorities. And it is very hard to get initiatives through because it's just one more thing that people have to do. I agree that we didn't have to go out and buy this referral module. It actually comes with Epic. They built this functionality, but if you have a system, you want to optimize its use."

Dr. Lopez answered some questions from the audience, including whether this can be accomplished without an electronic medical record.

"I think that in the absence of an EMR, I think one could conceivably do this in either a home-grown system. We actually had a home grown sort of simple database where, when referrals were made, we had our referral coordinators put that information into an access database that we could report off of. I mean, that's sort of an intermediate between electronic medical record and a pure paper system and that was helpful. Although we did eliminate that system and shut it down once we had this fully operationalized. I think one could do analogous steps on a paper system. I think it would just be more tedious. On the other hand, in a small practice it's probably very viable. It's just it would be an impossibility at Harvard Vanguard."

To the complaint that this puts all the onus on the PCP and not the specialist or the patient him or herself, Dr. Lopez sympathized. But he said the system is designed only to involve the referring PCP when a high-priority referral is overdue. He said most of the specialties and their staffs in the Atrius Health system are integrated within the sites and within the electronic record system. So the specialty staff share the monitoring of the referrals and do the initial patient follow-up.

According to the experience of professional liability experts, patients are not reliable partners to ensure the referral is completed. The courts and juries often put the responsibility for follow-up on the physician who made the referral in the first place.

January 1, 2009
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