The Uncertainty of Diagnoses

There was a sentinal event experienced when I matriculated into medical school at the age of 34.  The dean of the medical school stood up and quoted a study that showed in 1983 up to 40% of the time the working diagnoses at Johns Hopkins were found to be in error on autopsy results. He then went on to say that by the time we finished residency most of the knowledge we'd memorized in medical school would be obsolete. That's when I went out and spent over $3,500 for a computer only to be crushed that there was very little software that would help me 1) get through medical school and 2) help with diagnosing and treating a patient. 

A lot has happened since then but the promise of artificial intelligence, connected health information networks and computerization of health care hasn't really panned out the way I imagined over the last 25 years. But one thing that hasn't changed is the complexity of even simple diseases. Why?

Well, for one we don't practice medicine scientifically.  Take a simple sore throat.  We don't do viral and bacterial cultures on every one or even a random sample of patients to discover the exact pathogen with which we're dealing.  There are probably over 200 viruses and 50 bacteria and a multitude of mechanical and environmental agents that will produce almost identical symptoms.  We don't have instant tests with the exception of Rapid Strep, Rapid Influenza and Rapid Mono tests that can help us significantly.  Thus for the vast majority of cases we are practicing blind.  Fortunately most patient get well from this condition in 2 weeks no matter how we treat.  The evidence suggests that with the exception of a very small minority of conditions NOT treating is better than treating but it is really hard to convince patients no treatment is better than treating.

I purchased QMR, Iliad and a subscription to AMANet to access Octo Barnett's DxPlain to help me come to correct diagnoses. What I and my colleagues discovered is that there were about 1,500 signs and symptoms that covered almost all of the known diseases (over 20,000 in the databases).  That meant a large number of diseases presented with the same signs and symptoms.  There were very few diseases that had pathognomonic signs or symptoms.  Consequently we became pretty good at coming up the differential diagnosis (a list of the diseases that shared the same symptoms).  Our goal was to rule in or rule out the diseases by ordering tests and procedures.

In primary care we see patients every 10-15 minutes.  We go through the same process and usually have a relatively short differential list of diagnoses that we think we're treating.  We order tests that are returned to us over the next few days.  And yet we have to make a diagnosis for that visit at the time of the visit in order to get paid.  We usually pick the most probably diagnosis at the visit and that goes on the claims that is processed electronically.

The labs will come back and either rule this diagnosis in or out.  Guess what?  There isn't a process for us to go back and amend the visit diagnosis with the correct one if a test ruled the original one out and replace it with another one.  My guess is that over time up to 40% of the claims based diagnoses are totally bogus.

And then there are complicated diseases like Lupus Erythematosis or Fibromyalgia with no confirmatory tests.  A patient may be seen up to 10 times before these "diagnoses of exclusion" are made.  There is no systematic way to go back and amend the diagnoses of the previous 10 visits and change them to the final diagnosis made.

That's why most astute people will take claims based data in the ambulatory environment with a huge grain of salt.  What may be more valuable is a big picture of all of the diagnoses over time to get an idea of what's going on with a patient.  But that data is usually not available as it's hidden in many physician's charts, EMRs and insurance claims data.

We need a national system for experts to go through reams of claims based data, compare it with the symptoms documented and then systematically modify the diagnoses to improve their worth.  That's probably not going to happen.

Littman 3200 BT Stethoscope & Zargis Cardioscan - Is the PC the problem?

Am midway through testing the Littman 3200 BT Stethoscope and accompanying Zargis Cardioscan and StethAssist software. First, the scope and software do work as advertised.  User interface on the scope was relatively simple and didn't really require much training.  Similarly the software (both the StethAssist which ships with the stethoscope) and the $395 Cardioscan software do work reasonably well.  The problem is in the logistics.

Most of us physicians practice out of several exam rooms and usually are under significant time constraints.  In my clinic we have wireless desktop PC's with large 21" swivel monitors that are primarily for the patient to view along with the physician our digital records, radiologic images and patient information.  The EMR software (Cerner's PowerChart) is running on Citrix servers. Each of these devices is networked autologon device that is rigidly controlled for security purposes (limiting SD, BT local CD connections).

The Cardioscan software runs on a PC and after inputing the patient information and wirelessly connecting with the stethoscope guides the physician through the steps of collecting heart tones from the 4 standard chest locations (takes nearly 2 minutes to collect all of the information). When finished the softare analyzes the data and produces a graphical and sound output that highlights any murmurs that might be present.

So far so good. The problem is when I move from one exam room to another it's not easy to manage both the PC softare, the scope, the patient and the EMR that is collecting information at the point of care.  Installing the software on each of the exam room machines is possible but in our clinic that would entail loading it on 32 devices.  More limiting is that each of us with one of these stethoscopes would need to carry around the BT dongle and plugging it in to the networked devices would entail security changes that would compromise the network.  Right now we have to carry our own tablets or notebooks into the room along with the scope in order to use it effectively.  Even so, the logistics would quickly prevent the effective and timely use of this. The extra time would convert to lost appointments and revenue.

What's needed is for the software to reside on the scope itself allowing us to record a complete sequence.  The scope is able to record data but only short segments that can't be paired with specific locations for the Cardioscan software. Unfortunately the small user interface prevents a challenge.  What I'd really like to see is the Cardioscan software be published as an iPhone App.  This would allow us the flexibility and freedom to move quickly in the exam rooms, on the floor and other locations and collect heart tones needed for downstream analysis and documentation.

There's another problem.  The stethoscope costs around $400.  It ships with a virtually useless SethAssist software that does not provide any analytical tools and has very limited functionality.  Zargis then hits the user with another $400 for the more useful CardioScan software (and also nails you for $17 shipping and handling!).  Spending $800 for an 80% solution sticks in my craw as a primary care physician and especially for medical students and residents who would find this most useful.

Recommendations to Littman and Zargis: 

1. Make sure the BT is BT2 allowing pairing with multiple devices.
2. Enable the software to be easily installed on multiple devices.
3. Lower the price of the software with residents and PCPs in mind
4. Dump StethAssist and ship the system with CardioScan
5. Create an iPhone, Pre and other BT enabled device App and enable pairing of the scope to all of these smart phones

Oh, the same advice goes to Welch-Allyn who also manufacture digital otoscopes and ophthalmoscopes.  The problem to effective use is all in the logistics. It's not possible for a physician to control these devices AND click or manipulate an accompanying software on a PC or video screen in order to capture images to place in the EMR.  The controls have to be on the device and the connection has to be wireless to a very mobile device that can be carried on rounds, into many different exam rooms, nursing homes and wherever the patient being examined happens to be. 

It takes an comedian to make sense of the healthcare debate

Twitterworld has bounced Al Franken's interaction with the Tea Party confontists. I watched in fascination how deference, respect and acknowledgement of other's points of view (no matter how idiotic) carried the day.

The more I watch this video the more humbled I am and vow to spend more time listening to others, making sure that I don't insult them (either on purpose or inadvertently).

We need more leaders like Mr. Franken.